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)
T2 or greater tumors of gallbladder cancer
For tumors with full-thickness invasion INTO the perimuscular connective tissue but not to the serosa (T2)
radical cholecystectomy, with resection of segments IVb and V of the live
Regional lymphadenectomy is an important part of this procedure because 50% of the patients with T2 tumors are found to have nodal spread after resection.
Dissection of lymph nodes should include all tissue from the bifurcation of the hepatic duct to the distal common bile duct and include nodes along the hepatic artery to the celiac axis.
management of gallbladder cancer in the gallbladder infundibulum
the common bile duct is often involved with the tumor, either by direct extension or external invasion of the hepatoduodenal ligament.
In this case, an extended liver resection with removal of the portion of the common bile duct should be performed.
Reconstruction is then performed by Roux-en-Y hepaticojejunostomy.
Gallbladder cancer discovered during pathologic examination after cholecystectomy for presumed benign gallbladder disease. Patients with T2 or greater tumors and no signs of distant metastasis what is management
“radical resection” to eradicate all disease.
Even if patients are otherwise healthy, excision of laparoscopic port sites should also be performed because of the well-documented history of port-site seeding.
Pure cholesterol gallstones
are uncommon (10%) - (CAREFUL cholesterol stones or most common but PURE cholesterol stones are uncommon)
diagnosis and treatment of gallbladder dyskinesia is usually made
CCK cholescintigraphy obtained after an ultrasound negative for gallstones.
a gallbladder ejection fraction less than 35% is considered diagnostic.
major treatment option for patients with this disorder. Symptomatic improvement is noted in 90% of patients.
in the United States what % of bile duct stones or secondary
United States, more than 85% of all bile duct stones are secondary.
Right hepatectomy involves resection of segments
V through VIII.
Left hepatectomy involves resection of segments
II through IV.
Either left or right of these resections may or may not include resection of segment I,
NOT caudate! by default
Either of these resections may or may not include resection of segment I,
which should be stipulated.
Extended right hepatectomy involves resection of segments
V through VIII.
AND IV
(includes highest number of the other side -left)
Extended left hepatectomy involves resection of segments
II through V
AND VIII.
(includes highest number of the other side -right)
Right anterior sectionectomy includes segments
V
and
VIII
Right posterior sectionectomy includes segments
VI and VII.
Left medial sectionectomy involves segment(s)
IV only
Left lateral sectionectomy includes segment(s)
II and III
A segmentectomy involves resection of
a single segment
a bi-segmentectomy resolves resection of
two continuous segments
mneumonic for segments of liver
7
6 4a
8 1 2
5 4b 3
Diabetes is a clinical condition associated with gallbladder
stasis, making patients with diabetes at increased risk for the development of cholesterol gallstones. BUT not increased risk of complications from gallstones BUT increased risk with emergent cholecystectomy AND increased risk with elective cholecystectomy BUT not from diabetes rather from comorbidities:
Prophylactic cholecystectomy is not indicated in patients with diabetes and asymptomatic gallstones. While diabetics have an increased risk of surgery with emergent cholecystectomy, recent studies have shown that they also have an increased risk with elective cholecystectomy. This increased risk is related to comorbid conditions, not to the diabetes itself. Furthermore, no evidence suggests that asymptomatic diabetics are at increased risk to develop complications of gallstone disease.
Neoplasms of the ampulla of Vater include
malignant tumors and a variety of benign lesions.
The villous adenoma is the most common of the benign group. Other rarer lesions include carcinoids, lipomas, and adenomatous polyps. Although pancreaticoduodenectomy has been advocated for resection of most ampullary lesions, ampullectomy is an adequate procedure in certain situations. The decision to perform ampullectomy rather than pancreaticoduodenectomy should be based on the histologic diagnosis, patient risk factors, and the technical ability to develop adequate margins within the scope of a local resection. Radical pancreaticoduodenectomy is the procedure of choice for malignant ampullary tumors and large villous adenomas or those harboring carcinoma in situ. Most neuroendocrine tumors such as small carcinoids and functioning gastrinomas may be adequately treated by ampullectomy with nodal dissection, if indicated. Larger neuroendocrine tumors usually require pancreaticoduodenectomy. Solitary adenomatous polyps at the ampulla without associated duodenal dysplasia can be adequately treated by ampullectomy. Pancreaticoduodenectomy, however, should be considered for multiple polyps because of the unsuspected malignant degeneration often found in these polyps.
management of bile duct strictures associated with open cholecystectomy.
