BILIARY

Question 1

Prophylactic lap chole

Answer 1

proph does NOT equal incidental

True proph for:
Gallstones and TPN without ssx
Possible heart transplant
NOT for renal transplant
NO for bariatric

INCIDENTAL for:
hemotologic: 
sickle cell
AND
hereditary spherocytosis 
with ASX gallstones

MAYBE:
incidental if overy 70 and doing GI surgery
if needed in AAA

Question 2

Gallbladder wall thickening

Answer 2

4 mm

Question 3

define early lap chole for acute chole

Answer 3

36 h

Question 4

if survive choecystostomy tube how long is it left in place

Answer 4

3 mo!

then contrast to assess patent cystic duct

if duct patent:

remove tube

assess if candidate for elective chole

Question 5

Gallbladder cancer risks

Answer 5

stone > 2.5 cm
polyp > 1-1.5 cm
porcelain gb

Question 6

culture of acute chole bile

Answer 6

STERILE usually

Question 7

Most common bacteria of gallbladder necrosis

Answer 7

e coli
kleb
enerococcus
enterobacter

Question 8

critical view of safety

Answer 8

retract glabladder superior
retract infundibulum laterally

to see:
liver edge,
gallbladder,
cystic duct

wither attachemnts taken down - the only 2 structures remaining are:
cystic artery
cystic duct

Question 9

treatment of acute chole during first or third trimester of preg

Answer 9

“conservative treatment with intravenous abx is preferred with delay of chlecystectomy until either the second trimester or postpartum”

In sever cases ofcourse, still need immediate cholecystectomy

Question 10

give what to relax sphincter of oddi

Answer 10

glucogon

Question 11

T1 gallbladder cancer

Answer 11

Confined to the muscularis propria

now penetrated through the muscularis propria

Cholecystectomy simple alone

If margins positive:
Liver bed resection if liver is positive

Cystic duct stump positive excision of common bile duct including confluence of the cystic duct

NO nodal dissection needed

Question 12

T2 gallbladder cancer

Answer 12

Invade into the subserosa

But NOT into serosal plane

In the muscular coat but not into the serosal plane

Extended radical cholecystectomy includes liver resection of IVb and 5
Regional lymph node dissection
Removal of peri-portal, peripancreatic, celiac nodes

the requires a full Coker maneuver with lymphatic tissue behind duodenum, pancreas dissected with removal of aortocaval nodes and superior mesenteric nodes

Common bile duct transected as it courses posteriorly to the duodenum into the pancreas

Portal vein and hepatic artery skeletonized

Confluence of right and left hepatic ducts divided

Roux-en-Y hepaticojejunostomy

Excision of all laparoscopic port sites full-thickness

Alternative-2 cm wedge excision

The

Question 13

T3-T4 gallbladder cancer treatment

Answer 13

abdomen therapy not proven

maybe for positive nodes

Question 14

T groups for gallbladder cancer

Answer 14

TX: No description of the tumor’s extent is possible because of incomplete information.

T0: No evidence of primary tumor.

Tis: Cancer cells are only found in the epithelium (the innermost layer of the gallbladder) and have not grown into (invaded) deeper layers of the gallbladder. This is also known as carcinoma in situ.

T1: The tumor has grown into the lamina propria or the muscle layer (muscularis).

T1a: Tumor has grown into lamina propria.
T1b: Tumor has grown into the muscularis.

T2: The tumor has grown into perimuscular fibrous tissue.

T3: The tumor has grown through the serosa (the outermost covering of the gallbladder) and/or it has grown from the gallbladder directly into the liver and/or one nearby structure such as the stomach, duodenum (first part of the small intestine), colon, pancreas, or bile ducts outside the liver.

T4: The tumor has grown into one of the main blood vessels leading into the liver (portal vein or hepatic artery) or it has grown into 2 or more organs outside of the liver.

Generally speaking, most doctors think T3 tumors are potentially resectable (removable by surgery), while T4 tumors are not. However, there can be other factors that affect whether surgery is a good treatment option in any given case.

Question 15

The gallbladder wall has several layers. From the inside out, these are:

Answer 15

The epithelium, a thin sheet of cells closest to the inside of the gallbladder (very inner / superficial surface of the mucosa) [Tis]

The lamina propria, a thin layer of loose connective tissue (the epithelium plus the lamina propria form the mucosa) [T1a]

The muscularis, a layer of muscular tissue that helps the gallbladder contract [T1b]

The perimuscular (“around the muscle”) fibrous tissue, another layer of connective tissue [T2]

The serosa, the outer covering of the gallbladder that comes from the peritoneum, which is the lining of the abdominal cavity [T3]

Invades other structures [T4]