Gallbladder Flashcards
Does the gallbladder have a submucosa?
No, the gallbladder does not have submucosa.
Where do cystic veins drain?
Cystic veins drain into the right branch of the portal vein.
Where are lymphatics found in relation to the CBD?
Lymphatics are found on the right side of the CBD.
How does the gallbladder concentrate bile?
The gallbladder forms concentrated bile by active resorption of sodium by Na/K ATPase and then passive resorption of water.
What percentage of bile salts are reabsorbed?
95% of all bile salts are reabsorbed through enterohepatic recirculation.
Where does active resorption of conjugated bile salts occur?
Active resorption of conjugated bile salts occurs only in the terminal ileum (45%). (Na/K ATPase)
Conjugated bili is actively secreted to bile
Where does passive resorption of nonconjugated bile salts occur?
Passive resorption of nonconjugated bile salts occurs in the small bowel (mostly ileum) (40%) and colon (5%).
When is maximal gallbladder emptying observed?
Maximal gallbladder emptying is observed 2 hours postprandial.
What percentage of bile is secreted by hepatocytes?
Bile is secreted by hepatocytes (80%) and bile canalicular cells (20%).
What is the process of bilirubin breakdown?
Bilirubin is a breakdown product of hemoglobin in the spleen, converting from Hgb to Heme to biliverdin (green/yellow bruising) to unconjugated bilirubin, which then goes to the liver for conjugation back to bilirubin and then eventually enters the GUT.
What happens to bilirubin in the GI tract?
Bilirubin enters the GI tract, gets deconjugated into urobilinogen by bacteria, which is either converted to stercobilin (brown stool) or reabsorbed and converted to urobilin (yellow urine).
What occurs in obstructive jaundice?
In obstructive jaundice, less bilirubin enters the gut, resulting in less urobilinogen and urobilin in urine, and less stercobilin in stool, causing pale stool. more BILIRUBIN enters the urine (urine becomes dark and not light yellow)
This differs from hemolysis or GI bleed which would increase urobilinogen in urine and stercobilin in stool
What causes cholesterol stones?
Cholesterol stones are caused by stasis, increased water reabsorption from the gallbladder, calcium nucleation, and decreased lecithin and bile salts.
-Can also Form from terminal ileum resection: recycling of bile acids largely by absorption within the terminal ileum (ileocecectomy for Crohn)
Non-pigmented stones are the most common in the US.
-Micelles form: high bile salt, high lecithin, low cholesterol ratio
What are pigmented stones caused by?
Pigmented stones are caused by the solubilization of unconjugated bilirubin.
MC worldwide
Dissolution agents do not work here!!!
Where do black stones typically form?
Black stones almost always form in the gallbladder.
caused by hemolytic pathologies (sickle cell, beta thalassemia etc.), AND cirrhosis and TPN
What is the primary cause of brown stones?
Brown stones are primarily formed in the CBD due to E. coli producing B glucuronidase, which deconjugates bilirubin ->forms calcium bilirubinate.
- Also associated with parasites
- All these patients need a drainage procedure: ERCP with sphincterotomy. need to check for ampullary stenosis, duodenal diverticula, abnormal sphincter of oddi
What are the indications for cholecystectomy after HIDA CCK-CS test?
Indications include taking > 60 minutes for gallbladder to empty, EF < 40%, or if the gallbladder does not light up in 2 hours.
What are the indications to skip MRCP and go straight to ERCP?
Indications include CBD stone seen on US, clinical ascending cholangitis, bilirubin > 4, or dilated CBD > 6 mm AND bilirubin > 1.8 - 4.0.
Routine ERCP for dilated CBD OR elevated LFT with gallstone pancreatitis is discouraged, BC stone most likely passed and 5% complication rate
What is the most common complication following cholecystectomy?
Diarrhea is the most common complication following cholecystectomy due to excess bile salts in the colon.
What is Ursodiol used for?
Ursodiol is used only for stones < 2 cm, indicated in high-risk surgery or prophylaxis in patients with expected rapid weight loss.