CAREFUL- bile duct stricture is different from bile duct injury
SURGERY:
Historically, excellent long-term results were achieved in 70% to 90% of patients who underwent repair of bile duct strictures associated with open cholecystectomy.
75% of the patients had undergone laparoscopic cholecystectomy showed a successful outcome in more than 90% of the patients at follow-up approaching 5 years.
NONOPERATIVE:
nonoperative approaches of percutaneous or endoscopic dilatation are suitable alternatives for many patients.
retrospective comparative uggest that surgical reconstruction offers a better chance of long-term success than do other percutaneous endoscopic techniques.
Both endoscopic and percutaneous balloon dilatation involve the placement of transanastomotic stents and in almost all cases require repeated dilatations to achieve optimal results.
Contraindications to laparoscopic cholecystectomy include
inability of patients to withstand general anesthesia,
intractable bleeding disorders,
severe chronic obstructive pulmonary disease
or
congestive heart failure may not tolerate pneumoperitoneum required for performing laparoscopic surgery.
end-stage liver disease…
BUT Elective cholecystectomy can also be completed safely in patients with well-compensated cirrhosis, although difficulty in retracting a firm liver and increased bleeding from collaterals have been noted.
Associated with higher lap chole conversion rate
acute cholecystitis,
a higher conversion rate and operative time than in the elective setting.
NOT Morbid obesity, is not associated with a higher conversion rate! - actually advantage to the scope rather than wade through all that fat…
Elective laparoscopic cholecystectomy as an outpatient procedure.
Among patients selected for outpatient management, 77% to 97% of patients can be successfully discharged the same day.
Factors contributing to overnight admission include uncontrolled pain, nausea and vomiting, operative duration greater than 60 minutes, and cases completed late in the day.
medical therapy for primary sclerosing cholangitis
NOPE
There is no known specific medical therapy for primary sclerosing cholangitis.
ursodeoxycholic acid significantly improves liver function tests and liver histologic appearance. Unfortunately, there are NO significant DIFFERENCE in clinical outcomes in the two groups at up to 6 years of follow-up.
Because of a lack of effective medical therapy, an aggressive surgical approach is advocated for most symptomatic patients with primary sclerosing cholangitis.
surgical approach for primary sclerosing cholangitis
One surgical approach, in patients with a dominant stricture of the hepatic duct bifurcation, uses resection of the bifurcation and long-term transanastomotic stenting with Silastic stents.
however, does not eliminate or influence the results of hepatic transplantation.
The role of biliary surgery in primary sclerosing cholangitis has been decreased considerably with the growing success of liver transplantation.
Primary sclerosing cholangitis has become one of the most common indications for liver transplantation in the United States.
Liver transplantation should be considered before the disease is too advanced.
Preoperative recognition of cholangiocarcinoma is extremely important in this population in that the development of this complication significantly worsens the result of liver transplantation. The presence of a known malignancy results in many patients being refused transplantation.
asymptomatic gallstones can progress to symptomatic disease with what percentage
20% to 30% of patients become symptomatic within 20 years.
this translates to a per year rate of
1% to 2% of asymptomatic individuals with gallstones will develop serious symptoms or complications related to their gallstones per year.
The longer stones remain silent what happends to the chances of develping symptoms of gallstones
the less likely symptoms are to develop.
almost all patients will develop symptomatic disease before developing one of the complications of gallbladder disease.
Therefore, prophylactic cholecystectomy is not generally indicated in patients with asymptomatic gallstones.
The primary symptom associated with chronic cholecystitis or symptomatic cholelithiasis is
pain.
of mildly symptomatic patients what percent will develop gallstone-related complications per year
and what percent will require cholecystectomy per year to manage their gallbladder symptoms.
Approximately 1% to 3%
at least 6% to 8%
Cholesterol solubility
The bile cholesterol saturation index is a numerical value derived from the relative concentrations of
cholesterol,
lecithin,
bile salts
A value of greater than 1.0 represents supersaturation with cholesterol.
Acute cholecystitis association with infection
primarily inflammation and NOT an infectious process!
with bacterial infection appearing as a secondary event.
