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CGSO oral boards > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

Blumgart technique for bile duct cancer?

A

dissect out common bile duct. Transect just above the pancreas, continue working proximal. Need to commit early, have to accept that you may leave a R1 margin.

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2
Q

2 x 2 square for liver lesions?

A

————————–hypointense————Isointense
homogenous————MET————————FNH
heterogenous———–HCC——————- Adenoma

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3
Q

Factors with minimal risk adjustment for post op liver failure after PVE/resection

A

<8 cycles of chemo
small droplet steatosis
<30% large droplet steatosis

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4
Q

optimal time to wait after RT for borderline resectable PDAC?

A

4-8 weeks.

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5
Q

MRI v pancreatic protocol CT, NCCN preference

A

NCCN prefers CT, mostly due to cost and availability

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6
Q

PET for PDAC

A

not recommended/unclear benefit for routine cases [NCCN]

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7
Q

NCCN preferred PDAC neoadjuvant regimens?

A 
Folfirinox
Gemcitabine Abraxane (albumin-bound paclitaxel)

If BRCA or PALB2mutant
Gemcitabine/Cisplatin

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8
Q

Surgical techniques to minimize distal pancreatic leaks?

A

IF you can see the duct, suture ligate it.

?Seam guard

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9
Q

NCCN position on SMA resection

A

more data necessary but reasonable in select populations.

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10
Q

Low bifurcation of common bile duct on whipple?

A

Take CBD high and do a double barrel anastomosis

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11
Q

PDAC with non-regional lymph node metastasis?

A

unresectable by NCCN criteria

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12
Q

Management of an undrained liver segment with ongoing bile leak?

A

small segment and no infection - fibrin glue and clip

IF not, may be forced into a resection.

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13
Q

Size cutoff for ablation of CRC mets?

A

very technically challenging to get ablation of tumor >3cm.

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14
Q

LIRADS-5

A

Definitly HCC with no biopsy necessary (98-99%)

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15
Q

Pathologic evaluation of the bile duct and pancreatic duct?

A

look at slide en face.

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16
Q

Any difference in survival outcomes between a 2 staged hepatectomy and combined hepatectomy/ablation?

A

Cochrain review suggests no

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17
Q

Solitary liver lesion
Hypointense on T1
moderate to low enhancement on CT

A

most likely a hepatic adenoma

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18
Q

PDAC in body/tail with >180 contact with celiac axis?

A

currently borderline resectable by NCCN since you can do an Appleby, but controversial.

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19
Q

Bleeding during PDAC tunneling?

A

do not start tunnel until after completed wide Kocher
control the bleeding with direct pressure from below.
look for small branching vessel that could easily be controlled with a clip.
pack the tunnel with surgicel
call for backup
Get proximal and distal control

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20
Q

What to do for IgG4 related sclerosing cholangitis?

A

Not surgical; can mimic cholangiocarcinoma

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21
Q

When to transplant a cholangiocarcinoma?

A

Must be primarily unresectable
< 3cm
no mets or nodal disease

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22
Q

Pancreatic drain management

A

would still do

check amylase and remove early if negative.

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23
Q

Gallbladder cancer invades lamina propria?

A

T1a no further therapy

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24
Q

How do you do your biliary reconstruction?

A

bring up a jejunal limb
check for back bleeding
interrupted PDS duct to mucosal sutures

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25
Q

Avoid resection for suspicious cytology in PDAC?

A

no

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26
Q

Factors that decrease risk of post-op liver failure after PVE/major resection?

A

female sex

preoperative steroids

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27
Q

when to do a posterior approach adrenalectomy?

A

BMI <40

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28
Q

Standardized PDAC radiology reporting regions:

A 
SMA contact
Celiac axis contact
Common Hepatic Artery contact
Variant artery contact
Main Portal Vein contact
SMV contact
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29
Q

What do you do while working on SMV reconstruction?

A

Place a Rommel tourniquet on the SMA to prevent small bowel edema.
Heparinize the patient

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30
Q

Local recurrence of pancreatic cancer in operative bed

A

Clinical trial v add RT if not done previously.

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31
Q

NCCN recomendation for gastric outlet/duodenal obstruction?

