Biliary

Question 1

What is Type I Choledochal cyst?

Answer 1

Fusiform dilation of the extrahepatic bile ducts. The intrahepatic ducts are not involved.

Question 2

What is a Type II Choledochal cyst?

Answer 2

Diverticulum off the common bile duct. The malignant potential is low

Question 3

What is a Type III Choledochal cyst?

Answer 3

Also known as a choledochocele. This is defined as cystic dilation of the common bile duct within the wall of the duodenum

Question 4

What is a Type IV Choledochal cyst?

Answer 4

Both intrahepatic and extrahepatic involvement.

Type IVa: one extrahepatic cyst with intrahepatic cysts
Type IVb: multiple small extrahepatic cyst

Question 5

What type of choledochal cyst?

One Extrahepatic Cyst with intrahepatic cyst

Answer 5

Type IVa

Question 6

What type of choledochal cyst?

Multiple small extrahepatic cyst

Answer 6

Type IVb

Question 7

What is a Type V Choledochal cyst?

Answer 7

Only intrahepatic cysts; also known as Caroli disease

Question 8

What etiology is most associated with choledochal cyst?

Answer 8

anomalous pancreaticobiliary junction (APBJ). 30% association

APBC: long common biliary and pancreatic channel

Question 9

Treatment for Type I choledochal cyst?

Answer 9

cyst excision followed by Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy

Question 10

Treatment for Type II choledochal cyst?

Answer 10

Resection of the diverticulum off the side of the common bile duct

Question 11

Treatment for Type III choledochal cyst?

Answer 11

Endoscopic sphincterotomy versus transduodenal excision and sphincteroplasty

Question 12

Treatment for Type IV choledochal cyst?

Answer 12

cyst excision followed by Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy. Hepatic resection should be considered if cysts are limited to one lobe.

Question 13

Treatment for Type V choledochal cyst?

Answer 13

Typically, liver transplant required to treat entire disease

Question 14

Up to ____% of patient have anatomic variations in biliary anatomy

Answer 14

40%;

most commonly, insertion of the right posterior sectoral duct into the left hepatic duct

Question 15

Vascular supply of the biliary system:

Arterial blood supply runs along the common bile duct at the __ and __ o’clock positions

Answer 15

3 and 9

Question 16

The bile duct below the level of the duodenal bulb is perfused by tributaries of the ______________________ and __________________ arteries

Answer 16

posterosuperior pancreaticoduodenal and gastroduodenal

Question 17

The supraduodenal bile duct, cystic duct, and hepatic ducts are perfused by the ________________ and ______________ branches

Answer 17

right hepatic; cystic artery

Question 18

Modified Bismuth/Strasberg classification E1-E5 typically require

Answer 18

biliary-enteric anastomosis for repair

(most commonly Roux-en-Y hepatico- or choledocho-jejunostomy)

Question 19

Preoperative Preparation for bile duct injury repair with delayed identification

Answer 19

• Control Infection
• Preoperative cholangiography (ERCP to define injury and attempt to bridge with stent, Percutaneous transhepatic cholangiography for decompression, MRI/CT for vascular anatomy)
• Establish plan for definitive biliary enteric drainage

Question 20

Nonthermal injuries that involve less than ___% of the duct circumference may be considered for ______________

Answer 20

50%; primary repair over a T tube

Question 21

Injuries caused by electrocautery or those that involve more than _____% of the duct circumference ______________________________

Answer 21

50%; require major biliary reconstruction

Question 22

Defects shorter than _____ and distal to the hilum and hepatic duct bifurcation may be repaired with ____________________________________ if adequate mobilization can be performed to allow a tension-free anastomosis

Answer 22

1 cm; end-to-end choledocho-choledochostomy

(A transanastomotic T tube should be placed through a separate vertical choledochotomy.)

