Hepatobiliary Flashcards
Laparoscopic CBD exploration
- Incise cystic duct, place wire, use baloon dilator to dilate duct
- Hook cholecoscope up to saline, advance into duct
- Visualize stones, extract with wire basket, drive scope into duo if necessary
- Withdraw scope, shoot completion cholangiogram
Open CBD Exploration
- 2 cm Longitudinal incision in CBD with a 15 blade and potts scissors
- Place stay sutures to open up the duct
- Pass #4 fogarty catheter,***
- Choledochoscope, make sure hooked up to saline, visualize stones, extract with wire basket
- Place t-tube and shoot cholangiogram, secure t-tube with 4-0 PDS interrupted sutures
- T-tube can be capped if no leak on pre-discharge cholangiogram; it can come out in 2 weeks after that
Distal pancreatectomy & splenectomy
- Enter lesser sac by separating greater omentum from transverse colon, lifting posterior gastric wall away from pancreas & divide short gastric vessels
- Mobilize splenic flexure to expose inferior pancreas. Mobilize pancreas away from splenic vein and artery using energy device & clips. Create tunnel behind neck of pancreas.
- Use stapler to divide pancreas at neck, 2 cm to right of tumor, send for frozen section
- Isolate, then transect splenic artery then vein w vascular stapler, taking LN’s w specimen
- Mobilize pancreas off retroperitoneum, taking peripancreatic fat
- Mobilize spleen off lateral attachments
- Leave a drain
Pancreatic debridement
- Midline laparotomy
- Enter lesser sac through omentum or transverse colon
- Manually debride necrotic pancreatic tissue
- Place large sump drains
- Place g-tube and feeding J-tube
Pancreatic pseudocyst drainage
- Midline laparotomy
- Incise anterior stomach
- Aspirate contents with needle
incise 3-4cm posterior stomach and some cyst wall, elipse this out, send cyst wall to path for frozen to be sure not cystic neoplasm with epithelial lining - Running 3-0 pds suture for hemostasis to create the cyst-gastrostomy
- Close anterior gastrostomy in 2 layers
Splenectomy
Vaccinate for encapsultated organisms: pneumococcus, meningococcus, h-flu
- 45 degree right lateral decubutus
- Hassan supraumbilical; Look for accessory spleen tissue in splenic hilum, omentum
- Mobilize splenic flexure of colon
- Enter lesser sac by dividing omentum, divide short gastrics
- Take hilum with vascular stapler, taking care not to involve the tail of the pancreas
Cholecystectomy
Hassan
1. Incise peritoneum overlying gallbladder at the neck, expose the critical view of safety
2. perform cholangiogram if indicated
3. clip and divide duct and the artery
take gallbladder off the cystic plate
Roux en Y HJ
- Right subcostal incision
- Portal exposure via mobilization of duodenum, omentum, hepatic flexure away from porta
- Anterior only dissection of hepatic duct & lowering of hilar plate to expose confluence
- Fashion tension free Roux limb to RUQ - start at LOT count 20 cm distal, divide bowel with stapler, bring roux limb up to the bile duct through defect in transverse mesocolon to R of middle colic vessels
- Complete broad biliary enteric anastomosis
- Perform stapled side to side JJ anastomosis 50 cm distal; close JJ & Peter sons defect
- Leave a drain
Whipple
- Dx laparoscopy
- Enter lesser sac, expose infra pancreatic SMV, & develop plane behind neck of pancreas and encircle w umbilical tape
- Mobilize hepatic flexure and perform extended Kocher maneuver
- Cholecystectomy, portal dissection, transection of common bile duct, identification & ligation of GDA
- Transect stomach, dissect LOT, transect jejunum 20 cm distal to LOT, rotating duodenum under mesenteric vessels
- Transect pancreas @ neck & send distal margin for frozen section & complete RP dissection by removing specimen from SMV-PV & SMA margin