A

Gastrojejunostomy or enteral stent

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32
Q

How do you do a transileocolic PVE?

A

need to do a small laparotomy and obtain open access of the ileocolic vein.

makes procedure much easier for IR

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33
Q

NCCN surgical principles for SMA

A

skeletonize all but medial surface down to the adventitia

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34
Q

Metachronous CRC mets with previous chemo?

A

If doing upfront chemo, make sure you use a different regimen then before.

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35
Q

Evidence of PDAC invasion into stomach or bowel?

A

No longer a candidate for radiation…

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36
Q

GDA bleed?

A

Get large bore access
activate massive transfusion protocol
Go direct to angio

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37
Q

Ampullectomy or central pancreatectomy for oral boards?

A

Probably should rethink your answer…

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38
Q

Reexplore for a pancreatic leak?

A

Good retrospective data from Dutch Pancreatic Group that IR drainage is superior.

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39
Q

EUS for PDAC

A

not routinely recommended by NCCN

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40
Q

When do you stent before a whipple?

A

Bilirubin > 10 (retrospective data it reduces infectious complications)

When doing neoadjuvant therapy

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41
Q

NCCN guidelines for PDAC frozen section?

A

assure 5mm of clearance to avoid cautery artifact on bile duct and pancreatic duct

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42
Q

most effective methodology for PVE?

A

microspheres more effective than gel

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43
Q

Definition of growing HCC?

A

50% increase in volume in 6 months

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44
Q

Can you declare a PDAC patient to have progressive disease based on clinical deterioration and CA19-9

A

yes

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45
Q

Worst drug for hepatic function?

A

Irinotecan

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46
Q

PDAC with solid contact with IVC?

A

borderline resectable by NCCN.

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47
Q

Childs A PAtient with HCC < 2 cm?

A

resection

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48
Q

What is an Applebe procedure?

A

A distal pancreatectomy that takes the celiac axis and relies on retrograde flow via the GDA for hepatic perfusion.

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49
Q

NCCN resectable PDAC definition

A

No arterial contact (CA, SMA, CHA)

<180 venous contact without vessel irregularity

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50
Q

HCC with portal vein involvement?

A

no longer transplant or resection candidate

go on to TKI therapy

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51
Q

Arterial enhancing liver lesions with hypointensity in liver phase, and heterogenious enhancement?

A

HCC

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52
Q

Is ultrasound helpful for a Klatskin tumor?

A

yes, but dependent on skill; consider intraop.

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53
Q

Japanese protocol for PVE?

A

don’t wait for hypertrophy, go direct to surgery in one week

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54
Q

Visible tumor on scan for Klatskin

A

usually implies unresectable.

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55
Q

Utility/ significance of Kinetic Growth Rate after PVE?

A

if used in addition to traditional cutoff values then no mortality from liver failure if KGR>2%

(retrospective MDACC series)

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56
Q

“Cuban cigar” pancreas

A

radiologic finding suggesting autoimmune pancreatitis

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57
Q

LIRADS 5 lesion

A 
>1cm
HAS non-rim arterial phase enhancement
HAS at least one major feature (of 3)
   Enhancing capsule
   Non-peripheral washout
   Threshold growth
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58
Q

What to do if you find more disease then expected in liver while operating and concerned about a small FLR?

A

can convert the procedure to an ALPS

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59
Q

Where do you take the CBD for a whipple?

A

always above the cystic duct to preserve the bloodflow.

check for backbleeding and prepare to go higher.

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60
Q

pancreatic protocol CT

A

<1mm slices
portal and pancreatic phase
multiplanar reconstruction also preferred

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61
Q

Partial ALPPS v total ALPPS

A

don’t complete the partition so that segment IV does not get ischemic

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62
Q

Palliation of bleeding PDAC

A

Endoscopy
RT
Angiography with embolization

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63
Q

Three technical approached to PVE?

A

Ipsilateral - most technically demanding
contralateral - easier but can injure the FLR
transileocolic - rarely done in US

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64
Q

EUS v CT biopsy for PDAC

A

NCCN reccomends EUS biopsy, or direct to surgery if high suspicion

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65
Q

Diagnostic laparoscopy before doing radiation for a PDAC?

