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HEPATOBILIARY Flashcards

1
Q

Choledochal cyst type I and tx

A

Fusiform dilation of CBD; MC; 50-80%

Surgical excision

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2
Q

Choledochal cyst type II and tx

A

True diverticula of extra hepatic bile duct; 2% (low malig)

Tx: Diverticulectomy

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3
Q

Choledochal cyst type III and tx

A

Choledochocele
Cystic dilations of intra duodenal bile ducts; 1-5% (low malig)
Tx: Endoscopic sphincterotomy, if larger transduodenal excision

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4
Q

Choledochal cyst type IVa and tx

A

Cystic dilation of intra and extra hepatic bile ducts; 15-35%
Tx:
Affecting 1 lobe - partial hepatectomy +/- extra hepatic bile duct resection and reconstruction
Bilobar - extrahepatic resection and reconstruction still recommended

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5
Q

Choledochal cyst type V and tx

A

Carolis disease; 20%
Cystic dilations of intrahepatic ducts only
Tx:
Supportive care with abx, perc drainage of any complications (stones, cholangitis)
Partial hepatectomy possibly considered if 1 lobe only
Eval for liver tx if cirrhosis/portal HTN present

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6
Q

Choledochal cyst type IVb and tx

A

Cystic dilation of extra hepatic bile ducts; 15-35%
Complete resection of cyst followed by roux en y hepaticojejunostomy
Proximal extent should extend to nondilated duct, may require anastomosis to R and L hepatic ducts individually
Distal extent as much of bile duct as possible before enters pancreatic head, often requires kocherization

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7
Q

Etiology of choledochal cyst

A

Biliary stasis due to anomalous biliary-pancreatico duct union

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8
Q

Surgical excision of choledochal cyst type I

A

Cyst resection with proximal extent to non-dilated ducts and distally to where the duct enters the pancreas so that as much duct is excised as possible followed by roux en y enterobiliary reconstruction

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9
Q

Surveillance for choledochal cyst

A

Still remains risk of malignancy
No specific guidelines exist
Cross sectional imaging and LFTs annually

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10
Q

Pathology reveals T1a gallbladder CA with 1 negative node

A

No further surgery
CT C/A/P and baseline tumor markers
Repeat q3 months every 2 years, stretch out q6mos until 5 years out then annual
Surveillance only

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11
Q

Pathology reveals T1b gallbladder CA with positive margin

A

Radical chole + portal lymphadenopathy + 2 cm margin of liver resected –> refer to HPB surgeon
Prior to OR –> CT C/A/P to r/o mets, CEA, CA 19-9 and CA 125

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12
Q

OR for gallbladder CA

A

Staging lap to r/o peritoneal mets (esp if spillage at initial operation)
Liver resection of 2 cm around cystic plate (parts of IVb and V)
Portal lymphadenectomy - skeletonizing hepatic a starting at common hepatic node and moving distal down artery resecting all fibrofatty tissue off vessels, also portal vein
and resect lymphatic tissue around bile duct but being careful to not devascularize it
Also resect residual cystic duct down to junction with CBD again ensuring no narrowing of CBD

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13
Q

Contraindications to OR in gallbladder CA

A

Metastatic disease
Presentation with jaundice (relative - invasion of CBD indicates poor prognosis)
Evidence of node + disease upfront
Can kocherize and send aortocaval nodal packet for frozen

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14
Q

Mild transaminitis in pregnancy

A

Consider HELLP syndrome
Ask about HA, blurred vision, SOB
Check for proteinuria
Discuss w/OB

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15
Q

OR in symptomatic chole (pregnant patient)

A

PRe and post op fetal monitoring
Place lead shield under*** patient position to shield fetus from XRT (c arm)
Place pt in partial left decubitus (offset IVC)
SCDs on and functional prior to induction
Open hassan and shift ports superiorly based on fundal height
IOC with 50/50 mix saline and contrast after clipping GB side of cystic duct and making ductotomy

