BILIARY Flashcards
The initial treatment of acute suppurative (toxic) cholangitis
high-dose multiple antibiotic therapy and appropriate fluid resuscitation.
Urgent percutaneous catheter drainage of the biliary tree -catheter should be placed
proximal to the obstructing lesion.
Placement into the duodenum during the acute phase of the problem is not necessary.
Stones need not be removed if adequate drainage can be established.
Although the lower common duct can frequently be drained through a nasobiliary catheter, the upper duct cannot.
Emergency open choledochotomy should be done for acute suppurative (toxic) cholangitis
if drainage fails, because operation has a mortality rate of 25% in this patient population.
Gallbladder adenomas
tubular or papillary,
both arising from the epithelial layer of the gallbladder.
The direct association between benign adenomas, adenomas containing carcinoma in situ, and invasive carcinoma has been demonstrated and therefore these lesions are considered premalignant.
In general, adenomas less than 12 mm in size are typically all benign, whereas adenomas with cancerous foci are usually greater than 12 mm.
Adenomyomatosis of the gallbladders
is characterized by localized or diffuse hyperplastic extension of the mucosa into, and often beyond, a hypertrophic gallbladder muscular layer.
The etiology is unknown.
may be premalignant because cases of adenocarcinoma arising in or near adenomyomatosis have been reported.
Cholangiocarcinoma Risk factors
primary sclerosing cholangitis,
ulcerative colitis,
choledochal cyst,
biliary tract infection, either with clonorchis or in chronic typhoid carriers.
intraoperative technique of hepatic resection?
porta hepatis is dissected with identification of the main bifurcations of the hepatic artery, bile duct, and portal vein.
individual ligation of the branches of the structures supplying one side of the liver while preserving the branches to the other.
Ligation of the hepatic artery and portal vein to one side allows the liver parenchyma to demarcate a line of resection between the right and left liver.
Inflow control of the liver may be obtained by pedicle ligations in which small hepatotomies are made in the main right pedicle, the main left pedicle, the right anterior pedicle, or the right posterior pedicle after identification with ultrasound.
The pedicle of interest can be dissected out bluntly with a right angle or by palpation. The pedicle can then be clamped to confirm that it does indeed supply the liver area of interest (i.e., right half, left half, right anterior section, right posterior section). Once confirmed, the pedicle can be divided.
Alternatively, the inflow pedicles can be divided as they are encountered while transecting hepatic parenchyma.
hemorrhage can be minimized by intermittent portal inflow occlusion accomplished by gently clamping the main portal triad within the hepatoduodenal ligament.
Outflow control of the hepatic veins can be obtained before or after hepatic transection and should be decided on a case-by-case basis.
When there is a significant extraparenchymal component to the hepatic veins that need to be controlled, often it is easier to divide the hepatic veins early and prior to parenchymal transection (but after inflow control).
When the extraparenchymal component of the hepatic veins is very short or absent and when the tumor margin is near the junction of the hepatic veins and the inferior vena cava, it may be safer and easier to divide the hepatic veins within the hepatic parenchyma after most of the parenchymal transection has been performed. It is often useful to keep the central venous pressure of the patient low (<5 mm Hg) until the parenchymal transection is complete, as this will decrease bleeding from the inferior vena cava and hepatic vein branches.
The blood supply of the common bile duct
segmental
branches from the
cystic artery,
hepatic artery,
gastroduodenal arteries.
They meet to form collateral vessels in the 3- and 9-o’clock positions.
Bile leak from a cystic stump following laparoscopic cholecystectomy
Type A of the Bismuth-Strasburg classification of biliary injuries.
Type A injuries typically present during the first post-operative week.
The most appropriate management in this patient will involve percutaneous fluid drainage of the right upper quadrant fluid collection.
Endoscopic stenting, with or without sphincterotomy, will also aid in diverting bile flow away from the leaky cystic stump; eliminating the need for a potentially complicated surgery.
Patients with distal cholangiocarcinoma generally require what treatment and are associated with what prognosis
pancreaticoduodenectomy to obtain clearance of the tumor because of the intrapancreatic location of the distal common bile duct.
Patients with cholangiocarcinoma arising in the distal bile duct have both an increased resectability rate and an improved prognosis over those with hilar cholangiocarcinoma.