A

controversial…

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66
Q

Mortality with traditional liver volume cutoffs

A

“low” 1-5%, but not zero

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67
Q

Intrahepatic Cholangiocarcinoma work up?

A

Staging imaging
Biopsy not necessary
Do diagnostic laparoscopy

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68
Q

How do you transect liver parenchyma

A

Talk to anesthesia about keeping CVP low
Have pringle in place
score the line of transection with the bovie
Use Erbe device to dissect
clip or staple major vessels and branches as encountered.
Argon beam
check for leaks

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69
Q

NCCN unresectable PDAC definition

A

Arterial contact >180
unreconstructable venous involvement (includes thrombus)
contact with 1st jejunal branch of SMV

70
Q

Caudate lobe in hilar cholangiocarcinoma?

A

should generally resect, has direct communication with the bile duct at the bifurcation.

71
Q

NCCN surgical principles for SMV

A

since desmoplasia and invasion are hard to differentiate, data supports aggressive approach to resection.

72
Q

Things to do before closing if you are aborting a pancreatic cancer as unresectable?

A

Make sure you get a tissue biopsy for diagnosis
consider gastrojejunostomy
consider biliary bypass v metal stent
celiac plexus neurolysis

73
Q

follow-up after resection of HCC?

A

Imaging and AFP every 3-6 months

74
Q

length of induction chemotherapy for locally advanced PDAC?

A

4-6 months

after 6months would try RT

75
Q

Metachronous CRC mets with no previous chemo?

A

OK to go straight to resection if simple case/fit patients

76
Q

Unresectable hilar cholangiocarcinoma?

A

invades the secondary biliary radicals bilaterally.

77
Q

When to do a segment 4b/5 resection

A

Tb gallbladder cancer (invades the muscular layer)

only when on hepatic side

78
Q

NCCN definition of high volume pancreatic facility

A

15-20 cases yearly

79
Q

En-bloc left adrenalectomy for distal pancreatectomy?

A

Go for it! May be necessary for R0 in up to 40% of resections.

[NCCN guidelines]

80
Q

LIGRO RCT

A

randomized patients to PVE v ALPS
complete resection higher with ALPS (~90 v 60%)
mortality similar
PVE may have been poor quality

81
Q

How do you do a portal lymph node dissection?

A

Take the gallbladder
Kocher the duodenum
Consider sending superiormost pancreatic node for frozen (consider aborting if positive)
Take the node superior to the CHA (consider frozen/aborting)
dissect and score peritoneum along the artery.
Continue to sweep the tissue laterally.

82
Q

Measurement of Kinetic Growth Rate after PVE?

A

% change in liver volume/weeks since PVE

83
Q

ESPAC-3 trial

A

no difference between adjuvant gem or adjuvant 5FU for resectable PDAC (median OS 23 v 23.6 mo)

84
Q

Need to reconstruct portal vein and cannot get ends to reach?

A

can divide splenic vein to swing things over and get more length.

Make sure splenic vein can drain via the IMV.

If IMV enters SMV, then anastomose splenic V to L. renal vein to avoid sinestral portal hypertension

85
Q

PDAC contact with variant arterial anatomy?

A

NCCN borderline resectable

86
Q

BILCAP trial?

A

supports adjuvant capecitabine for resected bile duct cancer

87
Q

Preop moves for Intrahepatic cholangiocarcinoma?

A

May be in a IHC v CRC met, make sure you have done upper and lower endoscopy and staging.

do not need a biopsy if imaging highly suspicious and unlikely to be a met.

Start case with a diagnostic laparoscopy.

88
Q

GB cancer presents with jaundice and positive nodes?

A

Gem/Cis

89
Q

IR transgastric drainage of a distal pancreatic leak?

A

mixed opinions. Would stent the pancreatic duct first. would not do in early post-operative setting.

90
Q

Can’t find the pancreatic duct?

A

do a dunking anastomosis into the posterior wall of the stomach

91
Q

Vessels to check on PDAC scan?

A

Look at relation to the SMA/SMV down to 1st jejunal branches.
Look at IMV, (if distal)
look for replaced arteries.