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16
Q

Concern for CBD stone

A

1 mg glucagon, wait 3-5 min and flush duct with injectable saline. Repeat cholangiogram. May repeat glucagon x 1
Provided cystic duct is of adequate size, transcystic laparoscopic CBD exploration and stone retrieval
Other options: post op ERCP (XRT exposure to fetus, post ERCP pancreatitis)

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17
Q

Can’t obtain critical view

A

If workspace due to gravid uterus –> conversion to open
If planes obliterated 2/2 chronic inflammation –> perform subtotal fenestrated chole - (resecting anterior wall, stone removal, and fulgurating posterior wall mucosa; if cystic duct orifice visualized, can do IOC and close orifice from within gallbladder) and drain placement

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18
Q

Concern for bile duct injury intra op

A

Call for help from 2nd surgeon (most experienced partner)
Only open if you can perform definitive repair
Leave drains and transfer to tertiary center for definitive care

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19
Q

Physical exam for liver disease

A

Look for cachexia, lymphadenopathy, DRE (masses, bleeding), ascites, 2ndary signs of portal HTN such as caput medusa, BMI (NASH)

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20
Q

HCC imaging findings

A

LIRADS 4 or 5 + appropriate hx of unhealthy liver = HCC

Enhancing lesion on arterial phase with washout on venous phase, capsule

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21
Q

Hepatic tumor and low LIRADS

A

Mets (CRC), mixed type cholangioCA

Peripheral enhancing lesions

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22
Q

What else should you look for on liver imaging

A

Cirrhosis signs

Signs of portal HTN such as recanalized umbilical vein, splenomegaly

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23
Q

Margins for HCC

A

At least 1 cm

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24
Q

Poor surgical candidate with HCC

A

Transplant OR

Consider TACE, RF ablation (borderline with 3 cm tumor)

