Hepato-Biliary Surgery

Question 1

gallbladder function

Answer 1

Bile reservoir
Concentrates bile
Secretes after meal

Question 2

gallstones diseases

Answer 2

Other benign conditions of GB
Cholesterosis
GB polyps

Question 3

what is one of the commonest surgical problems?

Answer 3

gallstones

Question 4

gallstones compostition

Answer 4

Mixed(>50% cholesterol) 80%
Cholesterol
Pigment

Question 5

gallstones risk factors

Answer 5

Age- 40s
Gender- female
Parity + OCP (4F)
Cholesterol: obesity, ileal disease, cirrhosis, cystic fibrosis, DM, TPN, heart transplant, delayed GB emptying, clofibrate, long-term low-fat diet
Pigment (far east): M=F, haemolytic anaemia, bile infection (e-coli, Bacteroides)

Question 6

gallstones presentation

Answer 6

Asymptomatic
Dyspeptic symptoms (flatulent dyspepsia)
Biliary colic
Acute cholecystitis
Empyema
Perforation
Jaundice (Mirrizi’s Syn.)
Gallstone Ileus

Question 7

what is Choledocho-lithiasis

Answer 7

is the presence of a gallstone in the common bile duct

Question 8

consequences of Choledocho-lithiasis

Answer 8

Post-cholecystectomy pain
Obstructive jaundice (painful)
Pain, jaundice, dark urine, pale stool, pruritus, steatorrhoea
Acute pancreatitis
Ascending cholangitis (Charcot’s triad)

Question 9

gallstones investigations

Answer 9

Blood tests: 
LFT’s: AST, ALT, ALP
Amylase, Lipase
WCC
USS
EUS
Oral cholecystography
CT scan
Radio iso-tope scan (HIDA)

IV cholangiography
MRCP
PTC
ERCP

Question 10

gallstones management

Answer 10

Asymptomatic
Non-operative treatment:	
Dissolution
Lithotripsy
Operative:
Open cholecystectomy 
Mini-cholecystectomy
Laparoscopic cholecystectomy +/- OTC “Gold Standard” 
Single port cholecystectomy
NOTES cholecystectomy
Cholecystostomy
Subtotal Cholecystectomy

Question 11

management of CBD stones

Answer 11

Expectant treatment (incidental)
Lap trans-cystic CBD exploration
Lap exploration of CBD
Open exploration of CBD
ERCP
Pre-op
Intra-op
Post-op
Transhpatic stone retrieval

Question 12

benign biliary tract disease

Answer 12

Congenital: 
biliary atresia
Choledochal cysts
Benin biliary stricture
Iatrogenic
Gallstone related (Mirrizi’s)
Inflammatory:
Pyogenic
Parasitic
PSC
Pancreatitis
HIV

Question 13

jaundice- malignant tumours

Answer 13

Cholangiocarcinoma
Intrahepatic 6%
Extrahepatic
Hilar (Klatskin 1965) 67%
Distal 27%
Gallbladder Cancer
Ampullary Cancer
Cancer of the Head of Pancreas

Question 14

Cholangiocarcinoma

Answer 14

Rare
Increases with age
Peak at 80 years

Question 15

Cholangiocarcinoma risk factors

Answer 15

PSC (strong association)
Congenital cystic disease
Biliary-enteric drainage
Thorotrast (contrast)
Hepatolithiasis
Carcinigens: aflatoxins, etc.

Question 16

what are the three types of Cholangiocarcinoma

Answer 16

Mass forming
Peri-ductal
Intra-ductal

Question 17

Cholangiocarcinoma presentation

Answer 17

Obstructive jaundice
Itching
None-specific symptoms

Question 18

Cholangiocarcinoma investigaations

Answer 18

Lab
Radiology: USS, EUS, CT, MRA, MRCP, PTC, Angiography, FDG PET
ERCP, Cholangioscopy and Cytology

Question 19

Cholangiocarcinoma management

Answer 19

Surgical: only potential curative option
Palliative:
Surgical bypass
Stenting (Percutaneous vs Endoscopic)
Palliative radiotherapy
Chemotherapy
PDT
liver transplant (not standard)

Question 20

treatment for ampullary tumours

Answer 20

Endoscopic excision
Trans-duodenal excision
Pancreatico-duodenectomy