92
Q

Level of evidence for not doing routine preoperative stenting of PDAC?

A

Level I RCT in NEJM 2010s

93
Q

LAP07 trial

A

No added survival benefit to doing chemoradiation and gemcitabine alone for pancreatic cancer. [JAMA 2016]

94
Q

NCCN biliary stent recommendations

A 
only do for symptoms or delays (neoadj)
PTC only if ERCP not possible
short as feasible
Metal stent only if biopsy proven PDAC
fully covered SEMS stent for neoadj (removable)
95
Q

Childs C with HCC?

A

only option is transplant

96
Q

NCCN position on neoadjuvant therapy for PDAC?

A

limited evidence to recommend a specific regimen outside a clinical trial or high volume center for resectable or borderline resectable disease.

97
Q

Poor performance status and PDAC progression after neoadjuvant?

A

single agent chemotherapy or palliative RT

98
Q

Interstage management of ALPPS?

A 
last one week
monitor for infection/biloma
ensure good nutrition
evaluate FLR with a HIBA
consider futility
99
Q

nodal radiation for borderline PDAC?

A

highly controversial, most of main benefit of RT is to sterilize vascular margins and prevent local progression.

If irradiating for nodal disease, then need to do chemorads and not RT alone.

100
Q

What must you do before placing an enteral stent for PDAC?

A

ensure biliary drainage

101
Q

Adjuvant chemo for bile duct cancer?

A

R0/R1 - capecitabine (BILCAP)

R2 - Gem/cis (ABC-02)

102
Q

Caudate biliary dilation implies obstruction of which side of liver?

A

Proximal left

103
Q

Surgical planning for a Klatskin tumor?

A
  1. look at arterial phase to determine sidedness.
  2. Look for ductal dilation.
  3. Look for patency of the portal vein.
  4. Look for atrophy.
104
Q

Would you check your SMA margin?

A

No, I would skeletonize the SMA down to it’s lateral adventitia as per NCCN guidelines and thus I would not have any more tissue I could safely take.

105
Q

Who gets FOLFIRINOX as adjuvant after PDAC?

A

ECOG 0-1 status only

106
Q

Intrahepatic Cholangiocarcinoma operation?

A

always start with diagnostic lap

Formal lobectomy with LND is probably the safer answer even though some are doing non-anatomic.

107
Q

Adjuvant therapy for resected bile duct tumors?

A

Gemcitabine plus cisplatin

extrapolation on the basis of ABC-02 which was a RCT proving survival benefit in Stage IV.

108
Q

RT for resected bile duct tumors?

A

no

109
Q

additional systemic option besides traditional chemotherapy for unresectable PDAC?

A

consider testing for MSI for immunotherapy

110
Q

Give RT for metastatic PDAC?

A

only for palliative purposes

111
Q

No change in imaging of locally advanced PDAC and stable or smaller CA19-9

A

consider resection anyway or refer to a high volume center.

112
Q

Factors that substantially increase risk of post-op liver failure after PVE/major resection?

A 
Chemo> 8 cycles
DM+obesity+irinotecan
Age >75
LArge droplet steatosis
Shock (pringle and do a good operation)
113
Q

CONKO 001 trial

A

OS benefit for adjuvant gem v observation for resectable PDAC

114
Q

stent SMV for pancreatic cancer?

A

some think is palliative for ascites

115
Q

Traditional cutoffs for future liver remnant

A

Normal patient 20%
Extensive chemo (>8cycles) 70%
Childs A cirrhosis 60%

116
Q

Is there any level I evidence that additional chemotherapy after complete resection of colorectal cancer to NED status improves survival?

A

No

117
Q

Positive peritoneal cytology for PDAC,

NCCN statement

A

should be considered M1, even if resection is done.

118
Q

Best standardized measurement of liver size after PVE?

A

Liver volume (CT scan) to body surface area ratio

119
Q

three methods for enlarging the future liver remnant

A

PVE
double embolization (faster)
ALPS

120
Q

LIRADS M

A

Highly likely to be an intrahepatic cholangiocarcinoma

121
Q

Solitary liver lesion
intense homogenous enhancement
central scar with delayed enhancement

A

Focal Nodular Hyperplasia

122
Q

Multiple hyperintense Liver lesions?

