Biliary Flashcards
What is Type I Choledochal cyst?
Fusiform dilation of the extrahepatic bile ducts. The intrahepatic ducts are not involved.
What is a Type II Choledochal cyst?
Diverticulum off the common bile duct. The malignant potential is low
What is a Type III Choledochal cyst?
Also known as a choledochocele. This is defined as cystic dilation of the common bile duct within the wall of the duodenum
What is a Type IV Choledochal cyst?
Both intrahepatic and extrahepatic involvement.
Type IVa: one extrahepatic cyst with intrahepatic cysts
Type IVb: multiple small extrahepatic cyst
What type of choledochal cyst?
One Extrahepatic Cyst with intrahepatic cyst
Type IVa
What type of choledochal cyst?
Multiple small extrahepatic cyst
Type IVb
What is a Type V Choledochal cyst?
Only intrahepatic cysts; also known as Caroli disease
What etiology is most associated with choledochal cyst?
anomalous pancreaticobiliary junction (APBJ). 30% association
APBC: long common biliary and pancreatic channel
Treatment for Type I choledochal cyst?
cyst excision followed by Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy
Treatment for Type II choledochal cyst?
Resection of the diverticulum off the side of the common bile duct
Treatment for Type III choledochal cyst?
Endoscopic sphincterotomy versus transduodenal excision and sphincteroplasty
Treatment for Type IV choledochal cyst?
cyst excision followed by Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy. Hepatic resection should be considered if cysts are limited to one lobe.
Treatment for Type V choledochal cyst?
Typically, liver transplant required to treat entire disease
Up to ____% of patient have anatomic variations in biliary anatomy
40%;
most commonly, insertion of the right posterior sectoral duct into the left hepatic duct
Vascular supply of the biliary system:
Arterial blood supply runs along the common bile duct at the __ and __ o’clock positions
3 and 9
The bile duct below the level of the duodenal bulb is perfused by tributaries of the ______________________ and __________________ arteries
posterosuperior pancreaticoduodenal and gastroduodenal
The supraduodenal bile duct, cystic duct, and hepatic ducts are perfused by the ________________ and ______________ branches
right hepatic; cystic artery
Modified Bismuth/Strasberg classification E1-E5 typically require
biliary-enteric anastomosis for repair
(most commonly Roux-en-Y hepatico- or choledocho-jejunostomy)
Preoperative Preparation for bile duct injury repair with delayed identification
- 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
Nonthermal injuries that involve less than ___% of the duct circumference may be considered for ______________
50%; primary repair over a T tube
Injuries caused by electrocautery or those that involve more than _____% of the duct circumference ______________________________
50%; require major biliary reconstruction
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
1 cm; end-to-end choledocho-choledochostomy
(A transanastomotic T tube should be placed through a separate vertical choledochotomy.)
_________ bile duct injuries can be reimplanted in the _______________________________________ if a tension-free repair can be achieved with a Kocher maneuver
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)
__________ sectoral ducts (segments V-VIII) join to the ________ ___________ duct
Right; Right hepatic
__________ sectoral ducts (segments II-IV) to the _______ ___________ duct
Left; Left Hepatic
Workup of an extrahepatic biliary stricture:
- 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).
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
secondary biliary radicals bilaterally; unilateral secondary biliary radicals with contralateral encasement of the hepatic artery or portal vein
The lower limit of FLR volume is _______________ in a normal liver; ________________ in a patient treated with preoperative chemotherapy; and ______ in a patient with cirrhosis
25% to 30%; 30% to 35%; 40%
Patients with inadequate FLR volume, _______________________________ can be performed to obtain preoperative liver hypertrophy
portal vein embolization
Hepatic resection is contraindicated in patients with ____________________________; cirrhosis with a _________________________; or the presence of clinical findings of ___________________________
unresectable cholangiocarcinoma; MELD score > 10 to 12; portal hypertension (varices, portal vein thrombosis)
During Hepatic resection CVP should be kept at:
0 and 5 mm Hg
Bismuth-Corlette classification for peri-hilar cholangiocarcinoma: Type I
Common hepatic duct involvement proximal to the cystic duct with sparing of the confluence
Bismuth-Corlette classification for peri-hilar cholangiocarcinoma: Type II
Tumor involvement of the confluence and potentially extending into the caudate
Bismuth-Corlette classification for peri-hilar cholangiocarcinoma: Type III
Tumor involvement of the confluence with extension to right (IIIA) or left (IIIB) secondary confluence
Bismuth-Corlette classification for peri-hilar cholangiocarcinoma: Type IV
Tumor involvement of confluence with extension to right and left secondary biliary radicals
Features that make transcystic CBD exploration more likely to be successful include:
- small stones (< 6-8 mm)
- fewer than eight total stones
- a large cystic duct (> 5 mm)
Features that make transductal CBD exploration more likely to be necessary include:
- large stones
- multiple stones
- a small or friable cystic duct
- having stones proximal to the cystic duct–CBD junction
Indications for open CBD exploration include:
- 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)
Choledochotomy should be avoided in the setting of a
small (< 7 mm) CBD