- Pancreatic-jejunostomy, hepatico-jejunostomy, & gastrojejunostomy & leave drains
Liver segments & partial hepatectomy steps
Partial hepatectomy general steps:
1. Mobilization
2. cholecystectomy & cannulation of cystic duct
3. isolation & control of vascular structures
4. Ligation of hepatic artery, PV, then hepatic vein
5. Division hepatic parenchyma
Functional liver remnant required in cirrhotic vs Childs A cirrhotic
No cirrhosis → 25%
Childs A → 30-40%
Work up for bile duct injury
Begin w U/S & CT
HIDA has limited role unless unable to tell from U/S & CT
MRCP with Eovist is good next step for anatomy
Next is cholangiography w ERCP vs PTC with transhepatic biliary drain
Management of BD injuries
A - cystic duct or accessory duct leaks; EHBD in continuity
B - ligation & division of anomalous R sided segmental hepatic duct; EHBD partial continuity
C - leakage from R sided anomalous duct; difficult to see with ERCP!; EHBD partial continuity
D - lateral injury to biliary tree; EHBD in continuity
Type E are “major,” EHBD not in continuity
Type A-D are “minor”
A - cystic duct or accessory duct leaks; EHBD in continuity → ERCP sphincterotomy & stent placement
B - ligation & division of anomalous R sided segmental hepatic duct; EHBD partial continuity → Roux en Y HJ if symptomatic
C - leakage from R sided anomalous duct; difficult to see with ERCP!; EHBD partial continuity → Percutaneous transhepatic biliary drainage followed by Roux en Y HJ
D - lateral injury to biliary tree; EHBD in continuity → ERCP sphincterotomy & stent placement; HJ if refractory stricture develops
Type E are “major,” EHBD not in continuity → Percutaneous transhepatic biliary drainage followed by Roux en Y HJ
Types of choledochal cysts and management
Gallbladder adenocarcinoma management
Primary tumor
T1a: invades lamina propria
T1b: invades muscle
Surgical treatment
If muscle is not involved (T1a) – cholecystectomy sufficient
If T1a, but at cystic duct margin → resect cystic duct to obtain negative margins
If in muscle but not beyond (T1b)& resectable (need CT chest/abd/pelvis)
1. Staging laparoscopy - examine port sites - convert to open if resectable
2. Portal lymph node dissection - skeletonize common hepatic artery beginning w cystic duct node, then PV, then CBD but dont devascularize…
3. Wedge resection of segments IVb and V for 2 cm negative margin
Chemotherapy: Capecitabine or Gemcitabine/Cisplatin
Management of echinococcal cysts
Depending on stage and size of the cyst, options include, Albendazole vs Albendazole w treatment (PAIR, large bore percutaneous treatment, or surgery)
PAIR = puncuture, aspiration, injection w ETOH/scolicidal agent, reaspiration
Hepatic hemangioma appearance & management
CT: Late contrast puddling is pathognomonic
PERIPHERAL enhancement on ARTERIAL phase
CENTRIPETAL filling on PORTAL VENOUS phase
Retention of contrast on washout or delayed phase
Tx: angioembolization for bleeding; enucleation if symptomatic
LI-RADS factors & score
- Arterial phase hyperenhancement
- Enhancing capsule
- Non-peripheral washout
- Threshold growth
LI-RADS score and general management
High LIRADS Scoring (4 to 5 = Heterogenous; Early arterial enhancement and washout of contrast on delayed phase) & appropriate hx is diagnostic for HCC
DONT FORGET CEA, AFP, CA199, & CHEST CT FOR STAGING
Hepatic adenoma work up & management
Hx of OCP &/or steroids
RISK OF BLEEDING & MALIGNANT TRANSFORMATION (5%)
Appears well-marginated, isointense on NC CT; HYPERINTENSE on ARTERIAL phase; rapid washout; +/- heterogenous due to hemorrhage
– No Eovist (Gd) [MRI] or sulfur colloid [NM scan] retention (no Kupffer cells) UNLIKE FNH
Management
Discontinue estrogen agents & maintain ideal body weight
Bleeding → embolize, repeat MRI in 6 months
Men → Resect
Women → Resect if symptomatic or if lesion is >5 cm or if pregnant?
