BILIARY Flashcards
Types of choledochal cysts
I fusiform - Hepatico J II sacular - just resect if no cancer III periampullary - papillotomy and stent - if in older patient decrease risk of malignancy IV involves liver and duct V hepatic
Management of common bile duct injury
If identified at the time of operation in less than 50% of the circumference
AND right hepatic artery is open and unmolested
Primary repair 50 PDS
Separate T-tube separate ductotomy
Otherwise, hepatico-J at the bifurcation.
Management of gallbladder cancer
if resectable –> chole + en block hepatic resection + LAD (including porta hepatis, gastrohepatic ligament, retroduodenal) +/- bile duct excision
Stage I :
T1a:
Tumor invades lamina propria mucosa
simple (open) cholecystectomy, lymph node biopsy, frozen section
T1b:
Tumor invades muscular layer OF MUCOSA
Radical cholecystectomy:
- removal of the gallbladder
- plus at least 2 cm of the gallbladder bed,
- dissection of the regional lymph nodes)
cystic duct (Calot's) node pericholedochal hilar peripancreatic duodenal, periportal celiac SMA nodes
CBD obstruction and resultant jaundice
• • Stage II: T2 perimuscular connective tissue – cholecystectomy – segmental hepatectomy (4b, 5) – lympatic resection – en bloc resection of involved organs
Stage III
T3 perforates serosa or invades liver
N1 cystic duct, cbd, hepatic artery, PV (nodes not encasement)
This is aggressive:
Radical Cholecystectomy
Segmental resection (IV, V, VIII)
trisegmentectomy (IV, V, VI, VII, VIII),
extrahepatic CBD
en bloc resection involved viscera
pancreaticoduodenectomy,
hepatectomy
(morbidity 50%, mortality 20%)
Contraindications four surgery of gallbladder cancer
Contraindications to surgery:
extensive involvement of hepatoduodenal ligament
encasement or occlusion of major vessels
mets liver, peritoneal, distant metastases ascites
patient status
No role for debulking surgery, only do curative surgery
critical view of safety
may need to disect GB out of liver a little
dome retracted to cephalad
Infundibulum attracted lateral
Dissections carried out following the cystic artery and cystic duct onto the gallbladder.
When no other structures can be seen posteriorly the critical give safety is been achieved
Cystic artery and cystic duct clipped and divided hugging my gallbladder
Amount of glucagon given during cholangiogram for Stone
1 mg
What part of papilla is incised for trans duodenal sphincter up last
10 o’clock
Longitudinal duodenal incision transverse closure
Culture bile
(possibly send a pathology)
MELD needed to get on the transplant list for primary sclerosing cholangitis
15
Type II choledochal cysts
isolated diverticulum protruding from the common bile duct.
simple cyst resection only.. Biliary reconstruction is typically not required - Ped Surg 2012 (vs This can be performed with extrahepatic biliary resection and Roux-en-Y reconstruction or complete excision with primary closure over a T tube Cameron 2014)
Type I and IV choledochal cysts
dilations in the extrahepatic and/or intrahepatic bile ducts.
These types of choledochal cysts are associated with
recurrent cholangitis,
progressive liver damage
high risk of cancer.
The choledochal cyst wall is the primary location of carcinomas.
The current surgical strategy of cyst excision with Roux-en-Y jejunostomy
advocated because this operative approach eliminates the potentially premalignant epithelial cyst lining
also separates the pancreatic drainage from the biliary drainage.
Type III choledochal cysts
” or choledochoceles”
NOT a cancer operation!
intraduodenal
or
intrapancreatic
dilations of the distal common bile duct.
associated with cholangitis and pancreatitis due the build up of protein.
Management has traditionally been transduodenal marsupialization of the cyst.
Increasingly choledochoceles are being treated by sphincterotomy or cyst marsupialization during an ERCP
treatment for primary sclerosing cholangitis
no 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,
aggressive surgical approach is advocated for most symptomatic patients with primary sclerosing cholangitis
surgical approach for primary sclerosing cholangitis
TRANSPLANT!
Liver transplantation should be considered before the disease is too advanced.
Primary sclerosing cholangitis has become one of the most common indications for liver transplantation in the United States.
One surgical approach, in patients with a dominant stricture of the hepatic duct bifurcation:
resection of the bifurcation
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.
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.
Cholangiocarcinoma Risk factors
35 year old female with biliary construction in painc
choledocal cyst fusiform
Path is ambiguous
Resect to negative margin
Frozen is positive near pancreas
Hepatico J
T stage for gallbladder cancer
T1 a mucosa T1 B submucosa T2 muscularis propria's T3 subserosa T4 serosa
