GI Tract 3 Flashcards
F. No evidence per score
What % of pts with PSC who undergo ccy have mass or lesions?
What % of those lesions are cancer?
14% have lesions
Half of the lesions are cancer.
Up to what % of the general population have biliary anatomy variation?
Up to 30%
What are the Tokyo guideline grades?
Grade 1 (mild acute cholecystitis) is defined as acute cholecystitis in a patient with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure.
Grade 2 (moderate acute cholecystitis) is associated with no organ dysfunction but there is extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy. Grade 2 disease is usually characterized by an elevated white blood cell count; a palpable, tender mass in the right upper abdominal quadrant; disease duration of more than 72 hours; and imaging studies indicating significant inflammatory changes in the gallbladder.
Grade 3 (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.
What is the sump syndrome?
Side-to-side choledochoduodenostomy can result in recurrent episodes of cholangitis as a result of the accumulation of stones, sludge, and debris in the distal common bile duct. This results in biliary stasis and obstruction, which puts the man at increased risk for cholangitis. For this reason, side-to-side choledochoduodenostomy is not the preferred method of biliary reconstruction following bile duct injury. Treatment includes ERCP with sphincterotomy and balloon sweeping to clear the debris from the duct.
Difference between todani 4a VA 4b vs 5
4a: fusiform dilation of CBD + intrahepatic cysts
4b: just extrahepatic cysts
5: just intrahepatic cysts (caroli)
You bring a patient with distal cholangiocarcinoma to the operating room for a Whipple procedure. She presented with biliary obstruction and had a plastic biliary stent inserted. Preoperative workup indicates the tumor is localized to the distal common bile duct and there is no metastatic disease. After performing your exploratory laparotomy, you find white deposits on the peritoneum above the left liver. Frozen section analysis shows adenocarcinoma. What is your next step?
A.Close the abdomen, and refer the patient to the medical oncology department for consideration of chemotherapy.
B.Proceed with the Whipple procedure.
C.Close the abdomen, and refer the patient for exchange to a metal stent via endoscopic retrograde cholangiopancreatography (ERCP).
D.Perform a hepaticojejunostomy for palliative decompression.
C. This is metastatic disease, and therefore an R0 curative resection is not possible. Proceeding with a Whipple procedure is futileand introduces morbidity and mortality risks in this patient who now has known stage IV disease. If the patient were to receive chemotherapy, the plastic stent would likely obstruct. Referral for exchange to a metallic stent before chemotherapy would be wise. Although performing a hepaticojejunostomy for palliative decompression is an option, a metallic stent would also provide adequate palliation of biliary obstruction. If this is not available, an operative bypass by either hepaticojejunostomy or hepaticoduodenostomy is an option for this patient.
After IOC, best initial way to close the cystotomy? Clip or endoloop?
Endoloop
Common hepatic stone is a contraindication for what?
What are some other contraindications for this?
Relative contraindications to laparoscopic transcystic common bile duct exploration include:
- gallstones in the common hepatic duct above the junction of the cystic and common bile ducts
- small (< 3 mm) or friable cystic duct
- gallstones greater than 6 to 8 mm
- more than eight common bile duct stones
Compared with endoscopic sphincterotomy, transduodenal sphincteroplasty is associated with which of the following?
A.Decreased incidence of restenosis B.Improved symptomatic relief C.Shorter length of hospitalization D.Ability to perform concomitant diagnostic evaluation E.Increased incidence of pancreatitis
A. When properly performed, transduodenal sphincteroplasty results in decreased incidence of restenosis when compared with endoscopic treatments.
You’re doing a lap ccy in a septic pt. Can’t see a safe plane for critical view. What to do next?
What if anesthesia is starting pressors?
No plane + stable: lap subtotal ccy
No plane + unstable: lap tube cholecystostomy
If IOC were to be performed in all lap ccys, what is the rate of finding stones in CBD?
10%
A 24-year-old woman is being evaluated for abdominal pain and elevated biliary enzymes. A CT scan demonstrates a dilated common bile duct. Choledochal cyst is suspected. Which test is preferred next?
A.Endoscopic ultrasound
B.Magnetic resonance cholangiopancreatography
C.Hepatobiliary (HIDA) scan
D.Endoscopic retrograde cholangiopancreatography
E.Transabdominal ultrasound
B. Although all these studiescan help diagnose choledochal cyst, magnetic resonance cholangiopancreatography is best for defining the anatomy of the cyst as well as the anatomy of the entire biliary tree. Also, it is less invasive than endoscopic retrograde cholangiopancreatography.
Big stone in CBD. Can’t get it out after glucagon, flush, transcystic exploration, basket. Next step?
CholedochoDUODENOSTOMY
or transduodenal sphincteroplasty