What is the most reliable indicator of persistent duct stone in gallstone pancreatitis?
The most reliable indicator is persistent bilirubin elevation. #2 is alk phos
What should be done for CBD stones < 2 mm found intraoperatively?
CBD stones < 2 mm found intraoperatively should be left alone as they will pass on their own.
CBD obstruction found intra op Post op ERCP and sphincterotomy
- Unless really large that cannot undergo ERCP extraction laparoscopic CBD exploration
Retained CBD stone after gastric bypass (RYGB, billroth II) PTC tube with stone extraction (BEST) OR lap chole with CBD exploration (if GB present)
What is the treatment for retained CBD stones after T-tube placement?
Use choledochoscope through T-tube to remove the stone.
-If a patient presents with stones within a T-tube, the T-tube track must mature for at least 4-6 weeks prior to any instrumentation and stone retrieval
What are the complications of ERCP?
Complications include retroperitoneal perforation, bile duct perforation, and duodenal perforation.
- Retroperitoneal perforation- this is contained, and extraperitoneal. Tx: NPO and abx
- Bile duct perforation – place stent
- Duodenal perf (ONLY IF INTRAPERITONEAL) open repair
What is the treatment for emphysematous cholecystitis?
-Emphysematous cholecystitis: air present in gallbladder wall; 2ary infection of the gallbladder wall with gas-forming organisms; rarely crepitus in the abdominal wall adjacent to the gallbladder may be present; urgent cholecystectomy
Antibiotics used are penicillin G and clindamycin.
What is the first step in common bile duct exploration?
The first step is to obtain a cholangiogram and find the obstruction.
Blood supply to CBD is: RHA (9 o’clock) and GDA (3 o’clock)
What is the management for bile duct injury recognized postoperatively?
Control sepsis first, then place a percutaneous drain into the biloma.
Post op bile leak any patient who is septic, has peritonitis, or post op > 3 days never try to operate to do hepaticoJ first step is controlling sepsis place perc drain into biloma PTC vs ERCP operate in 6-8 weeks
- US is the first step to diagnose a post operative bile leak.
* If there is a fluid collection place a drain if bile you diagnosed a leak
* Depending on what you find
* ERCP vs PTC should be next step (unless below) Finds the site of the leak. If doing ERCP Type A through D injury place stent
* *** Bile duct ligations, clips placed on CBD/CHD or completely excised extrahepatic ducts CANNOT be diagnosed with ERCP. You need PTC here to define anatomy
* E.g. Post lap chole Find dilated intrahepatic ducts, cant see CBD, and no fluid collection completely blocked CBD due to a CLIP on it PTC + drain biloma then 6-8 weeks do hepaticoJ
- HIDA only for ones where you can’t drain the fluid or diagnosis is not 100%
- If a seg¬mental or accessory duct smaller than 3 mm has been injured and cholangiography demonstrates segmental or subsegmental drainage of the injured ductal system simple ligation of the injured duct is adequate.
- If the injured duct is 4 mm or larger, it is likely to drain multiple hepatic segments or the entire right or left lobe and thus requires operative repair.
What is the best test for jaundice not caused by stones?
MRCP is the best test for jaundice not caused by stones.
If CA not ruled out ERCP with brushings
What is the most common cause of biliary duct strictures?
The most common cause is ischemia due to laparoscopic cholecystectomy.
Biliary strictures without history of pancreatitis or instrumentation = CA until proven otherwise
Tx depends on the level of the strictue:
-Transhepatic or endoscopic dilation and stent placement: successful in about 50% of patients
-Roux-en-Y choledocojejunostomy or hepaticojejunostomy
What is the treatment for benign biliary strictures after cholecystectomy or liver transplant?
The treatment is ERCP and stent, which is the gold standard.
Months to years after operation the stricture forms
What is the management for cholangitis?