A

Most likely metastatic disease

123
Q

T1b GB cancer?

A 
Don't forget to restage!
dedicated liver imaging
CT C/A/P
LFTs, CA 19-9
Then go to OR for 4b/5 resection and portal LND
124
Q

Management by LIRADS score

A

1 - 2: Repeat imaging in 6 months

3: Repeat imaging in 3 months
4: probably HCC, biopsy or repeat imaging in 3 mo
5: definitely HCC, surgery without biopsy

125
Q

Makuuchi algorithm for extent of hepatectomy?

A 
Uncontrolled ascites -> no resection
V
Bilirubin >2 -> no resection
Bilirubin 1-2 -> very limited wedges
Bilirubin <1 -> use IcG functional study to determine extent
126
Q

recurrence of PDAC at <6months of completion of primary therapy?

A

switch from gem based therapy to 5Fu based therapy

or vice-versa

127
Q

When would you do a portal vein ligation?

A

PVE shown to have identical results in most retrospective studies, but could do if PVE was technically unfeasible, or as part of a bail-out

128
Q

Portal lymph node dissection for fibrolamellar variant of HCC?

A

would always do given high risk for locoregional recurrence (retrospective data)

129
Q

Safe time length of Pringle?

A

normal liver - 1 hour

cirrhotic liver - 30 mins.

130
Q

Total vascular exclusion of the liver?

A

Do a pringle

Also dissect under the IVC and place a Rommel tourniquet around it.

131
Q

Still evidence of arterial bleeding after a pringle?

A

“Milk down” the tourniquet

Check for a replaced left artery

132
Q

Things to do in a liver case before closing?

A

check for bile leak
repeat ultrasound
place drains
reattache falciform ligament

133
Q

What pressure do you set the ERBE to?

A

40 bar

134
Q

Difficulty getting around the right portal vein in dissection?

A

Likely a small branch to the caudate.
Continue dissecting 1-2 cm up into liver parenchyma away from the bifurcation and take the right portal vein above the caudate branch.

135
Q

How low do you want CVP for parenchymal transection?

A

3 mm Hg

136
Q

How to you repair a bile leak?

A

figure-of-eight 5-0 PDS suture

137
Q

Relationship between right hepatic artery and duct?

A

duct passes over the artery.

138
Q

Need to take ducts before starting an anatomic liver dissection?

A

OK to wait until after parenchymal transection since anatomy becomes more apparent afterwards.

139
Q

Difficulty during dissection of hepatic veins?

A

don’t force anything!
can try to dissect out with the ERBE
can do the parenchymal transection and take intraparenchymally or at end of parenchymal dissection.
No change in blood loss as long as you keep CVP low!

140
Q

How to do a trisectionectomy?

A 
do basic steps of a right hepatectomy
diagnostic laparoscopy
mobilize the liver
Ultrasound assessment
dissect out the right artery, PV and RHV, MHV
Pringle
dissect parenchyma
Can identify the s4 pedicle during parenchymal transection or before
141
Q

How to identify the s4 pedicle? (left anterior pedicle)

A

1st branches of the left PV, left HA.

clamp and confirm with ultrasound.

142
Q

How to identify the s5/8 pedicle? (right anterior pedicle)

A

1st branches off the right PV and right HA

clamp and confirm with ultrasound

143
Q

major contraindications to laparoscopic liver resection?

A

tumors >5cm

tumors close to hilum or outflow

144
Q

Operative pearls for cryoablation of liver tumors?

A 
do not wash to speed thawing
make sure N2 tank is full
can freeze more than one tumor at once
do not freeze same tumor with two probes
do US to make sure ice ball is thawed with no cracks
keep UOP high after case.
145
Q

Labs to perform second stage of ALPPs?

A

trend LFTS do not do until bilirubin and INR are normal.

futile if MELD goes above 10

146
Q

Trying to microwave ablate a liver tumor near a major vessel?

A

Do a pringle and clamp during ablation to avoid heat sink

147
Q

Known gallbladder cancer, what to check on CT?