FNH management
No risk of bleeding or malignant transformation
CT: homogenous mass with CENTRAL scar; HYPERINTENSE on ARTERIAL phase
Central Scar: hypoattenuating on arterial phase; hyperattenuating on delay
Eovist (Gd) and sulfur colloid uptake (+ Kupffer cells)
HCC Work Up
H&P focus on GI cancer (colonoscopies, rectal bleeding, etc) & liver disease (hepatitis, ETOH, IVDU, smoking, NASH etc) vs infection
Labs for liver fx
Child-Turcotte-Pugh score
Bilirubin, Albumin, PT, encephalopathy, ascites
MELD
Bilirubin, INR, creatinine
Need triple phase CT scan & CHEST CT
HCC management for Child-Pugh A vs B/C (hint - know Milan criteria)
Resection with 1 cm margins is appropriate if good hepatic reserve (Child-Pugh A) but all patients should be offered transplant bc high risk of recurrence
Liver Transplant: Milan Criteria (gold standard for patients with Child-Pugh B/C cirrhosis & limited hepatic reserve)
–Single lesion < 5 cm
–Up to 3 lesions, each < 3 cm
–No extra-hepatic metastatic disease or major vessel involvement
Local therapies if not candidate for surgery
–TARE: transarterial radioembolization
–TACE: transcatheter arterial chemoembolization
–HAIC: hepatic arterial infusional chemotherapy
–SBRT: stereotactic body radiation therapy
–RFA: radiofrequency ablation
Pancreatic cyst work up - dont forget to ask about these in H&P
Things to ask in history
1. ETOH, smoking, diabetes, pancreatitis
2. Hypoglycemia (Insulinoma)
3. Refractory ulcers (Gastrinoma)
4. Diabetes, dermatitis, DVT (Glucagonoma)
5. Cholecystitis, steatorrhea (Somatostatinoma)
6. Watery diarrhea (VIPoma)
Imaging & labs
1. DONT FORGET CA-19-9, CEA
2. MRCP & usually EUS with FNA to assess cyst cytology, amylase, CEA, mucin, DNA analysis (KRAS)
Pancreatic cyst features - know features, cytology, amylase levels, CEA & Mucin for 1. pseudocyst, 2. SCN/SCA, 3. MCN, 4. SPN, 5.IPMN
Resect all SPN, MCN, IPMN-MD, & IPMN-BD w borderline features
IPMN-BD high risk features
High risk features → Consider surgery without further evaluation
MRCP
–Main duct ≥10 cm
–Enhancing mural nodule ≥5 mm
–Obstructive jaundice
IPMN-BD worrisome features
Pancreatitis
Cyst ≥3 cm
Thickened/enhancing cyst wall
Main duct 5-9 mm
Non-enhancing mural nodule < 5 mm
Abrupt change in the caliber of pancreatic duct w distal atrophy, elevated CA-19-9
Need EUS/FNA
Management of IPMN-BD without high risk or worrisome features
<1 cm → CT/MRI in 2-3 years
1-2 cm → CT/MRI yearly for 2 years
2-3 cm → EUS in 3-6 m, consider surgery in young/healthy
>3 cm → EUS in 3-6 m, strongly consider surgery in young/healthy
Laparoscopic distal pancreatectomy - Spleen preserving
Hasson access, 4x 5 mm ports triangulated to LUQ, examine for mets
Mobilize stomach - enter lesser sac by separating greater omentum from transverse colon, lifting posterior gastric wall away from pancreas
Examine pancreas from duodenum to splenic hilum to verify location of lesion & relationship to main duct & vessels - identify splenic artery along superior border of pancreas
Mobilize splenic flexure to expose inferior pancreas. Mobilize pancreas away from splenic vein and artery using energy device & clips
Use stapler to divide pancreas at neck, 2 cm to right of tumor, send for frozen section (if HGD, need negative margins! LGD does not)