Resuscitate first with IV fluids and Zosyn (pseudomonas coverage), then perform ERCP. If ERCP fails, then place a PTC tube. If PTC tube fails then go to OR and place T tube
-Cholangitis -> decompression of the biliary system with ERCP & sphincterotomy and biliary stent
-Most common organisms: Escherichia coli, klebsiella pneumoniae, enterococci, bacteroides fragilis
-Charcot: fever, jaundice, RUQ pain
-Reynolds pentad: fever, jaundice, RUQ pain, shock, AMS
What is the #1 risk factor for gallbladder cancer?
The #1 risk factor for gallbladder cancer is large gallstones.
-Risk factors: chronic inflammation, porcelain gallbladder (much lower risk than previously thought), polyps > 1 cm, typhoid infection, primary sclerosing cholangitis, IBD
laparoscopy is contraindicated
Symptoms: #1 symptom is jaundice!
Remember, gallbladder does not have a submucosa
Can present as mid bile duct obstruction not caused by stones gallbladder CA until proven otherwise
Spreads to cystic nodes 1st
What is the staging requirement for gallbladder cancer?
All gallbladder cancer needs US and CT chest/abdomen/pelvis.
-If you find incidental GB mass on imaging, or polyp > 2 cm (this should be considered CA) these need to be evaluated by CT!!
What is the treatment for Stage Ia gallbladder cancer?
For Stage Ia (T1a), laparoscopic cholecystectomy is sufficient.
If you have done lap chole and get T1a: you’re done.
If Stage Ia, T1a (lamina propria = mucosa) (NO Muscle layer INVASION): lap chole
What is required for T1b (muscle layer) or T2 (peri-muscular) gallbladder cancer?
Extended (radical) cholecystectomy, resection of anatomical segment IVb/V with lymphadenectomy in porta hepatis and hepatoduodenal ligament.
Always start with diagnostic laparoscopy to rule inoperable tumor.
Cholecystectomy and resect anatomic segments IVb and V until clear margin.
Wedge resection is no longer supported; must do formal anatomical resection.
Always do lymphadenectomy: porta hepatis and hepatoduodenal ligament
Send cystic duct margin for frozen
If cystic duct margin is positive: need CBD/CHB resection (hepaticoJ) with hepatoduodenal lymphadenectomy
ONLY OPERATE IF NO METASTASIS (cystic nodal mets can still operate)
DO NOT RESECT PORT SITES
Adjuvant Chemo – gemcitabine and cisplatin or gemcitabine and capecitabine, for all > T1b
Roux-en-Y hepaticojejunostomy: connecting the hepatic duct to jejunum
What is cholangiocarcinoma associated with?
Biliary parasites (Clonorchis sinensis- liver fluke) and bacterial infections (salmonella).
Known risk factors for cholangiocarcinnoma: PSC, choledocochal cysts, biliary tract infection
What are cholangiocarcinoma precursors found on the bile duct?
Biliary intraepithelial neoplasia and intrapapillary neoplasm of the biliary duct.
BIN= microscopic diagnosis that evolves 2/2 chronic inflammation (from PSC, choledochal cysts, chronic viral hepatitis, alcoholic cirrhosis, pancreaticobiliary malunion). NO ADDITIONAL RESECTION.
What are the risk factors for cholangiocarcinoma?
Chronic pancreatitis, PSC, choledochal cyst.
What markers should be checked for cholangiocarcinoma?
Check CA 19-9 and CEA.
What are the types of perihilar cholangiocarcinoma?
(Klatskin tumor)
Type I - CHD
Type II - hepatic duct bifurcation
Type IIIa - confluence of ducts extending up R intrahepatic duct
Type IIIb - confluence extending up L intrahepatic duct
Type IV - confluence and R and L ducts -> neoadjuvant chemo then transplant
What is the first step in diagnosing a patient with jaundice?
RUQ ultrasound.
What is the best test for diagnosing cholangiocarcinoma?
MRCP is the best test for working up a stricture or bile duct mass.
What should be done if MRCP shows evidence highly diagnostic of cholangiocarcinoma?
Proceed with staging; you don’t need tissue for diagnosis, especially for Klatskin tumor.
What is the next step after MRCP?
Next step is ERCP/PTC with brushing or EUS with FNA.
If has obstructive jaundice then ERCP with stent and FNA is best
What is preferred for drainage in distal cholangiocarcinoma?