The “gold standard” for the evaluation of patients with bile duct strictures
cholangiography.
PTC is usually more valuable that ERC.
PTC is more useful in that it defines the anatomy of the proximal biliary tree that is to be used in the surgical reconstruction.
Furthermore, PTC can be followed by placement of percutaneous transhepatic catheters, which can be useful in decompressing the proximal biliary system either to treat or prevent cholangitis or to control an ongoing bile leak.
ERCP to remove stones is successful in what percent
Stones can be successfully removed from the common bile duct in 85% to 95% of cases,
although multiple endoscopic procedures may be necessary.
ERCP complication rate
Complications occur in 5% to 8% of patients, which include cholangitis, pancreatitis, perforation, and bleeding. The overall mortality rate is 0.2% to 0.5%.
The indications for transcystic duct exploration are filling defects noted on cholangiography,
stones smaller than 9 mm in diameter,
stones below the cystic duct entrance to the bile duct, and fewer than six stones.
Success rates greater than 95% have been reported for bile duct clearance using choledochoscopy via this technique.
Laparoscopic choledochotomy is another excellent approach to common bile duct stones when the common bile duct diameter is
6 mm or greater.
This procedure, however, does require significant laparoscopic technical skills. Open common bile duct exploration is performed much less frequently with increased use of endoscopic, percutaneous, and laparoscopic techniques to remove common bile duct stones.
Management of the diabetic patient with gallstones
has changed over time.
Most authors do not recommend prophylactic cholecystectomy for an asymptomatic diabetic patient.
Because the risk of developing acute cholecystitis is not increased, and there is no increased operative risk other than that associated with the patient’s comorbid disease,
dissolution therapy is also not indicated in asymptomatic patients!!
With the advent of laparoscopic cholecystectomy, gallstone lithotripsy confers no advantage from a cost, or patient satisfaction/return to work standpoint.
There also appears to be no difference in outcome when comparing insulin dependent versus non-insulin dependent patients. Again, their risks are more related to their associated comorbid disease
formation of micelles.
The micelle structure allows the lipid units to be absorbed by enterocytes.
This process begins with the emulsification
The outer, hydrophilic side of bile salts is positively charged by lecithin and other phospholipids, therefore there are located on the surface of the micelle rather than the core.
Cholesterol is located in the hydrophobic center, or core, of micelles. The principal component of micelles is phospholipid, not cholesterol.
The hydrophilic ends of the bile salts are directed outward, toward the aqueous environment.
incidence of bile duct injury
exact is unknown because many cases are unreported in the literature.
Data suggest that the incidence of bile duct injury during open cholecystectomy is 1 in 500 to 1,000 cases.
The incidence of bile duct injuries during laparoscopic cholecystectomy compared to open
is clearly higher.
suggest an incidence of bile duct injury during laparoscopic cholecystectomy ranging from 0.3% to 0.7%.
bile duct injury with laparoscopic cholecystectomy does not appear to have diminished in more recent surveys, suggesting not simply the result of a learning curve
97% of injuries were a result of visual perceptual illusion or inadequate visualization.
The role of intraoperative cholangiography in preventing bile duct injury during laparoscopic cholecystectomy is
does not prevent bile duct injury.
minimize the extent of injury.
??might lower the overall incidence of bile duct injury.
Among the laboratory tests listed, what is most characteristic of patients with severe obstructive jaundice of long standing.
prolongation of the prothrombin time (PT)!
Vit K def becuase bile not avlb for this fat sol vitamin
Vitamin K is a necessary cofactor for hepatic synthesis of
prothrombin,
factors VII, IX, and X.
The 5-year survival rate for all patients with gallbladder cancer is
less than 5% in most series,
with median survival of 6 months.
survival rates are reported after simple cholecystectomy for T1 disease,
Nearly 100%!
survival rates are reported after simple cholecystectomy for T2 and T3 tumors
without nodal disease have a 5-year survival rate greater than 50%.
Node positivity is an ominous finding, with few series reporting 5-year survivors.
The most common site of recurrence after resection of gallbladder cancer is
intra-abdominal,
specifically in the liver or the celiac or retropancreatic nodal basins.
For tumors limited to the muscular wall of the gallbladder
(T1b muscular wall)
Needs full Monty (maybe Lap chole if complete negative margins and no lymphovasc Sab / Cam says full Monty)