Mobilize pancreas off retroperitoneum, taking peripancreatic fat
Leave a drain
PNET work up
H&P - cancer risk factors (smoking, personal/family history malignancy, personal/family hx of endocrine/MEN syndrome) & endocrine symptoms -
Hypoglycemia (Insulinoma)
Refractory ulcers (Gastrinoma)
Dermatitis, DVT, diabetes (Glucagonoma)
Cholecystitis, steatorrhea (Somatostatinoma)
Watery diarrhea (VIPoma)
Labs
Fasting C peptide, insulin, glucose
Fasting gastrin
Fasting glucagon
Fasting somatostatin
Fasting VIP
Ask for EUS & bx to confirm dx, determine grade/differentiation, Ki67
Triple phase CT is usually sufficient but get Dototate-PET to r/o mets/distant disease
Management of nonfunctional PNET
Elevated Ki67
Most are malignant
<2 cm & no symptoms → observe w repeat CT in 6 months, then yearly MRI if stable
If malignant features present, formal resection necessary (includes spleen in tail)
Insulinoma diagnosis & management
Most are single & benign (90%)
Location → Evenly distributed
Sxs: “Whipple Triad:” Fasting hypoglycemia, neuroglycopenic symptoms, relief of symptoms after glucose
Dx:
Fasting glucose (Symptoms w glucose < 55 mg/dL)
Fasting Insulin > 18 pmol/L
Fasting C-peptide ≥ 0.6 ng/mL
Localization (NOT somatostatin scintigraphy; only PNET that can’t be tx w octreotide):
1. Triphasic CT/MRI___2. EUS___3. selective intra-arterial calcium injection w hepatic venous sampling for insulin
Tx: Enucleation usually ok unless close to duct then better off w formal resection
Gastrinoma diagnosis & management
Mostly malignant
Sporadic forms (80%) - usually solitary tumor within duodenum, most are cured w/ surgery
Familial forms (20%) - associated with MEN I, more aggressive
Location → Triangle (cystic duct/CBD, D2/D3, pancreas neck/body); usually arise in D1, only 25% found in pancreas
Sxs: Triad of abdominal pain, diarrhea, weight loss in setting of PUD
Dx:
Elevated fasting gastrin (>1000 pg/mL) in setting of low pH is dx
If < 1000 pg/mL → Secretin stimulation test (increased gastrin more than 120 pg/mL above basal level at 10 minutes)
Localization:
1. Triphasic CT/MRI___2. SRS___3. EUS ___4. selective arteriography___5. OR
Tx:
Need chole
Duodenal mucosa or noninvasive & < 5 cm in head of pancreas → Enucleation w LN dissection
> 5 cm or invasive in head of pancreas → Whipple
Glucagonoma diagnosis & management
Mostly malignant
Location → Tail of pancreas
Sxs: Dermatitis (necrolytic migratory erythema), Diabetes, Depression, DVT (F X-like antigen)
Dx: Glucose intolerance & fasting glucagon 1,000-5,000 pg/mL
Localization:
1. Triphasic CT/MRI___2. SRS___3. EUS ___4. selective arteriography
Tx: Resection with regional lymphadenectomy & cholecystectomy
Somatostatinoma diagnosis & management
Mostly malignant
Location → Most frequent PNET at head of pancreas
Sxs: Cholecystitis, DM, malabsorption, steatorrhea
Localization:
1. Triphasic CT/MRI___2. SRS___3. EUS ___4. selective arteriography
Tx: Resection with regional lymphadenectomy & cholecystectomy
VIPoma diagnosis & management
Mostly malignant, usually single
Location → Body or tail of pancreas (can also be extra-pancreatic)
Sxs: WDHA syndrome
Dx: Elevated fasting VIP & diarrhea
Localization:
1. Triphasic CT/MRI___2. SRS___3. EUS ___4. selective arteriography
Tx: Resection with regional lymphadenectomy & cholecystectomy