ERCP is preferred for drainage.
What is preferred for drainage in proximal cholangiocarcinoma?
PTC is preferred for drainage.
When should surgery be performed for cholangiocarcinoma?
Only do surgery if no mets/nodes, vessels (celiac nodes) and tumor is resectable.
Portal mets is NOT a contraindication.
What is indicated if functional liver remnant is < 25% or <50% (cirrhotic)?
Pre-op embolization on the side of tumor is indicated.
What is the treatment for intrahepatic cholangiocarcinoma?
Formal liver resection.
What is the treatment for proximal (Klatskin tumor) cholangiocarcinoma?
- Proximal (Klatskin tumor)- from cystic duct to hepatic confluence = MC TYPE
o Type I and II - resect entire extrahepatic ducts, cholecystectomy, portal lymphadenectomy and Roux en y hepaticojejunostomy
o Type III – require the above + liver lobectomy
What is required for Type III cholangiocarcinoma?
Resect entire extrahepatic ducts, cholecystectomy, portal lymphadenectomy and Roux en y hepaticojejunostomy + liver lobectomy.
What is the treatment for distal cholangiocarcinoma?
Distal ⅓ (Cystic duct to ampulla): Whipple procedure.
When is adjuvant chemotherapy indicated in cholangiocarcinoma?
Adjuvant chemo (capecitabine) only for positive margins or nodal disease.
When is transplantation considered in cholangiocarcinoma?
Generally only for unresectable hilar tumors <3 cm in size with negative sampled regional nodes and treated with neoadjuvant chemoradiation protocol.
Additional indications for liver transplant: Primary sclerosing cholangitis with resectable disease, and no contraindications for liver transplant.
What is adenomyomatosis?
Thickened nodules of mucosa; benign. No cholecystectomy indicated unless symptomatic.
Has Rokitansky Aschoff sinuses: epithelial invaginations (mucosa invagination into muscle); evidence of chronic cholecystitis, not pre-malignant.
What is porcelain gallbladder?
If found on US, need to get CT to work up porcelain gallbladder.
What is the risk associated with selective mucosal calcification in porcelain gallbladder?
Increased risk of cancer.
Selective mucosal calcification have increased risk of CA vs complete mucosal calcifications which do not
What should be done for symptomatic patients with porcelain gallbladder?
Cholecystectomy.
What should be done for asymptomatic patients with selective mucosal gallbladder calcification?
Laparoscopic cholecystectomy.
What should be done for asymptomatic patients with complete mucosal calcifications?
Laparoscopic cholecystectomy vs observation.
What is cholesterolosis?
Strawberry gallbladder caused by accumulation of cholesterol in GB mucosa; benign, no cholecystectomy indicated.
What is primary sclerosing cholangitis?
MC in males in 40s; 80% have IBD, especially UC.
-Inflammatory fibrosis of intra and extra hepatic biliary tree, strictures, string of beads -> biliary obstruction
jaundice, RUQ pain, pruritus, fever, weight loss, fatigue
tx= endoscopic dilation & stenting of dominant stricture
- Any GB polyps found in these patients needs cholecystectomy
- Many require biliary stenting
- Ursodeoxycholic acid will have normalize LFT and alk phos, but no survival benefit
What does primary sclerosing cholangitis lead to?
Cirrhosis, liver failure, biliary infection
-Risk for HCC, cholangiocarcinoma, and gallbladder cancer.
What is the gold standard for diagnosing primary sclerosing cholangitis?
MRCP.
What should be checked for high risk of cholangiocarcinoma in PSC patients?
Check CA 19-9.
What is the association of PSC with IBD?
Associated with IBD, especially UC.
Positive for P-ANCA.
What should all newly diagnosed PSC patients undergo?
Colonoscopy.
What is the treatment for liver failure in PSC?
Liver transplantation. 20% chance to recur with this
What is primary biliary cirrhosis?
Autoimmune condition affecting extra-hepatic biliary ducts. Associated with HCC
What is the diagnosis for primary biliary cirrhosis?
