Biliary Flashcards
Define the different types of choledochal cyst
1) Type 1
2) Type 2
3) Type 3
4) Type 4
5) Type 5
1) fusiform / saccular dilation of the bile duct
2) supraduodenal extrahepatic diverticulum
3) choledochocele in intraduodenal CBD
4)
a) dilations in intrahepatic + extrahepatic
b) dilations in extra hepatic
5) dilations in intrahepatic. (Caroli’s)
Bismuth classification (bile duct injury)
Type 1
Type 2
Type 3
Type 4
Type 5
- CBD +/- CHD, >2cm from confluence
- proximal CHD < 2cm from confluence
- hilar, no residual CHD, confluence preserved
- complete hilar transection, no communication between L and R
- Aberrant RHD + hilar injury
Strasberg classification (bile duct injury) ABCD E1,2,3,4,5
A. cystic duct leak
B. Abberant RHD occlusion
C.Abberant RHD transection w/o ligation
D.lateral injury to CBD (<50% circumference
E1. CBD injury > 2cm from confluence
E2. CBD injury <2cm form confluence
E3 high CBD injury
E4 no R/L communication
E5. CBD + R aberrant duct injury
Causes of Jaundice
1) Prehepatic
2) Hepatic
3) Post-hepatic /Obstructive
1) hemolysis (thalassemia, G6PD), Gilbert’s, spherocytosis
2)hepatitis, late-stage cirrhosis, HCC with cirrhosis, drugs (alcohol, anti-TB, lipid-lowering)
3)
Intrahepatic: sepsis, scleorsing cholangitis, PBC
Extrahepatic: stone, MBO, pancreatitis, mirizzi, recurrent cholangittis, benign stricture, choledochal cysts
Causes of Malignant Biliary Obstruction
Ca head of pancreas
Malignant porta hepatic LN
CA ampulla
Cholangiocarcinoma
CA duodenum
CA gallbladder
HCC
Lymphoma
LN met (cholangioCA, Ca GB, pancreas, distal stomach)
Blood supply of common bile duct
Retroduodenal, branch of GDA (3OC =)
Right hepatic artery (9OC)
Courvoisier’s Law
The presence of a palpable gallbladder in a painless jaundice patient, unlikely to be due to gallstone
Enterohepatic circulation of bilirubin
unconjugated bilirubin in blood -> enter hepatocytes -> conjugated by glucuronic acid -> excreted to small intestines -> turned into urobiliogen by bacterial proteases -> 90% excreted in faces, 10% enter portal vein, excreted in kidney
Csendes classification (mirizzi syndrome Type 1,2,3,4
Type 1: extrinsic compression of CHD
Type 2: cholecysto-choledochal fistula, less than 1/3 circumference
Type 3: fistula <2/3 circumference
Type 4: > 2/3 circumference
McSherry classification
Type 1a, 1b, 2
Type 1a: compression over CHD
Type 1b: obliteration CHD
Type 2: cholecysto-choledochal fistula
Indications for ERCP
Therapeutic:
-stone removal, stent insertion, sphincterotomy, lithotripsy
Diagnostic:
-cholangiogram, brush cytology
Management of local complications
Complications of ERCP
General:
respiratory depression from benzodiazepines
arrhythmia due to buscopain
Papillotomy bleeding
Pancreatitis
Sepsis
Perforation
Stent complications
T staging for Gallbladder Cancer
T1a: lamina propria
T1b: muscular layer
T2: perimuscular layer , not beyond serosa
T3: perforate serosa, into adjacent organs
T4: invade two organs
N staging for Gallbladder Cancer
N1: LN along cystic duct, CBD, hepatic artery, portal vein (basically portal hepatis)
N2: periaortic, peri-caval, SMA/celiac trunk
Definition of extended cholecystectomy
Cholecystectomy + wedge resection of 2 cm of GB bed
Risk factors for gallbladder cancer
Female
Obesity
Multiparity
Porcelain GB
Chronic infection with salmonella
Adenomatous GB > 1cm
Choledochal cyst
Indication for lymph node dissection in gallbladder cancer
T1b or higher
Proper lymph node dissection in ca gallbladder
all lymph nodes of the porta hepatis and hepatoduodenal ligaments (including cystic duct, CBD, hepatic artery and portal vein)
Cholangiocarcinoma perihilar classification
Bismuth Classification:
Type 1: below confluence
Type 2: confluence, not involving left or right
Type 3: occluding CHD with
a: involving right
b: involving left
Type 4: multi-centric OR bilateral intrahepatic involvement OR involving confluence both ducts
Risk factors for cholangiocarcinoma
Age
Chronic intraductal gallstone
Choledochal cysts
Bile duct adenoma / biliary papillomatosis
Liver flukes
Chronic typhoid carrier
Classification of cholangiocarcinoma
Intrahepatic 6%
Perihilar 67%
Distal 27%
Indication of unresectable disease in cholangiocarcinoma
Portal vein invasion
Extensive liver involvement
Inadequate residual liver volume
Distal cholangiocarcinoma regional lymph nodes
Same as head of pancreas:
common bile duct
common hepatic artery
portal vein
anterior/posterior pancreaticoduodenal nodes
nodes along right lateral wall of SMA
Perihilar cholangiocarcinoma regional lymph nodes
Hilar
Cystic duct
Choledochal
Portal
Hepatic arterial
Posterior pancreaticoduodenal
*distal to hepatodudoenal ligament =distant met
Intrahepatic cohlangiocarcionma regional lymph nodes
1) Left
2) Right
Left:
inferior phrenic
hilar (CBD, HA, PV, CD)
gastrohepatic
Right:
hilar
periduodenal
peripancreatic
Charcot’s triad
*biliary obstruction
upper abdominal pain
fever
jaundice
Reynold’s pentad
Upper abdominal pain
Fever
Jaundice
Hypotension
Confusion
Strasberg Type A
Leakage from the cystic duct stump or minor hepatic ducts draining the liver bed
Strasberg Type B
Occlusion of the biliary tree, most commonly the aberrant right hepatic duct
Strasberg Type C
Transection without ligation of the aberrant right hepatic duct
Strasberg Type D
Lateral injury to a major bile duct
Criteria for resectability of cholangiocarcinoma
Traditional criteria:
- Absence of retropancreatic and paraceliac nodal metastasis or distant liver metastasis
- Absence of invasion to portal vein and hepatic artery ( in some centers, en bloc resection)
- Absence of extrahepatic adjacent organ invasion
- Absence of disseminated disease
Management based on Bismuth-Corlette classification for Klatskin tumors
Type 1 + 2: bile duct resection + HJ + regional lymphadenectomy
Type 3: hepatic lobectomy + regional lymphadenopathy
Type 4: multiple hepatic segment resection with portal vein resection vs palliative
What is the surgical option for distal cholangiocarcinoma?
Pancreaticoduodenectomy (Whipple operation, usually pylorus preserving)