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25
History for pancreatic cyst
Hx abdominal pain, diarrhea, episodes of pancreatitis, steatorrhea, new onset DM, weight loss
26
Serous cystadenomas
``` Females > males 6th-7th decade Honeycomb pattern, stellate scar No connection to pancreatic duct Low CEA*, low amylase ```
27
Mucinous cystic neoplasms
``` 10-50% malignant transformation Mostly females, 5th-6th decade Body or tail of pancreas Peripheral calcs High CEA, low amylase ```
28
IPMNs
Men = females Up to 60% risk of malignancy High risk stigmata: mural nodule >5 mm, obstructive jaundice, main pancreatic duct dilation > 10 mm High CEA, HIGH amylase*
29
Worrisome features of IPMNs
Mural nodule <5 mm, cyst > 3 cm, thickened enhancing cyst wall, main duct dilation 5-9 mm, abrupt change in caliber of pancreatic duct with distal pancreatic atrophy, lymphadenopathy, increased CA 19-9, cyst growth rate > 5 mm over 2 years --> EUS and FNA
30
Distal Pancreatectomy
After exploring peritoneal cavity to r/o mets Enter lesser sac dividing gastrocolic ligament Retract stomach to expose pancreas and retroperitoneum ID splenic artery coursing on superior border of pancreas Using energy device, open a plane along inf border of pancreas May have to mobilize splenic flexure by dividing splenocolic ligament Proceed with dissecting splenic v away from overlying pancreas towards hilum using combo of energy + clips Similarly dissect splenic a away from pancreas Divide pancreas at neck using stapler Intra-op frozen section at proximal margin to ensure no high grade dysplasia Leave drain - check amylase day 1 and 3
31
Resected IPMNs surveillance
Dictated by grade of dysplasia on final pathology | If high risk, semi annual surveillance CA 19-9 and MRI or EUS recommended
32
Preoperative biliary drainage in pancreatic adenoCA if
bilirubin > 12 Also pts receiving neoadjuvant therapy Medical optimization due to malnutrition
33
Ca19-9 can be falsely elevated in
biliary stasis | should obtain AFTER stent placement
34
once pt diagnosed with pancreatic adenoCA, don't forget (2 things)
germline genetic testing | complete staging workup
35
pancreatic adenoCA - OR
Perform diagnostic lap - surface of liver, small bowel, peritoneal cavity, mesentery Midline laparotomy Take attachments between gr omentum and transverse colon entering lesser sac Trace middle colic vein up to ID SMV at inf border of pancres and develop plane behind neck of pancreas and encircle with umbilical tape Mobilize hepatic flexure, complete kocher maneuver --allows to palpate course of SMA Cholecystectomy, portal dissection, division of CHD and ID and ligation of GDA Transect distal stomach Divide SB distal to LoT mobilizing distal duodenum from mesentery Divide pancreatic neck and send distal duct margin for frozen section Divide uncinate process attachments adjacent to SMA adventitia Reconstruction tension-free duct-mucosa pancreaticojej, hepaticojejunostomy, and GJ Closed suction drains near biliary and pancreatic anastomoses
36
Mgmt of drains post-whipple
Check amylase day 1 and 3 | Remove prior to DC if output <30 mL/day, amylase WNL, no clinical signs of post op pancreatic fistula
37
N&V, fever, HoTN post whipple
``` NPO and examine Labs: CBC, drain amylase Large bore IV access 1L bolus crystalloid KUB ```
38
Concerns for post whipple pancreatic fistula
NGT to LIWS IVF resusc Broad spec abx CT scan abdomen to check drains
39
Surveillance for pancreatic adenoCA
CT scan C/A/P q6 mos x 2 years H&P q3-6 mos CA 19-9 levels
40
Labs for insulinoma
CBC, CMP, LFTs Fasting glucose, insulin C peptide
41
R/o mets in insulinoma
Dotatate scan
42
Asymptomatic PNET - workup
Fasting gastrin and insulin-glucose levels to r/o function
43
Indications for resection of nonfunctional PNET
>2 cm | Otherwise short interval followup
44
Distal panc + splenectomy
Left side up Mobilize stomach and transect short gastrics Suspend stomach and fully mobilize splenic flexure to expose inf edge of pancreas Create retropancreatic tunnel 2 cm to patient right of tumor, transect pancreas at this location using gradual compression with blue load stapler Dissect out splenic a, transect and bring LN and artery with specimen Dissect out splenic v, transect using vascular stapler load Dissect pancreas off RP in a plane outside peripancreatic fat taking tissue along with specimen Remove spleen from lateral attachments
45
Principles in hepaticojejunostomy
Right subcostal incision, LOA Careful portal dissection—mobilizing duodenum, omentum, hepatic flexure away from porta. Identify R and L lateral aspects of porta for proper orientation. “Anterior-only” dissection of hepatic duct. Lowering of hilar plate to allow exposure of anterior aspect of hepatic duct confluence. ID long extrahepatic portion of the L hepatic duct to facilitate exposure of hepatic duct confluence. Creation of tension-free Roux-en-Y limb, brought up to RUQ via defect in transverse mesocolon to right of the middle colics. Inspect biliary mucosa to ID area for anastomosis. Reconcile the preoperative understanding of ductal anatomy with intraoperative findings and confirm all ductal orifices are included and adequately drained via the planned anastomosis. Broad (2 cm) side-to-side biliary–enteric anastomosis using absorbable monofilament suture. Closed suction drainage.