Anti-mitochondrial antibody then confirmed with biopsy.
What are the symptoms of primary biliary cirrhosis?
Pruritis, cholestatic jaundice, cirrhosis, xanthomas.
What is the treatment for primary biliary cirrhosis?
Liver transplantation; supportive treatment- : Ursodeoxycholic acid is 1st line, cholestyramine
What is granular cell myoblastoma?
Benign neuroectoderm tumor of gallbladder presenting with symptoms of cholecystitis; treatment is laparoscopic cholecystectomy.
What is the most common type of gallbladder polyp?
Cholesterol polyp.
Nearly 50% of all non-neoplastic gallbladder polypoid lesions are cholesterol polyps (cholesterolosis), resulting from epithelium covered, cholesterol-laden macrophages in the lamina propria.
When is laparoscopic cholecystectomy indicated for gallbladder polyps?
For polyps > 1 cm, with vascular flow into the stalk, symptomatic, with gallstones, > 3 polyps, or any polyp in primary sclerosing cholangitis.
-If over 18 mm, gallbladder CA until proven otherwise
-Over 6 mm= serial imaging
-Patient with asymptomatic cholelithiasis and a 5 mm gallbladder polyp. Next step?
-Cholecystectomy
-Risk of malignant transformation within gallbladder polyps has been linked to concurrent cholelithiasis; surgery recommended regardless of polyp size if concurrent stones
What are the risk factors for gallbladder polyps?
Age > 50, primary sclerosing cholangitis, Indian ethnicity, sessile polyp.
What is required for gallbladder polyps at the very least?
Follow-up ultrasound.
What is the risk associated with papillary adenoma?
Gallbladder polyp with risk of cancer; laparoscopic cholecystectomy is indicated.
When should cholecystectomy be performed for asymptomatic patients?
For > 3 cm stone, gallstones in pediatrics, sickle cell, long common pancreatic and bile duct channel, or any gallbladder polyp who also has PSC.
What is hydrops gallbladder?
Gallbladder mucocele due to long-standing obstruction; not inflammatory or infectious. No CA risk.
-bile salt resorption, mucus secretion; White bile
- It can rupture.
- US: thin walled GB, heavily distended. Impacted stones in neck.
What is the treatment for hydrops gallbladder?
Laparoscopic cholecystectomy.
What are the criteria for elective surgery in liver disease?
For Child A and Child B, and MELD < 15; OK to do elective surgery.
What is indicated for Child C or MELD > 15?
No elective surgery.
What is gallstone ileus?
Gallstone ileus:
-SBO 2/2 gallstone (typically= IC valve) resulting from cholecystoenteric fistula (usually fistula to duodenum from gallbladder fundus)
-Rigler triad: bowel obstruction, gallstone seen in intestine, pneumobilia on imaging
-Tx: enterotomy proximal to obstruction and milk stone back and remove through enterotomy; Avoid cholecystectomy and fistula takedown (increased morbidity)
What is Bouveret’s syndrome?
- Gastric outlet obstruction caused by impaction of gallstones in the pylorus or proximal duodenum. Migration of gallstone through choledochoenteric fistula.
May see Rigler’s triad: bowel obstruction, pneumobilia, ectopic gallstone
Tokyo guidelines
Severity of acute cholecystitis
CCK
CCK contracts GB
Functional gallbladder disorder (biliary dysinesia) criteria for dx
- ROME III Criteria below 1-8 is fulfilled, no gallstones or other pathology = functional gallbladder disorder
- HIDA scan < 40% EF = supportive criteria
Functional biliary sphincter of Oddi disorder criteria for dx
-ROME III Criteria below 1-8 is fulfilled, s/p cholecystectomy, no biliary stones
- Elevated LFT OR dilated CBD but not both LFT normalize between attacks
o Next step is sphincter of Oddi manometry
o Tx: ERCP with sphincterotomy
- If no elevated bili or dilated CBD don’t get manometry
Pregnancy
Pregnancy with acute cholecystitis – SAFE and okay to proceed with surgery during all trimesters. Riskier in 3rd trimester
Pregnancy with biliary colic: OK to proceed with surgery in all trimesters vs non-op.
