Gallbladder Disease Flashcards
What is the incidence of choledocholithiasis if cholangiogram done routinely at time of cholecystectomy (with nL lab values)?
10%
What is the incidence of retained stones after cholecystectomy despite nL lab values?
1-2%
What percent of cholangitic people present with Charcot’s triad?
15-20%
Charcot’s triad / Reynold’s pentad?
Jaundice, RUQ pain, fever / +hypotension +AMS
How do you diagnose choledocholithiasis?
RUQ US = CBD > 6-8 mm, hepatic function panel, EUS (can proceed to ERCP), MRCP (may not detect stones/sludge < 6 mm).
What is the treatment of choledocholithiasis?
ERCP with sphincterotomy of deep Oddi muscles (if CI (bleeding risk), can do balloon dilation of ampulla), basket or balloon stone removal. Early cholecystectomy. (>48-72 hours)
What is the rate of success of ERCP for choledocholithiasis?
75% 1st time, 90% 2nd time.
What size CBD stone will pass spontaneously?
1cm or smaller
Balloon vs basket removal of CBD stone?
Basket = dilated duct with multiple stones
Balloon = normal ducts or single free floating stones
Mechanical lithotripsy = when multiple or large stones
What is the rate of ERCP complications?
10%
What are the types of ERCP complications?
Recurrence (MOST COMMON), pancreatitis, perforated bowel/duct, bleeding, infection, papillary stenosis (sphincterotomy), cholangitis
Timing of cholecystectomy after choledocholithiasis ERCP?
Within 2 weeks to decrease risk of recurrent biliary events and conversion to open cholecystectomy.
Before patient leaves the hospital.
What do you need for intraoperative cholangiogram and subsequent intervention?
0.0035 inch guidewire, water soluble contrast, 3-5Fr biliary fogarty catheter, wire basket, 8mm balloon, 7-12Fr dilators, 3-5 mm choledochoscope with 1.1mm or larger channel, loop ligatures and T tubes, C arm (left side).
How do you improve visualization during intraoperative cholangiogram?
To see proximally, IV morphine (contract sphincter of Oddi), occlude distal bile duct, Trendelenberg positioning.
Then to see distally, IV glucagon (relax sphincter)
When is a transcystic CBD exploration indicated?
Preferred in pt with small stones < 1cm, duct < 6mm, stone location DISTAL to junction of cystic/CBD and cystic duct > 4mm*.
Cannot do for CHD stones.
How do you perform a transcystic CBD exploration?
After confirmatory IOC, duct cannulated with wire.
Dilate or balloon the duct.
Flush CBD with saline DISTALLY (not proximally - don’t push stones up to liver).
Use balloon catheter 3-5Fr, advance into DUO, retract inflated balloon to ampulla, deflate/withdraw/inflate to pull back the stones.
Withdraw catheter SUPERIORLY along axis of CBD.
Try BASKET retrieval if balloon fails via scope (dilate if needed).
Finish with irrigation and then completion cholangiogram.
Close the cystic duct with loop > clip ligation.
if cannot visualize hepatic ducts on IOC?
- pull catheter back and flush
- trendelenberg reimage
What is the indication to make a direct choledochotomy laparoscopically in CBD exploration?
Narrow or tortuous cystic duct, dilated CBD 6-10mm, large >1cm or multiple stones, stones proximal to junction. All preclude transcystic approach.
What is the downside of choledochotomy for CBD exploration?
Longer OR time, longer hospital length of stay, more leak rates.
How to make the choledochotomy for CBD exploration?
Stay sutures around 1 cm incision below the cystic duct takeoff.
If T tube drainage 12-16 Fr tube is planned, make LONGITUDINAL incision.
If primary repair planned, make TRANSVERSE incision. Will need to close transversely since there are posterior attachments to duct that precludes mobilization.
Close with monofilament absorbable suture.
T tube vs primary closure of choledochotomy?
Primary closure is preferred (equivalent leak, decreased OR time, LOS). T tube may provide drainage when edema/spasm of sphincter is anticipated, but overall can increase leak rate, duct obstruction, infection.
How to expose in open CBD exploration?
Subcostal or midline incision.
Liver retracted superiorly.
Duo retracted inferiorly.
Omentum and stomach retracted to the patient’s left.
Kocherize duo to expose distal CBD.
Palpate duct and milk stone to incision at distal CBD.
1.5 cm incision with stay sutures.
Extract (balloon or basket) stone.
Postclearance cholangiogram via 18Fr T tube (trim obliquely proximally, lay distal limb just before the ampulla). Excise posterior wall of T tube to adi in removal. Bring tube out to costal margin.
Another cholangiogram.
When to remove the T tube?
