GALLBLADDER

Question 1

How do gallstones form?

Answer 1

four conditions for GS formation

• 1 super saturation of bile with cholesterol
• 2 gall bladder hypomotility
• 3 cholesterol nucleation
• 4 mucus hypersecretion in the GB traps the crystals allowing their agglomeration into stones

Question 2

What is the pathophysiology of acute cholecystitis?

Answer 2

4 steps (4 I’s) = impaction, irritation, inflammation, infection

Impaction

• Cystic duct obstruction

Irritation

• Lysolecithin produced irritates GB
• GS impaction causes trauma to gallbladder wall activating phospholipase A which converst lecithin to lysolecithin

Inflammatory mediators released

• PGE2, PGI2

Ischaemia

• bladder dysmotility leading to distension & ischemia

Infection

• Secondary bacterial infection if ongoing obstruction

Question 3

What are the causes of GB polyps?

Answer 3

Benign

• cholesterolosis
• adenoma
• adenomyomatosis
• lipoma
• inflammatory

Malignant

• adenocarcinoma
• SCC
• cystadenoma

Question 4

How do you manage a patient with GB polyps?

Answer 4

Surgery if

• Symptomatic (biliary type pain, pancreatitis, ? PSC = controversial)
• Stones
• Size > 10 mm or increasing on surveillance

Serial imaging if 6-9 mm

• repeat ultrasound in 6/12
• if stable then U/S annually

Type of surgery depends on size

• > 20 mm
  
  • open cholecystectomy, partial liver resection and lymph node dissection
• <20 mm
  
  • laparascopic cholecystectomy + IOC

Question 5

What is Todani’s classification of choledochal cysts?

Answer 5

Type I

• fusiform/saccular dilatation of CBD

Type II

• CBD diverticulum (supraduodenal)

Type III

• choledochocele

Type IV

• IVa = intra + extrahepatic cyts
• IVb = intrahepatic cysts only

Type V

• Caroli’s disease

Question 6

Managment of choledochocal cysts

Answer 6

Extra-hepatic

• Cholecystectomy, Resection of EH bile duct/cyst & reconstruction

Intra-hepatic

• Segmental resection (if possible) or liver transplant

Intraduodenal

• Sphincterotomy = small
• Transduodenal resection = large/malignant

Question 7

Pathogenesis of cholangitis?

Answer 7

Four mechanisms keep bile sterile

• Sphincter of Oddi prevents reflux of bile from duodenum
• Unimpeded efflux of bile from CBD
• Immunoglobulin A in bile acts as an anti-adherence factor preventing bacterial colonization
• Bacteriostatic properties in bile

If any of these 4 mechanisms is disturbed, then cholangitis can develop and the organisms typically ascend from the duodenum.

Biliary obstruction causes

• increased permeability of bile ducts with resultant translocation of bacteria from portal circulation into biliary tree.
• Decreased production of IgA and Kupfer cells

Question 8

Strasberg classification of BDI

Answer 8

(A) Bile leak from cystic duct stump or minor biliary radical in gallbladder fossa.

(B) Occluded right posterior sectoral duct (ie. b for both ends)

(C) Bile leak from divided right posterior sectoral duct.(only 1 end clipped, other end draining freely)

(D) lateral injury to EHBD

(E1) Transected main bile duct with a stricture more than 2 cm from the hilus.

(E2) Transected main bile duct with a stricture less than 2 cm from the hilus.

(E3) Stricture of the hilus with right and left ducts in communication.

(E4) Stricture of the hilus with separation of right and left ducts.

(E5) Stricture of the main bile duct and the right posterior sectoral duct.

Question 9

How do you manage GB cancer?

Answer 9

T-STAGE dictates treatment

T1a = Lamina propria

• Simple cholecystectomy

T1b-2 (1b = Muscular layer, T2 = subserosa)

• Extended cholecystectomy with en bloc resection of of liver segments IVb/5
• Regional lymphadenectomy

T3 = Penetrates serosa or adjacent organs (duodenum, colon, pancreas, stomach), extrahepatic bile ducts

• As above +/- R hepatectomy, bile duct excision, Roux-en-Y HJ

T4 = major vessel/organ invasion

• jaundice – stenting (ERCP/PTC) or surgical bypass to segment III of liver
• chemotherapy –multiple regimes (gemcitabine + oxaliplatin)

OTHER KEY FACTORS

cystic duct stump margin

• Positive margins (R1) = regional lymphadenectomy + extrahepatic bile duct resection
• Negative margins (R0) = regional lymphadenectomy (bile duct resection not required)

Port site extraction

• extraction site, mode of gallbladder extraction, and occurrence of perforation may impact the decision to resect trocar sites at the time of subsequent operation
• resection is unlikely to improve survival;

Question 10

What are the contraindications for transcystic CBD exploration?

Answer 10

Conditions for unsuccessful and safe transcystic laparoscopic CBD exploration include

size of the ducts

• CBD diameter >6 mm
• Cystic duct diameter <4 mm

size of the stones

• stones >1 cm

Location of the stones

• Stone location proximal to the cystic duct/CBD junction

Number of stones

• >6-8

Question 11

What does bile consist of?

Answer 11

• Water(97%)
• bile salts(0.7%)
  
  • 40% cholic!acid!(cholate)
  • 40% chenodeoxycholic acid (chenodeoxycholate)
  • 20% deoxycholic acid (deoxycholate)
• Lecithin (0.1%)
• Cholesterol (0.06%)

Question 12

what are the risks if incidental gallstones are observed?

Answer 12

0.1%

• mortality for elective laparoscopic cholecystectomy
• risk for developing gallbladder cancer per decade

0. 3-1%
   * risk for becoming symptomatic annually

2%

• will present with complicated cholelithiasis (cholecystitis, pancreatitis) once they become symptomatic

Question 13

What are the predictors of successful of transcystic CBD exploration

Answer 13

Conditions for successful and safe transcystic laparoscopic CBD exploration include

●CBD diameter <6 mm

●Stone location distal to the cystic duct/CBD junction

●Cystic duct diameter >4 mm

●Fewer than 6 to 8 stones within the CBD

●Stones smaller than 10 mm