-Symptomatic cholelithiasis in pregnancy:
-Higher rates of spontaneous abortion with non-op
-laparoscopic cholecystectomy during 2nd trimester
-Place ports via open Hassan technique
-Keep pneumoperitoneum as low as possible
-Place bump under right side to offload cava
RF for conversion of lap to open chole
males, elderly, repeated attacks, previous upper abdominal surgery, obesity, comorbid conditions, GBW thickness > 4 mm
Early <24 hours vs delayed cholecystectomy
Early <24 hours vs delayed cholecystectomy for acute chole has shorter hospital stay. No difference in complications, morbidity/mortality
Child A or B
Child A or B, NOT C– safe to undergo laparoscopic chole for symptomatic cholelithiasis/acute chole. Don’t do open
For child A and child B, and MELD < 15 OK TO DO ELECTIVE SURGERY proceed with lap chole
CHILD C or MELD > 15 NO ELECTIVE SURGERY
Common bile duct exploration
Indicated for patients who have failed or are not candidates for ERCP or PTC
1st try trans-cystic common bile duct exploration
- Fastest, safest, easiest
- Remember 1st step is to obtain cholangiogram and find the obstruction. Then flush biliary duct with saline and give IV glucagon to try to push stones down.
- If that doesn’t work, you can advance a Fogarty balloon catheter down to the duodenum, blow it, and pull it back
- Can dilate cystic duct if stone too big
- Cystic duct must be > 4 mm
- Won’t be able to get stones in CHD
- Contraindicated if > 8 stones, > 1 cm stone, CHD stone, or cystic duct that cannot be dilated
- Use Endo-loop to close the cystic duct stump when done vs a clip. It provides the most secure closure.
Choledochotomy
Choledochotomy
- Only used if failed trans-cystic CBD exploration and ERCP
- Incision should be made 1-2 cm distal to cystic duct on CBD anterior portion. Do this to avoid proximal bile duct stenosis which is more complex to fix
- Higher risk of CBD stricture and thus if CBD is < 6 mm there is very high risk for stricture and should not pursue choledochotomy if this is the case, just place a percutaneous cholecystostomy tube (will only work if cystic duct is patent)
- Used for stones in the CHD
- Used for large stones that you can’t pull out the cystic duct > 10 mm
- Create 1 cm longitudinal incision
- You can use a balloon or wire basket to retrieve stones
- If patient is septic and really sick intra-op just place T-tube for decompression and close, don’t go after stones
- Place a T-tube when done for choledochotomy
Trans-duodenal sphincteroplasty is used when all other methods have failed because of such high morbidity
- Has decreased incidence of restenosis when compared to ERCP
Bile duct injury recognized intra-op
- Intra operative bile duct injury (MC = complete transection of CBD):
- If you suspect an injury intra-op 1st step is to perform a cholangiogram. Don’t convert to open.
- Should not be repaired unless the person is a skilled HPB surgeon
- If in outpatient or not skilled, place drains and transfer to tertiary center
- If < 3 mm duct –> ligate
- If injury not caused by electrocautery and involves < 50% of the circumference, can do primary repair with T tube through exiting THROUGH the repair
- Any thermal injury or > 50% circumference –> will need resection of duct injury area and anastomosis (hepaticoJ)
- (Very unusual) if injury < 1 cm in length and > 1 cm from hepatic duct bifurcation –> end to end anastomosis. This needs a T tube that has to exit through ANOTHER choledochotomy. However, this has a high rate of stricture when compared to hepticoJ
- Should never have T tube exit the site of anastomosis
- Any injury < 1 cm to hepatic bifurcation or > 50% circumference –> hepaticoJ
If you have stricture at the hepaticojejunostomy site–> treatment is PTC and dilation
Strasberg-Bismuth classification defines
Type A ERCP, stent, sphincterotomy
Type B or C often do not require operative intervention unless septic/cholangitis
Type D – If caused by thermal source (need to transect back to healthy tissue first) then hepaticoJ
Type E – all require hepaticoJ
-More than half bile duct injuries unrecognized intraoperatively present within the first month.
