Hepato-Biliary Surgery Flashcards
What are the functions of the gallbladder?
Bile reservoir
Concentrates bile
Secretes after meal (CKK)
What can be said about the anatomy of the gallbladder from person to person?
Anatomical variations exist
What can be said about the anatomy of the blood supply to the gallbladder?
Anatomical variations exist
What are some examples of conditions of the gallbladder?
Gallstone disease
Cholesterosis
What is the procedure where the gallbladder is removed called?
Cholecystectomies
What is the composition of gallstones?
Mixed (>50% cholesterol), 80%
Cholesterol 10%
Pigment 10%
What are risk factors for gallstones?
Age
Gender
Parity + oral contraceptives (OCP)
Cholesterol
Pigment (haemolytic anaemia, bile infection)
What are risk factors for high cholesterol?
Obesity
Ileal disease
Cirrhosis
Cystic fibrosis
DM
TPN
Heart transplant
What is the presentation of gallstones?
Asymptomatic
Dyspeptic symptoms
Biliary colic
Acute cholecystitis
Empyema
Perforation
Jaundice
Gallstone ileus
What is inflammation of the gallbladder?
Cholecystitis
What is the presence of a small gallstone in the comment bile duct?
Choledocholthiasis
What is the presentation of choledocholithiasis?
Post-cholecystectomy pain
Obstructive jaundice (painful)
Dark urine
Pale stool
Steatorrhoea
What investigations are done for gallstones?
Blood tests (LFTs, amylase, lipase, WCC)
USS
EUS
Oral cholecystography
CT scan
What are the two broad categories of gallstone management?
Non-operative treatment
Operative treatment
What is the non-operative management for gallstones?
Dissolution
Lithotripsy
What is a treatment that uses shock waves to treat gallstones?
Lithotripsy
What is the operative management of gallstones?
Open cholecystectomy
Mini-cholecystectomy
Laparoscopic cholecystectomy
Singl eport cholecystectomy
Cholecystectomy
Subtotal cholecystectomy
What does CBD stand for?
Common bile duct
What does the management of common bile duct stones involve?
Expectant treatment (incidental)
Lap trans-cystic, lap or open exploration of CBD
ERCP
Transhepatic stone retrieval
What procedure allows examination of the CBD or pancreatic duct using an endoscopy through the mouth?
Endoscopic retrograde cholangiopancreatography (ERCP)
What are benign biliary tract diseases?
Diseases that affect the bile ducts, gallbladder and other structures involved in the production and transportation of bile
What are examples of benign biliary tract diseases?
Biliary atresia
Choledochal cysts
What is biliary atresia?
congenital
Biliary atresia is a condition in infants in which the bile ducts outside and inside the liver are scarred and blocked. Bile can’t flow into the intestine, so bile builds up in the liver and damages it. The damage leads to scarring, loss of liver tissue and function, and cirrhosis.
What are choledochal cysts?
A choledochal cyst (CC) or biliary cyst is a congenital or acquired anomaly affecting the biliary tree. It involves the dilation of the biliary tree that could affect the extrahepatic and/or the intrahepatic segments.
What are the different categories of biliary atresia
Iatrogenic
Gallstone related (Mirrizi’s)
Inflammatory:
Pyogenic
Parasitic
PSC
Pancreatitis
HIV
What are examples of inflammatory causes of biliary atresia?
Pyogenic
Parasitic
PSC
Pancreatitis
HIV
What are the different types of choledochal cysts?
type 1, 2, 3, 4A, 4B, 5
What are examples of malignant tumours that can cause jaundice?
Cholangiocarcinoma
Cancer of the Head of Pancreas
What is the name of bile duct cancer?
Cholangiocarcinoma
What are the broad categories of cholangiocarcinoma?
Intrahepatic 6%
Extrahepatic
Hilar (Klatskin 1965) 67%
Distal 27%
Gallbladder Cancer
Ampullary Cancer
Which of intra and extra-hepatic cholangiocarcinoma occurs more often?
extrahepatic
Out of hilar and distal, where do most extrahepatic cholangiocarcinomas occur?
hilar
What are risk factors for cholangiocarcinoma?
Increases with age
Peak at 80 years
Risk factors:
PSC (strong association)
Congenital cystic disease
Biliary-enteric drainage
Thorotrast (contrast)
Hepatolithiasis
Carcinigens: aflatoxins, etc.
What is the presentation of cholangiocarcinoma?
Obstructive jaundice
Itching
None-specific symptoms
What investigations are done for cholangiocarcinoma?
Lab
Radiology: USS, EUS, CT, MRA, MRCP, PTC, Angiography, FDG PET
ERCP, Cholangioscopy and Cytology
what are the three types of intrahepatic cancer
Mass forming
Peri-ductal
Intra-ductal
Surgery is only option
What is MRA?
use MRA to: identify abnormalities, such as aneurysms, in the aorta, both in the chest and abdomen, or in other arteries.
What is MRCP?
Magnetic resonance cholangiopancreatography (MRCP) is a special type of magnetic resonance imaging (MRI) exam that produces detailed images of the hepatobiliary stones/tumour/inflammation
What is PTC?
A percutaneous transhepatic cholangiography is a way of looking at your bile ducts using x-rays. Your doctor puts a long thin needle through the skin and into your liver and bile ducts.
How is cytology different from histology?
Cytology generally involves looking at a single cell type. Histology is the exam of an entire block of tissue.
What is the management of cholangiocarcinoma?
Surgical: only potential curative option
Palliative:
Surgical bypass
Stenting (Percutaneous vs Endoscopic)
Palliative radiotherapy
Chemotherapy
PDT
liver transplant (not standard)
What can be done for palliative care for cholangiocarcinoma?
Surgical bypass
Stenting (Percutaneous vs Endoscopic)
Palliative radiotherapy
Chemotherapy
PDT
liver transplant (not standard)
What is PDT?
involves administration of a photosensitizing drug with affinity for neoplastic tissue and subsequent selective irradiation with light of a defined wavelength.
What is the incidence of gallbladder cancer like?
Rare 2-5% of GI cancers
90% existing Gallstones
Aggressive
What is the prognosis of gallbladder cancer?
poor
Except if detected early
Incidental in gallstones
How is gallbladder cancer usually diagnosed?
blood tests. scans, like an ultrasound scan (sometimes from inside your body using an endoscope), CT scan, PET scan, MRI scan, or a type of X-ray called a cholangiography. collecting a small sample of cells from the gallbladder (called a biopsy) to be checked for cancer.
What does the treatment of gallstone cancer depend on?
whether tumour is adenoma vs. adenocarcinoma
What is ampullary cancer?
Ampullary cancer is a rare type of cancer. It occurs when cancer starts in the part of the body called the ampulla of Vater. The ampulla of Vater is a small opening where the pancreatic and bile ducts (from the liver) connect to the first part of the small intestine (the duodenum)
What is the ampulla of Vater?
small opening that enters into the first portion of the small intestine, known as the duodenum. The ampulla of Vater is the spot where the pancreatic and bile ducts release their secretions into the intestines.
What are the 2 histological classifications of ampullary tumours?
adenoma vs. adenocarcinoma
What is an adenoma?
An adenoma is a benign (noncancerous) tumor.
What is an adenocarcinoma?
type of cancer that starts in mucus-producing (glandular) cells
What are the treatment options for ampullary tumours?
Endoscopic excision
Trans-duodenal excision
Pancreatico-duodenectomy
What is a pancreatico-duodenctomy?
The Whipple procedure, also called pancreaticoduodenectomy, is an operation to remove the head of the pancreas.