46
CBD exploration - OR
An upper midline or right subcostal laparotomy is performed. A self-retaining retractor is used to lift liver cephalad and retract colon caudally. If present, gallbladder is dissected using “dome-down” technique until Calot’s triangle is identified. The cystic artery is ligated and divided. Cystic duct is followed antegrade to the common bile duct, which is dissected anteriorly. The cholecystectomy is completed. A longitudinal choledochotomy is made 1–2 cm distal to the confluence of the cystic duct and the common bile duct. The common bile duct is cleared with irrigation or a Fogarty catheter. The choledochotomy is closed using absorbable suture over a T tube and a closed-suction drain is left in the area of the choledochotomy.
47
Pancreatic Necrosectomy - OR
Midline vertical or Chevron incision and full exploration Access to lesser sac obtained via gastrocolic ligament Drainage of purulent material Debridement of necrotic tissue Placement of feeding jejunostomy JP drains placed into the lesser sac for postoperative irrigation and drainage
48
Open Cystgastrostomy - OR
``` Chole + IOC for biliary pancreatitis. Intraoperative US to define necrotic collection. Anterior gastrotomy (at least 5 cm) to expose posterior gastric wall. Aspiration of pseudocyst/WON fluid for microbiology cultures. Electrocautery for entry into the pseudocyst/WON cavity. Bx pseudocyst wall to R/O epithelial-lined cyst. Explore pseudocyst/WON cavity and debride necrosis. Anastomosis (at least 5 cm) completed with locking PDS suture. ```
49
Liver tumor - staging evaluation (after CT or MRI liver)
CT chest serum AFP Bone scan if appropriate
50
Multifocal liver HCC
Transarterial therapy (chemoembolization or radioembolization) UNLESS Milan criteria
51
Milan criteria
Single nodule <5 cm or 3 nodules <3 cm
52
Solitary HCC in childs class A with FLR <40%
Portal vein embolization --> hepatic resection if successful
53
Solitary HCC in childs class A with FLR <40% and portal vein embolization is NOT successful?
Liver txp eval
54
Solitary HCC in Childs class A with portal HTN and plt <100K
Liver txp eval
55
Childs class B-C with solitary HCC <3 cm
Radiofrequency or microwave ablation
56
Childs class B-C with extensive HCC burden
Systemic chemo with sorafenib vs supportive care
57
Important anesthesia notes for hepatic resection
Maintain low CVP*** Establish large bore venous access A line for continuous BP monitoring CV access if more complex case
58
Contraindication to TACE
Total bili >3
59
T tube placement.
Postclearance cholangiography via 18Fr T-tube performed before duct closure Trim ends obliquely so proximal limb doesnt obstruct hepatic ducts, distal limb terminates before ampulla Posterior wall of tube excised to improve flexibility Bring out through skin of abdominal wall under costal margin and secured Completion cholangio via T tube to confirm position and no retained stones PLACE CLOSED SUCTION DRAIN NEXT TO CBD and remove POD # 3
60
When to remove T tube
About 3 weeks postoperatively after repeat T-tube cholangiography demonstrates patent distal flow
61
Tx of pyogenic liver abscess
CT guided drainage and abx
62
Tx of schistosomiasis
praziquantel and control of variceal bleeding
63
Bleeding pancreatic pseudoaneurysm w/o evidence of arterial bleeding - tx
Correct coagulopathy | Decrease splanchnic blood flow with octreotide infusion
64
If you're operating on a pancreatic pseudocyst and patient has gastric varices, you should also perform ...
Splenectomy
65
Ransons criteria - admission
``` Glucose >200 Age >55 LDH > 350 AST > 250 WBC >16K ```
66
Ransons criteria - admission
``` Glucose >200 Age >55 LDH > 350 AST > 250 WBC >16K ```
67
Tx of echinococcal cyst
DON'T ASPIRATE Pre op albendazole. x 2 weeks Surgical removal (intra op can inject cyst with alcohol to kill organisms then aspirate out) Must get all of cyst wall
68
Dx of echinococcal cyst
Casoni skin test, positive serology
69
Tx of amebic cyst
Flagyl Aspirate IF refractory Surgery IF free rupture
70
Portal vein pressure considered significant
>10-12 mm Hg
71
Basics of TIPS
transjugular intrahepatic portosystemic shunt Catheter passed into hepatic v via the jugular v A needle inserted through catheter is passed from hepatic v through liver tissue into a major portal v branch Liver tract dilated with angioplasty balloon catheter and tract kept open after deployment of expandable metal stent
72
Dx of amebic abscess
Serology for entamoeba histolytica

ORAL BOARDS (11 decks)

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