-Can go undetected for years until stricturing, cholangitis, cirrhosis occurs.
5 months after lap chole for gangrenous cholecystitis (difficult gallbladder= increased chance of bile duct injury) now with sx of obstruction= hyperbilirubinemia, elevated LFTs, RUQ abdominal pain, itching
Palliation of malignant biliary obstruction
- Metal stents have better patency over silastic, and are able to be 4 times larger in diameter
- Plastic stents need to be changed every 3 months but are cheaper
- MCC of obstruction in metal stent tumor ingrowth
- MCC obstruction in silastic stent sludge
- Silastic stent can migrate
- Both cause pancreatitis and cholecystitis as complications
Hemobilia
Hemobilia- fistula between bile duct and hepatic arterial system
Hematemesis, jaundice, RUQ pain (triad)
Usually 2/2 to trauma or PC liver instrumentation MCC PTC tube, or after lap chole
Dx: Angiogram (best= localize bleeding), but usually start with EGD for w/u of UGIB: find blood out of ampulla of vater
Tx: transarterial embolization
Gallstone pancreatitis
Cholecystectomy:
-During index admission after clinical pancreatitis resolves
-Severe cases with significant peripancreatic fluid collections-: interval cholecystectomy at 6 weeks; ERCP with sphincterotomy to reduce risk of complications during waiting period
-Post-cholecystectomy pain:
-Immediate: bile leak, bile duct injury, retained CBD stone
-Delayed: biliary stricture, spilled gallstones, remnant gallbladder, cystic duct stones
-Functional: sphincter of Oddi dysfunction- caused by stenosis of the pancreatic CBD/the sphincter of Oddi- colic type symptoms + normal RUQ US following cholecystectomy; manometry= high pressures at biliary sphincter
Prophylactic Cholecystectomy for Asymptomatic Cholelithiasis:
-Hemolytic disorders: sickle-cell, hereditary spherocytosis -> chronic hemolysis -> hyperbilirubinemia -> bile stones (black; pigment)
-Large stones > 3 cm
-Porcelain gallbladder
-Gallbladder polyps > 1 cm (> 6 mm with risk factors: increase in size, sessile, sx, PSC, native american, > 50 y.o., concurrent gallstones)
-Anomalous pancreatic ductal drainage/ long common channel between bile & pancreatic ducts (risk for developing gallbladder cancer)
-Surgical management of neuroendocrine tumors that will require octreotide treatment
-Transplant of liver allograft/ prior to any major organ transplant
-children with gallstones typically develop symptoms- early consideration for cholecystectomy
-on immunosupression? cholecystitis can be lifethreatening
Mirizzi syndrome
-Common hepatic duct obstruction secondary to EXTERNAL compression by an impacted stone in the gallbladder neck or cystic duct. Can also be due to chronic inflammation arising from the gallbladder or cystic duct next to common hepatic duct.
-Associated with gallbladder cancer
4 types; type 3 requires Roux-en-Y hepaticojejunostomy; type 4 requires cholecystectomy + Roux-en-Y hepaticojejunostomy
-Management of Mirizzi syndrome depends on the presence and extent of the cholecystobiliary fistula. In cases where a fistula is absent or involves less than 1/3 the circumference of the common bile duct (CBD), cholecystectomy can be performed.
When there is a small fistula, the CBD is repaired primarily, usually over a T-tube.
For larger fistulas, a cholecystectomy with biliary enteric anastomosis procedure such as Roux-en-Y hepaticojejunostomy is recommended.