3 weeks after OR; repeat T tube cholangiogram before removal to confirm patent flow.
if retained stone, repeat 6 weeks postop and then attempt removal (tract to mature)
Indication for transduodenal sphincteroplasty?
Provide drainage with nondilated biliary tree and stones impacted at the AMPULLA.
Contraindication to transduodenal sphincteroplasty?
Long suprasphincteric stricture or severe periampullary inflammation.
How to perform transduodenal sphincteroplasty?
Lap or open.
Kocherize panc and duodenum.
Longitudinal incision in the lateral aspect of D2 with electrocautery.
Papilla catheterized with 4-5Fr flexible catheter (nelaton probe).
Cauterize at 11 o clock position to avoid injury to panc duct.
Suture open the sphincterotomy with absorbable suture between duo wall and CBD. Total sphincterotomy length is 10-12 mm.
Advance angled Randall’s forceps and extract stones.
Close duodenotomy with transverse incision (Vicryl, Maxon).
Indications for biliary enteric drainage (choledochoduodenostomy vs RNY CJ)?
Elderly patients, risk of primary stone formation, multiple large duct stones, dilated ducts, intrahepatic stones, benign distal CBD stricture.
How to perform choledochoduodenostomy?
Duo must be completely mobilized and uninflamed.
Kocherize duo.
Either END (duct) to side (duo).
Or Side to side.
If side to side, 1.5 cm longitudinal supraduodenal choledochotomy made in anterior wall. 1 cm longitudinal adjacent duodenotomy.
Hand sewn in side to side, interrupted.
Complications of choledochoduodenostomy?
Sump syndrome, enteric reflux into the distal CBD causing inflammation
sump syndrome presentation
recurrent episodes of cholangitis or pancreatitis
sump syndrome mgmt?
ERCP with sphincterotomy and balloon sweeping to clear the duct
How to perform a RNY choledochojejunostomy?
Divide jejunum with a stapler 20 cm distal to LoT (creates a 50 to 70 cm Roux)
Divide mesentery to allow reach to duct
Roux passed retrocolic or antecolic
End to side or side to side anastomosis
(if end, stump oversewn with 3-0 absorbable)
Jejunotomy on antimesenteric side 2 cm from staple line
Anastomosis constructed in single layer with interrupted 4-0s
Jejunojejunostomy 40 cm distal to choledochojejunostomy.
Side to side vs end to side in RNY choledochojejunostomy?
Less bile duct devascularization (anterior duct 2.0 cm hole to side jejunum)
How much time is passed to call choledocholithiasis a primary duct stone?
2 years after cholecystectomy.
Other causes of gallstone formation?
Cholesterol stones, cystic fibrosis, strictures, periampullary diverticuli, parasitic infections, choledochal cysts, sclerosing cholangitis
Normal dilation of CBD after cholecystectomy?
Up to 10 mm
What is the rate of conversion to open cholecystectomy in acute cholecystitis?
10-20%.
Benefits of laparoscopic vs open cholecystectomy?
Less morbitidy, shorter LOS, less time until normal function, lower costs.
What kind of staple do you use to come across cystic duct if cannot clip or endoloop?
2.5 mm x 30 mm long linear cutting stapler.
How do you perform a subtotal cholecystectomy?
+/- leave the posterior wall of the gallbladder and suture the inside of the cystic duct; cauterize the wall to prevent a mucocele.
When do you leave a drain after laparoscopic cholecystectomy?
When there is concern for bile leak (intrahepatic gallbladder, getting into the liver).
How long do you give antibiotics for in acute cholecystitis (nonoperative management)?
7-10 days
What is the rate of success of NOM for acute cholecystitis?
85%
Indication for percutaneous cholecystostomy tube?
Failed NOM (3-4 days), adjacent liver abscess, poor surgical candidate, anticipated conversion to open.
Success rate of PCT?
90%
Risk of recurrent acute cholecystitis after PCT?
10-15%
When to pull PCT?
4-6 wks later, confirm patent cystic duct then pull.
What are the endoscopic therapies for acute cholecystitis?
Transpapillary stenting (drain into cystic duct into duo) vs transmural drainage (puncture gallbladder under EUS and dilate the tract and stent.
How to manage acute cholecystitis in pregnant patients?
1st - NOM (organogenesis, spotn abortion)
2nd - same admit cholecystectomy
3rd - NOM (preterm labor)
What anomaly is associated with (TYPE I) choledochal cysts and contributes to pathogenesis?
An anomalous pancreatobiliary junction (APBJ) is a fused, long common pancreatic and biliary channel. This anomaly allows pancreatic enzymes to reflux into the biliary tree, causing inflammation that results in cystic degeneration.
todani classification of choledochal cysts?