A

look for patency of the right hepatic artery.

may need to do a right lobe.

148
Q

Parapancreatic lymph node involvement with GB cancer?

A

Considered N2/metastatic disease, but many centers have reported non-zero 5 year survival while taking so can take in highly selected patients.

149
Q

How to identify boundaries of seg5/4b?

A

use ultrasound to identify R hepatic vein and follow that line down for seg 5

150
Q

trying to get a roux limb to a right liver?

A

can go retrocolic and retro gastric for shortest length

151
Q

multiple bile ducts for biliary anastomosis?

A

perform ductoplastsy with pds sutures to try and create one lumen to sew the jejunum to.

Place anterior row of pds sutures in bile duct and clamp. Hold these up to tent open the anastomosis while sewing the posterior wall

152
Q

How to do a palliative biliary bypass?

A

D’Angelica chapter; largely replaced by IR approaches, may still need to do as a bailout in an unresectable Klatskin tumor

Divide ligamentum teres (complete the umbilical fissue)

bring up a roux limb

do a side to side hepatico jejunostomy to the proximal left bile duct.

closer to the end of the jejunal limb, do a hepaticojejunostomy to the S3 bile duct.

May need to wedge out some liver and divide s3 portal branch to expose s3 bile duct

can try to needle aspirate to find the duct

153
Q

Pancreas tumor attached to SMV?

A

Mobilize the venous confluence and complete the SMA dissection

Save the SMV resections/reconstruction for last.

154
Q

Persistent pancreatic fistula?

A

control with drainage, antibiotics, TPN octreotide.
Once inflammation/sepsis is controlled get dedicated imaging (MRCP, contrast drain study?)

If fistula is persistently high and communicates directly with the duct may need to do surgical enteric drainage of fistula.

155
Q

How to do surgical enteric drainage of persistent pancreatic fistula?

A

needs to be stable patient and direct communication with the duct.

fistulagram preop

consider IV secritin to find the leak.

Open pancreas anterior to the leak.

side to duct anastomosis of a jejunal roux limb.

Alternatives include resection of distal leak and Puestow.

156
Q

pancreatic cyst with clear thin fluid
mucin negative
glycogen positive
CEA low

A

serous cystadenoma

157
Q

pancreatic cyst with PAS-positive globules and cellular aspirates?

A

solid pseudopapillary neoplasm

158
Q

pancreatic cyst with high amylase?

A

IPMN v pancreatic pseudocyst

159
Q

pancreatic cyst with high cea?

A

mucinous cystic neoplasm v IPMN

160
Q

eosinophilic pancreatic tumor with arthralgias and fat necrosis?

A

Acinar Cell Carcinoma
very rare (1%)
prognosis a little better than PDAC
treat same as PDAC given lack of other data

161
Q

ruptured HCC?

A

bland embolization

work up and take for resection if candidate once stable

162
Q

pancreatic cyst with central calcifications/central scar?

A

highly likely to be a benign serous cystadenoma.

serial imaging alone.

163
Q

arterial phase enhancing pancreatic lesion?

A

PNET&raquo_space; PDAC

164
Q

When do you do liver volumetrics after PVE?

A

4-8 weeks

165
Q

When to resect hepatocelular adenomas?

A

all in men
all growing or >5cm in females
stop contraceptives but don’t get pregnant

166
Q

Management of solid pseudo-papillary tumor of the pancreas?

A

occur in young women
prognosis is excellent
retrospective data also supports metastasectomy.

167
Q

Treatment for high grade stage IV PNET?

A

cisplatin etoposide

168
Q

Bismuth classification of bile duct tumors

A

I - below the bifurcation
II - at the bifurcation
III - invades either the left or right duct
IV - multicentric or invades both ducts

169
Q

multicystic pancreatic lesion with central scar

A

serous cystic neoplasm

170
Q

septated pancreatic cyst with eccentric calcifications

A

mucinous cystic neoplasm

171
Q

When to EUS a pancreatic cyst?

A

If not definitively identified on initial MRCP then:

Size > 1.5
Solid component
symptomatic
main duct 0.5-1cm

CGSO oral boards (7 decks)

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