Acalculous cholecystitis
best initial test= RUQ US, if still unclear then HIDA
-On US: gallbladder wall distension, gallbladder wall thickening, pericholecystic fluid, intraluminal sludge
Choledocholithiasis
-Strong suspicion (CBD stone on imaging, clinical cholangitis, bilirubin > 3, dilated CBD > 6 mm)= preop ERCP for duct clearance; IOC + CBD exploration
-Moderate suspicion (abnormal liver tests other than bili, mild elevation in bili, clinical gallstone pancreatitis): MRCP or IOC
-CBD stones identified during IOC: flush + glucagon up to twice
-If small stone and large enough cystic duct: transcystic CBD exploration using fluoroscopic guidance or choledochoscope
-For small common bile duct stones ( < 3-4 mm in diameter), saline injection should be attempted to flush the stones into duodenum. IV administration of 1 mg of glucagon (can be repeated once if necessary/unsuccessful) can help relax the sphincter of Oddi and facilitate the passage of small stones. 4 minutes following glucagon administration, the cystic duct is again flushed with saline. Repeat cholangiogram. If duct not clear: Fogarty balloon catheter or stone retrieval basket inserted through cholangiogram catheter into common bile duct.
-Hx of Roux-en-Y: ERCP difficult to access the papilla using a standard duodenoscope due to length of bowel that must be traversed; laparoscopic cholecystectomy with intraoperative cholangiogram
Biliary obstruction/ cholestasis
decreased delivery of bilirubin into intestine; as it worsens conjugated hyperbilirubinemia develops -> jaundice; malabsorption of fat-soluble vitamins occurs with cholestasis= D, E, A, K
-Poor absorption of vitamin K in the gut due to absence of bile= deficits of vit k dependent clotting factors
-Vitamin D deficiency= osteomalacia
-Vitamin A: night blindness
-Vitamin E: neuromuscular weakness
Open common bile duct exploration:
anterior, longitudinal choledochotomy to access obstruction; once stone removed, T-tube placed to prevent strictures, CBD closed over T-tube with absorbable sutures; T-tube removed in 2 weeks if tube cholangiogram demonstrates patency without a leak; blood supply to CBD at 3 and 9 o’clock positions
Cystic artery
High incidence of anatomic variability. Normally passes posterior to the common hepatic duct. Double cystic arteries in up to 10% of patients.
**
Injury to the proximal common bile duct with >50% diameter or tissue loss
Usually present with biloma in RUQ
-For any injury to the CBD with ductal tissue loss or when > 50% of the duct is involved:
-Distal CBD injury= Roux-en-Y choledochojejunostomy= connects the common bile duct to the jejunum
-Proximal CBD injury= Roux-en-Y hepaticojejunostomy= connects hepatic duct and the jejunum
Transductal common bile duct exploration vs trancystic CBDE?
-Transductal: accesses CBD through the cystic duct
-Transcystic: accesses the CBD through the gallbladder
Transcystic prefferred: less bile leak, biliary stricture, pancreatitis, length of postopertive stay
Common hepatic duct exploration
-Primary choledocholithiasis: arise in bile duct (not passed from gallbladder)
-If stones found on IOC need common hepatic duct exploration via incision in common bile duct (can’t access stones in hepatic duct via trancystic route becasue of angle)
-Contraindication via trans-CBD approach is small common duct (< 7 mm)= strictures on closure
-If too small: then can do open bile duct exploration, percutaneous transhepatic billiary draine and stone extracction, or postoperatie ERCP
Percutaneous cholecystostomy
-Minimum duration of drainage 3-6 weeks: to allow for tract to develop
-Then: cholangiogram to assess duct patency
-Then when recovered/ optimized for surgery: cholecystectomy + tube removal
-Transhepatic or transperitoneal route
If laparoscopic CBDE fails
-Can do open CBDE with either transduodenal sphincteroplasty or biliary-enteric drainage (preferred when multiple stones and dilated CBD > 2 cm)
- Choledochoduodenostomy via side-to-side anastomosis between supraduodenal CBD and duodenum; kocher maneuver to expose distal CBD
- Transection choledochoduodenostomy with end-to-side anastomosis of transected CBD to duodenum
- Roux-en-Y choledochojejunostomy
Sphincteroplasty: 1cm incision of sphincter musculature at ampulla along anterosuperior border (opposite of pancreatic duct): allows passage of stone
Lab tests and associated pathology
Elevated total bilirubin has the best predictive value for diagnosing biliary obstruction