I: fusiform dilation of extrahepatic biliary duct - cyst excision with RNY hepaticoJ
II: saccular outpouching from CBD - simple resection only vs RNY
III: choledochocele or dilation of distal CBD (intraduodenal or intrapancreatic); ass’d cholangitis/pancreatitis
Tx: transduodenal marsupialization of cyst vs sphincterotomy or marsupialization via ERCP
IVA: multiple dilations of intra and extra hepatic ducts - hepatic resection and biliary reconstruction
IVB: multiple dilations of extra hepatic ducts - excision and hepaticoJ
V: Caroli disease; dilation of intrahepatic ducts only - transplant or resection (if at all possible)
tokyo guidelines for acute cholecystitis
mild (1):no organ disease; limited disease
moderate (2): extensive disease in the gb
severe (3): with organ dysfunction
gallbladder cancer risk factors
Mexican Americans and Native Americans.
southeast Asia, Korea, and Japan
females > males
obesity
Larger gallstones (> 3 cm)
Larger gallbladder polyps (> 1.0 cm)
segmental mucosal calcifications
primary sclerosing cholangitis
anomalous pancreaticobiliary junction
PSC assocaition
UC
gallbladder cancer treatment after finding gallbladder polyp?
stage T1b (into muscle [beyond lamina propria T1a] and above that are resectable require re-resection of segment IVb and V of the liver and regional lymphadenectomy.
adjuvant chemo if T3+
neoadjv if T4
gallbladder ca T staging
T0X; cannot assess
T1: no tumor
Tis: CIS
T1: lam propria or muscle layer
T2: perimuscular CT
T3: serosa and/or liver or ONE other adjacent organ
T4: invades main portal vein or hpeatic artery or 2+ extrahepatic organs
T2a vs T2b staging gallbladder cancer
T2a: perimuscular connective tissue on PERITONEAL side
T2b: perimuscular connective tissue on HEPATIC side
mgmt of gallbladder ca if liver masses seen?
metallic stent (if symptomatic) and referral for palliative chemotherapy
MC injury to extrahepatic biliary system during lap chole?
complete transection of CBD
<1%
indication for prophylactic lap chole?
- hemolytic anemias, such as sickle cell anemia (these patients have an extremely high rate of pigment stone formation, and cholecystitis can precipitate a crisis).
- calcified gallbladder wall (known as porcelain gallbladder).
- large (> 2.5 cm) gallstones.
- large polyps (>1 cm).
- long common channel of bile and pancreatic ducts.
gallbladder adenomyomatosis found on lap chole path?
most commonly occurs in the fundus (although diffuse disease has been involved) associated with rokitansky aschoff sinus
1% to 9% of gallbladder specimens
not premalignant condition
manage based on sx. (nothing if post chole).
sphincter of oddi dysfunction
if presumed, can do endoscopic sphincterotomy without imaging/manometry prior.
11o clock, suture to wall of CBD to duodenal mucosa….
endoscopic preferred over transduodenal sphincteroplasty surgical
bismuth corlette classification for cholangiocarcinomas?
type I. limited to CHD below confluence
type II. involves confluence
type IIIa. extends to origin of RHD (confluence of R post and ant)
type IIIb. extends to LHD (confluence of 2nd, 3rd, and 4th seg ducts)
type IV. extends to both RHD and LHD
type V. stricture of CD and CBD junction
rigler triad for gallstone ileus
pneumobilia, gallstone in intestine, bowel obstruction sx
E.coli producing gallstones pathophy
E. coli produces B-glucuronidase; deconjuates bilirubin with formation of calcium bilirubinate (BROWN STONE)
biliary dyskinesia dx
CCK cholescintigraphy shows: >60 min to empty or EF < 40%
primary sclerosing cholangitis
ass’d UC, pancreatitis, DM
strictures in BOTH INTRA AND EXTRA ducts (does not improve with colectomy)
primary biliary cirrhosis
INTRA ducts only
AMA+
colovenous reflux (causes cholangitis) at what pressure
> 200 mm Hg
granular cell myoblastoma
benign NET of gallbladder causing chole sx
mgmt: cholecystectomy
mgmt of gallstone ileus
leave the fistula alone (increase morbidity & recurrence is very low!) unless they REALLY need their GB out (gangrenous ie)
what size GB polyp do you need to surveil
6mm+
highest negative predictive value test for choleodcholithiasis
GGT = beta-gltamyl transpeptidase .. normal ggt = 97% predictive
port site resection at re-resection?
no onc benefit
definitive tx PSC (UC)?
liver txp; not TAC IPAA
bouveret sydrome
gallstone to pylorus/prox duo causing GOO
porcelain gallbladder ca risk
3%
submucosa in gallbladder?
NO!
