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ORAL BOARDS > HEPATOBILIARY > Flashcards

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
Q

History for pancreatic cyst

A

Hx abdominal pain, diarrhea, episodes of pancreatitis, steatorrhea, new onset DM, weight loss

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26
Q

Serous cystadenomas

A 
Females > males
6th-7th decade
Honeycomb pattern, stellate scar
No connection to pancreatic duct
Low CEA*, low amylase
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27
Q

Mucinous cystic neoplasms

A 
10-50% malignant transformation
Mostly females, 5th-6th decade
Body or tail of pancreas
Peripheral calcs
High CEA, low amylase
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28
Q

IPMNs

A

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*

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29
Q

Worrisome features of IPMNs

A

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
Q

Distal Pancreatectomy

A

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
Q

Resected IPMNs surveillance

A

Dictated by grade of dysplasia on final pathology

If high risk, semi annual surveillance CA 19-9 and MRI or EUS recommended

32
Q

Preoperative biliary drainage in pancreatic adenoCA if

A

bilirubin > 12
Also pts receiving neoadjuvant therapy
Medical optimization due to malnutrition

33
Q

Ca19-9 can be falsely elevated in

A

biliary stasis

should obtain AFTER stent placement

34
Q

once pt diagnosed with pancreatic adenoCA, don’t forget (2 things)

A

germline genetic testing

complete staging workup

35
Q

pancreatic adenoCA - OR

A

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
Q

Mgmt of drains post-whipple

A

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
Q

N&V, fever, HoTN post whipple

A 
NPO and examine
Labs: CBC, drain amylase
Large bore IV access
1L bolus crystalloid
KUB
38
Q

Concerns for post whipple pancreatic fistula

A

NGT to LIWS
IVF resusc
Broad spec abx
CT scan abdomen to check drains

39
Q

Surveillance for pancreatic adenoCA

A

CT scan C/A/P q6 mos x 2 years
H&P q3-6 mos
CA 19-9 levels

40
Q

Labs for insulinoma

A

CBC, CMP, LFTs
Fasting glucose, insulin
C peptide

41
Q

R/o mets in insulinoma

A

Dotatate scan

42
Q

Asymptomatic PNET - workup

A

Fasting gastrin and insulin-glucose levels to r/o function

43
Q

Indications for resection of nonfunctional PNET

A

> 2 cm

Otherwise short interval followup

44
Q

Distal panc + splenectomy

A

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
Q

Principles in hepaticojejunostomy

A

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
Q

CBD exploration - OR

A

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
Q

Pancreatic Necrosectomy - OR

A

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
Q

Open Cystgastrostomy - OR

A 
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
Q

Liver tumor - staging evaluation (after CT or MRI liver)

A

CT chest
serum AFP
Bone scan if appropriate

50
Q

Multifocal liver HCC

A

Transarterial therapy (chemoembolization or radioembolization) UNLESS Milan criteria

51
Q

Milan criteria

A

Single nodule <5 cm or 3 nodules <3 cm

52
Q

Solitary HCC in childs class A with FLR <40%

A

Portal vein embolization –> hepatic resection if successful

53
Q

Solitary HCC in childs class A with FLR <40% and portal vein embolization is NOT successful?

A

Liver txp eval

54
Q

Solitary HCC in Childs class A with portal HTN and plt <100K

A

Liver txp eval

55
Q

Childs class B-C with solitary HCC <3 cm

A

Radiofrequency or microwave ablation

56
Q

Childs class B-C with extensive HCC burden

A

Systemic chemo with sorafenib vs supportive care

57
Q

Important anesthesia notes for hepatic resection

A

Maintain low CVP***
Establish large bore venous access
A line for continuous BP monitoring
CV access if more complex case

58
Q

Contraindication to TACE

A

Total bili >3

59
Q

T tube placement.

A

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
Q

When to remove T tube

A

About 3 weeks postoperatively after repeat T-tube cholangiography demonstrates patent distal flow

61
Q

Tx of pyogenic liver abscess

A

CT guided drainage and abx

62
Q

Tx of schistosomiasis

A

praziquantel and control of variceal bleeding

63
Q

Bleeding pancreatic pseudoaneurysm w/o evidence of arterial bleeding - tx

A

Correct coagulopathy

Decrease splanchnic blood flow with octreotide infusion

64
Q

If you’re operating on a pancreatic pseudocyst and patient has gastric varices, you should also perform …

A

Splenectomy

65
Q

Ransons criteria - admission

A 
Glucose >200
Age >55
LDH > 350
AST > 250
WBC >16K
66
Q

Ransons criteria - admission

A 
Glucose >200
Age >55
LDH > 350
AST > 250
WBC >16K
67
Q

Tx of echinococcal cyst

A

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
Q

Dx of echinococcal cyst

A

Casoni skin test, positive serology

69
Q

Tx of amebic cyst

A

Flagyl
Aspirate IF refractory
Surgery IF free rupture

70
Q

Portal vein pressure considered significant

A

> 10-12 mm Hg

71
Q

Basics of TIPS

A

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
Q

Dx of amebic abscess

A

Serology for entamoeba histolytica

ORAL BOARDS (11 decks)

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