Question 23

_________ bile duct injuries can be reimplanted in the _______________________________________ if a tension-free repair can be achieved with a Kocher maneuver

Answer 23

Distal; duodenum (choledocho-duodenostomy)

(allows for future endoscopic access to the biliary tree but is associated with a higher risk of anastomotic leak than a Roux-en-Y choledocho-jejunal anastomosis)

Question 24

__________ sectoral ducts (segments V-VIII) join to the ________ ___________ duct

Answer 24

Right; Right hepatic

Question 25

__________ sectoral ducts (segments II-IV) to the _______ ___________ duct

Answer 25

Left; Left Hepatic

Question 26

Workup of an extrahepatic biliary stricture:

Answer 26

• Cross-sectional imaging of the liver with MRI/MR cholangiopancreatography (CP) or liver protocol CT is used to assess for a biliary or hepatic mass, the presence of intrahepatic metastases, major vascular involvement, or lymphadenopathy.
• ERCP with biliary brushings and endoscopic stent placement if indicated for obstruction with a percutaneous biliary drain is also an option.
• EUS is used for histologic diagnosis if it cannot be obtained with brushings.
• Consider cholangioscopy (if available) for directed biliary mass evaluation.
• Serum CA19-9 and CEA should also be checked.
• Exclude IgG4-related cholangiopathy in cases of diagnostic uncertainty (can mimic cholangiocarcinoma).

Question 27

Tumors are considered locally advanced and unresectable if the tumor involves the ____________________________________ or there is involvement of _______________________ ____________________________. Lobar atrophy is a secondary sign of portal vein impingement/occlusion

Answer 27

secondary biliary radicals bilaterally; unilateral secondary biliary radicals with contralateral encasement of the hepatic artery or portal vein

Question 28

The lower limit of FLR volume is _______________ in a normal liver; ________________ in a patient treated with preoperative chemotherapy; and ______ in a patient with cirrhosis

Answer 28

25% to 30%; 30% to 35%; 40%

Question 29

Patients with inadequate FLR volume, _______________________________ can be performed to obtain preoperative liver hypertrophy

Answer 29

portal vein embolization

Question 30

Hepatic resection is contraindicated in patients with ____________________________; cirrhosis with a _________________________; or the presence of clinical findings of ___________________________

Answer 30

unresectable cholangiocarcinoma; MELD score > 10 to 12; portal hypertension (varices, portal vein thrombosis)

Question 31

During Hepatic resection CVP should be kept at:

Answer 31

0 and 5 mm Hg

Question 32

Bismuth-Corlette classification for peri-hilar cholangiocarcinoma: Type I

Answer 32

Common hepatic duct involvement proximal to the cystic duct with sparing of the confluence

Question 33

Bismuth-Corlette classification for peri-hilar cholangiocarcinoma: Type II

Answer 33

Tumor involvement of the confluence and potentially extending into the caudate

Question 34

Bismuth-Corlette classification for peri-hilar cholangiocarcinoma: Type III

Answer 34

Tumor involvement of the confluence with extension to right (IIIA) or left (IIIB) secondary confluence

Question 35

Bismuth-Corlette classification for peri-hilar cholangiocarcinoma: Type IV

Answer 35

Tumor involvement of confluence with extension to right and left secondary biliary radicals

Question 36

Features that make transcystic CBD exploration more likely to be successful include:

Answer 36

• small stones (< 6-8 mm)
• fewer than eight total stones
• a large cystic duct (> 5 mm)

Question 37

Features that make transductal CBD exploration more likely to be necessary include:

Answer 37

• large stones
• multiple stones
• a small or friable cystic duct
• having stones proximal to the cystic duct–CBD junction

Question 38

Indications for open CBD exploration include:

Answer 38

• Large or impacted CBD stones
• Failed prior endoscopic interventions
• When biliary enteric drainage is indicated.

required for cholecystectomy in certain patients (those with Mirizzi syndrome, severe cholecystitis, and biliary-enteric fistula)

Question 39

Choledochotomy should be avoided in the setting of a

Answer 39

small (< 7 mm) CBD