BILIARY & HEPATIC Flashcards
contrainidcations to Laparoscopic cholecystectomy
Open cholecystectomy should be ONLY used when there is contraindication to laparoscopic approach such as:
inability of the patient to withstand a general anesthetic,
severe bleeding disorders,
end- stage liver disease CAREFUL here - you would think you would want to stay minimially invasive - but if you get into bleeding you want to be open)
severe chronic obstructive pulmonary disease
congestive heart failure
extracorporeal shock wave biliary lithotripsy
has never been approved for gallstone dissolution by the U.S. Food and Drug Administration.
Gallbladder cancer increased risk
women (female-to-male ratio = 3:1),
peak incidence is in the seventh decade.
choledochal cysts have an increased risk of carcinoma developing anywhere in the biliary tree, but the incidence is highest in the gallbladder.
Answer A: The increased risk of gallbladder cancer with cholelithiasis is well established; 70% to 90% of all patients with carcinoma also have gallstones. However, less than 0.5% of patients with gallstones are found to have gallbladder cancer.
Answer B: The association of gallstones with carcinoma is probably related to chronic inflammation. Larger stones (>3 cm) are associated with a 10-fold increased risk of cancer.
Answer C: In the past, the finding of a calcified gallbladder wall, “porcelain gallbladder,” was associated with a high risk of cancer, in some series ranging from 25% to 60%. Thus, the recommendation was for all patients with porcelain gallbladder to undergo open cholecystectomy, even if asymptomatic. Recent series evaluating this issue, however, suggest that the risk of gallbladder cancer in patients with porcelain gallbladder has likely been greatly overestimated. In fact, although patients with limited areas of calcification of the wall may have a higher incidence of gallbladder cancer (7%), patients with diffuse calcification of the gallbladder wall, the classic presentation for porcelain gallbladder, do not appear to have an increased risk of gallbladder cancer.
Answer D: Large polyps, greater than 10 mm, have the greatest malignant potential. Therefore, if large (>1 cm) polyps are present, even in asymptomatic patients without stones, cholecystectomy is warranted.
gallbladder cancer tx
T1a lesion (i.e., has penetrated the LAMINA PROPRIA), the procedure is considered complete in that lymph node metastases are uncommon with T1 tumors (incidence < 10%).
T1b has penetrated the MUSCULAR layer - prob ably needs the works.
Lymph node metastases are present in 50% of patients with T2 lesions (i.e., tumors that have invaded the muscularis).
resection of segments 4b and 5 of the liver and dissection of the portal and celiac lymph nodes are recommended.
In more advanced stages of disease (T3 and T4),
in addition to what is required for T2 tumors, more extensive hepatic resections
—up to a trisectionectomy (resection of segments 4 through 8).
port-site implantation of tumor.
Therefore, when evidence of gallbladder wall thickening is noted intraoperatively, the gallbladder should be extracted in a sac.
From an oncologic viewpoint, it would seem ideal to resect the tissue around all trocar port sites. From a technical viewpoint, however, it would be very difficult and impractical to excise the full thickness of the abdominal wall circumferentially around four port sites, especially because the tract of the port site often is not at a 90° angle to the abdominal wall. If the gallbladder was extracted through a port site without having been placed into a bag, it is reasonable to attempt excision of that one port site.
Hepatic artery aneurysms that should undergo intervention.
ruptured,
symptomatic,
or
greater than 2 cm
In patients with a common hepatic artery aneurysm the treatment of choice is
ligation or embolization only (USUALLY)
sim principle that celiac trunk can be ligated
EXCEPIONS:
NO gastroduodenal artery (GDA), such as occurs after a Whipple procedure, a bypass is needed as there is no collateral flow from the superior mesenteric distribution if the GDA is not patent
Cirrhotic patients should also not undergo ligation only, as any ischemic compromise can be catastrophic
In patients with a proper hepatic artery aneurysm the treatment of choice is
Ligation of the proper hepatic artery requires a bypass procedure
The proper hepatic artery is more distal than any other collateral vessel that could supply perfusion to the liver.
According to the T stage for gb cancer
T1a is a tumor that invades the lamina propria (this is still mucosa)
T1b Tumor invades muscle layer
T2 Tumor invades perimuscular connective tissue; no extension beyond serosa into liver.
T3 Tumor perforates serosa (visceral peritoneum) and/or directly invades one adjacent organ or structure such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts.
T4 Tumor extends > 2 cm into liver or invades two or more adjacent organs (e.g., duodenum, colon, pancreas, omentum, or extrahepatic bile ducts).
The right and left liver are divided by
Cantlie’s line
line through the IVC and gallbladder
left lateral segments
II and III are most lateral
careful- this is most lateral for the left liver but is actually most medial in the patient’s body!
most posterior right segments
VI and VII
both on the pinky
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 III choledochal cysts
or choledochoceles
are 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
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 is advocated because this operative approach eliminates the potentially premalignant epithelial cyst lining and also separates the pancreatic drainage from the biliary drainage.
management if tumor arises in the gallbladder infundibulum
In this case, an extended liver resection and removal of a portion of the common bile duct (CBD) should be performed. Reconstruction is then performed by Roux-en-Y hepaticojejunostomy.
bile duct is often involved with tumor, either by direct extension or external invasion of the hepatoduodenal ligament.
