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.
treatment of Tumors arising in the fundus of the gallbladder
treated with limited hepatic resection without excision of the CBD.
To clear the lymph nodes in the porta hepatis, complete lymphadenectomy should be performed, skeletonizing the CBD, hepatic artery, and portal vein.
Absolute contraindications to laparoscopic cholecystectomy include
inability to tolerate general anesthesia, gallbladder cancer (suspected or confirmed), and a “frozen upper abdomen” due to previous surgery or peritonitis.
Relative contraindications to laparoscopic cholecystectomy include
relative contraindications include
coagulopathy,
portal hypertension,
cholecystoenteric fistula,
any previous right upper quadrant surgery,
advanced acute cholecystitis,
pregnancy (during first and third trimesters)
A heterogeneously enhancing hepatic lesion most likely represents
an incidentally found hepatic adenoma.
Patients with colon cancer with metastatic lesions to the liver are eligible for resection of their liver lesions as long as
no evidence of extra hepatic disease.
sufficient liver parenchyma
patients benefit most when tumor-free margins greater than 1 cm are achieved.
Peripheral and centripetal enhancing hepatic lesions are most consistent with
cavernous hemangiomas.
These lesions do not need to be resected unless they become symptomatic.
hepatocellular carcinoma staging
VASCULAR invasion is part of staging!
size,
node status,
metastasis.
-T1
ANY solitary tumor regardless of size
NO vascular invasion.
-T2 solitary tumors WITH vascular invasion or multiple tumors if all < 5 cm.
-T3
multiple lesions > 5 cm
or
tumor invasion of a major branch of the portal or hepatic veins.
-T4 invade adjacent organs BUT invasion into GALLBLADDER does NOT COUNT or perforate the visceral peritoneum.
T2 hepatocellular carcinoma lesions are
solitary WITH vascular invasion
or
multiple and less than 5 cm in size.
Benign gallbladder tumors are most frequently
Cholesterol polyps (cholesterolosis)
or
polypoid lesions.
The incidence of polyps in asymptomatic patients is about 5%.
Cholesterol polyps
result from epithelium-covered,
cholesterol-laden macrophages in the lamina propria.
likely a result of an error in cholesterol metabolism.
They extend from the mucosa on a narrow stalk, grossly appearing as yellow spots on the mucosal surface.
Nearly all are multiple,
most are less than 10 mm in size.
Gallbladder adenomas
considered premalignant!
direct association between benign adenoma,
adenoma containing carcinoma in situ,
and invasive carcinoma
tubular or papillary,
both arising from the epithelial layer of the gallbladder.
Multiple papillary adenomas, or papillomas, are called papillomatosis.
Adenomyomatosis of the gallbladder
hyperplastic extensions of the mucosa into, and often beyond, a hypertrophied gallbladder muscular layer.
localized or diffuse
gallbladder Hyperplasia
This lesion MAY be premalignant, because cases of adenocarcinoma arising in or near adenomyomatosis have been reported, but this relationship is unclear.
Hyperplasia
outpouchings of the mucosa of the gallbladder through the wall
(Rokitansky-Aschoff sinuses)
and through the crypts of Luschka.
result in focal thickening of the gallbladder wall, resembling gallbladder adenocarcinoma.
The etiology is unknown.
Multiple papillomas also have been reported throughout the intrahepatic and extrahepatic biliary tree
termed multiple biliary papillomatosis.
these tumors have little, if any, malignant potential.
Although local recurrence and progression to death from obstructive jaundice and cholangitis occur frequently in these rare cases,
The only modality used to measure intracranial pressure (ICP) in patients with fulminant hepatic failure
invasive monitoring epidural, subdural or intraventricular catheters.
Not contraindicated until INR > 5!
This patient population always has an elevated INR due to their liver dysfunction and it cannot be used as a contraindication to invasive ICP monitoring.
Aggressive treatment of elevations in ICP is necessary for these patients to survive along with liberal use of blood products for thrombocytopenia and INR >5.
Non-invasive testing such as CT, MRI, EEG and transcranial Doppler flow has not proven to reliably detect this condition.