Approximately 50% of patients with acute cholecystitis will have positive bile cultures, with E. coli being the most common organism.
Laparoscopic cholecystectomy should be performed within what time period of acute cholecystitis
24 to 72 hours of presentation.
In most American populations, What is the composition of gallstones
70% to 80% of gallstones are cholesterol (CAREFUL these are not PURE cholesterol stones)
black pigment stones account for
Second most common gall stones after cholesterol stones
20% to 30%.
frequently are associated with hemolytic conditions or cirrhosis.
usually NOT associated with infected bile and are located almost exclusively in the gallbladder.
brown pigment stones
found in bile ducts,
especially in Oriental populations.
contain more cholesterol and calcium palmitate than black stones and occur as primary common duct stones
Western patients with disorders of biliary motility and associated bacterial infection
Common bile duct stones are present what percentage of patients with symptomatic gallstones - how does age affect this percentage
8% to 15% of patients with symptomatic gallstones.
Incidence varies with age and is approximately 5% in younger patients and more than 20% in older patients with gallstones.
Magnetic resonance cholangiopancreatography sensitivity forward identifying gallstones in the common bile duct
magnetic resonance cholangiopancreatography can diagnose common bile duct stones with a sensitivity of
90%, a specificity of 100%,
and an overall diagnostic accuracy of 75%. T
he main advantage of magnetic resonance cholangiopancreatography is that it allows for the direct imaging of the biliary tract without the need for contrast or an invasive procedure.
Endoscopic ultrasound for the detection of common bile duct stones - what is the overall success
is a semi-invasive test that can be performed with a very low rate of complications.
The sensitivity and specificity of common bile duct stones by endoscopic ultrasound ranges from 92% to 100% and 95% to 100%, respectively.
most common primary hepatic malignancy
HCC is the and is one of the most prevalent solid malignancies worldwide. Advances in cross-sectional imaging (contrast-enhanced three-phase computed tomography [CT] or magnetic resonance imaging [MRI]) have allowed the establishment of a diagnosis of HCC in most cases based on imaging criteria alone, specifically arterial enhancement with early washout of contrast on the delayed phases of the scan. Hepatic resection remains the treatment of choice in patients with resectable disease and adequate hepatic synthetic function. While tumor size and number are important criteria in selecting appropriate patients for hepatic resection, the presence or absence of vascular invasion on histopathology examination has proven to be the tumor characteristic most predictive of survival following surgical resection. Liver transplantation for early-stage HCC may also be performed with good long-term outcomes and is the optimal therapy for patients with advanced underlying liver disease that precludes resection. Selection of patients with HCC best served by liver transplantation is controversial and is dependent on the availability of donor organs. However, the Milan criteria are broadly accepted as reasonable selection criteria, defined as the absence of macrovascular invasion and a single tumor less than or equal to 5.0 cm or two to three tumors with none being greater than 3.0 cm. Ongoing study is under way to investigate the cautious expansion of liver transplantation to patients with more extensive tumor burden. In patients who are not candidates for resection or transplantation, available treatment options include ablative therapies or systemic treatment. Ablative therapies for HCC include radiofrequency ablation (RFA), TACE, microwave ablation, percutaneous ethanol ablation, cryotherapy, radiotherapy, and yttrium-90 microspheres. TACE is a very useful therapy for patients not eligible for other regional therapies as it has been proven in several randomized trials to provide a significant survival advantage, increasing median survival from 16 to 20 months in a meta-analysis of these trials, with one of the largest studies showing a median survival of 34 months. While historically systemic chemotherapy treatments have been ineffective against HCC, the multikinase inhibitor sorafenib has been demonstrated to modestly improve survival in patients not eligible for other therapies. Clinical trials are ongoing to investigate the use of sorafenib, and similar directed molecular therapies, in adjuvant treatment of HCC.
The risk of a recurrent gallstone ileus is
about 5% to 10%.
Such recurrences usually occur within 30 days of the initial episode and are usually due to stones in the small intestine that were missed during the original operation.
cholecystectomyat the initial operation for gallstone ileus?
The consensus is that except in highly selected patients.
The arguments in favor of disconnecting the fistula and removing the gallbladder have been the possibility of recurrence of gallstone ileus and the risk of cholangitis due to reflux of intestinal content into the biliary tree.
