Hepatobiliary Flashcards
Blumgart technique for bile duct cancer?
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.
2 x 2 square for liver lesions?
————————–hypointense————Isointense
homogenous————MET————————FNH
heterogenous———–HCC——————- Adenoma
Factors with minimal risk adjustment for post op liver failure after PVE/resection
<8 cycles of chemo
small droplet steatosis
<30% large droplet steatosis
optimal time to wait after RT for borderline resectable PDAC?
4-8 weeks.
MRI v pancreatic protocol CT, NCCN preference
NCCN prefers CT, mostly due to cost and availability
PET for PDAC
not recommended/unclear benefit for routine cases [NCCN]
NCCN preferred PDAC neoadjuvant regimens?
Folfirinox Gemcitabine Abraxane (albumin-bound paclitaxel)
If BRCA or PALB2mutant
Gemcitabine/Cisplatin
Surgical techniques to minimize distal pancreatic leaks?
IF you can see the duct, suture ligate it.
?Seam guard
NCCN position on SMA resection
more data necessary but reasonable in select populations.
Low bifurcation of common bile duct on whipple?
Take CBD high and do a double barrel anastomosis
PDAC with non-regional lymph node metastasis?
unresectable by NCCN criteria
Management of an undrained liver segment with ongoing bile leak?
small segment and no infection - fibrin glue and clip
IF not, may be forced into a resection.
Size cutoff for ablation of CRC mets?
very technically challenging to get ablation of tumor >3cm.
LIRADS-5
Definitly HCC with no biopsy necessary (98-99%)
Pathologic evaluation of the bile duct and pancreatic duct?
look at slide en face.
Any difference in survival outcomes between a 2 staged hepatectomy and combined hepatectomy/ablation?
Cochrain review suggests no
Solitary liver lesion
Hypointense on T1
moderate to low enhancement on CT
most likely a hepatic adenoma
PDAC in body/tail with >180 contact with celiac axis?
currently borderline resectable by NCCN since you can do an Appleby, but controversial.
Bleeding during PDAC tunneling?
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
What to do for IgG4 related sclerosing cholangitis?
Not surgical; can mimic cholangiocarcinoma
When to transplant a cholangiocarcinoma?
Must be primarily unresectable
< 3cm
no mets or nodal disease
Pancreatic drain management
would still do
check amylase and remove early if negative.
Gallbladder cancer invades lamina propria?
T1a no further therapy
How do you do your biliary reconstruction?
bring up a jejunal limb
check for back bleeding
interrupted PDS duct to mucosal sutures
Avoid resection for suspicious cytology in PDAC?
no
Factors that decrease risk of post-op liver failure after PVE/major resection?
female sex
preoperative steroids
when to do a posterior approach adrenalectomy?
BMI <40
Standardized PDAC radiology reporting regions:
SMA contact Celiac axis contact Common Hepatic Artery contact Variant artery contact Main Portal Vein contact SMV contact
What do you do while working on SMV reconstruction?
Place a Rommel tourniquet on the SMA to prevent small bowel edema.
Heparinize the patient
Local recurrence of pancreatic cancer in operative bed
Clinical trial v add RT if not done previously.
NCCN recomendation for gastric outlet/duodenal obstruction?
Gastrojejunostomy or enteral stent
How do you do a transileocolic PVE?
need to do a small laparotomy and obtain open access of the ileocolic vein.
makes procedure much easier for IR
NCCN surgical principles for SMA
skeletonize all but medial surface down to the adventitia
Metachronous CRC mets with previous chemo?
If doing upfront chemo, make sure you use a different regimen then before.
Evidence of PDAC invasion into stomach or bowel?
No longer a candidate for radiation…
GDA bleed?
Get large bore access
activate massive transfusion protocol
Go direct to angio
Ampullectomy or central pancreatectomy for oral boards?
Probably should rethink your answer…
Reexplore for a pancreatic leak?
Good retrospective data from Dutch Pancreatic Group that IR drainage is superior.
EUS for PDAC
not routinely recommended by NCCN
When do you stent before a whipple?
Bilirubin > 10 (retrospective data it reduces infectious complications)
When doing neoadjuvant therapy
NCCN guidelines for PDAC frozen section?
assure 5mm of clearance to avoid cautery artifact on bile duct and pancreatic duct
most effective methodology for PVE?
microspheres more effective than gel
Definition of growing HCC?
50% increase in volume in 6 months
Can you declare a PDAC patient to have progressive disease based on clinical deterioration and CA19-9
yes
Worst drug for hepatic function?
Irinotecan
PDAC with solid contact with IVC?
borderline resectable by NCCN.
Childs A PAtient with HCC < 2 cm?
resection
What is an Applebe procedure?
A distal pancreatectomy that takes the celiac axis and relies on retrograde flow via the GDA for hepatic perfusion.
NCCN resectable PDAC definition
No arterial contact (CA, SMA, CHA)
<180 venous contact without vessel irregularity
HCC with portal vein involvement?
no longer transplant or resection candidate
go on to TKI therapy
Arterial enhancing liver lesions with hypointensity in liver phase, and heterogenious enhancement?
HCC
Is ultrasound helpful for a Klatskin tumor?
yes, but dependent on skill; consider intraop.
Japanese protocol for PVE?
don’t wait for hypertrophy, go direct to surgery in one week
Visible tumor on scan for Klatskin
usually implies unresectable.
Utility/ significance of Kinetic Growth Rate after PVE?
if used in addition to traditional cutoff values then no mortality from liver failure if KGR>2%
(retrospective MDACC series)
“Cuban cigar” pancreas
radiologic finding suggesting autoimmune pancreatitis
LIRADS 5 lesion
>1cm HAS non-rim arterial phase enhancement HAS at least one major feature (of 3) Enhancing capsule Non-peripheral washout Threshold growth
What to do if you find more disease then expected in liver while operating and concerned about a small FLR?
can convert the procedure to an ALPS
Where do you take the CBD for a whipple?
always above the cystic duct to preserve the bloodflow.
check for backbleeding and prepare to go higher.
pancreatic protocol CT
<1mm slices
portal and pancreatic phase
multiplanar reconstruction also preferred
Partial ALPPS v total ALPPS
don’t complete the partition so that segment IV does not get ischemic
Palliation of bleeding PDAC
Endoscopy
RT
Angiography with embolization
Three technical approached to PVE?
Ipsilateral - most technically demanding
contralateral - easier but can injure the FLR
transileocolic - rarely done in US
EUS v CT biopsy for PDAC
NCCN reccomends EUS biopsy, or direct to surgery if high suspicion
Diagnostic laparoscopy before doing radiation for a PDAC?
controversial…
Mortality with traditional liver volume cutoffs
“low” 1-5%, but not zero
Intrahepatic Cholangiocarcinoma work up?
Staging imaging
Biopsy not necessary
Do diagnostic laparoscopy
How do you transect liver parenchyma
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
NCCN unresectable PDAC definition
Arterial contact >180
unreconstructable venous involvement (includes thrombus)
contact with 1st jejunal branch of SMV
Caudate lobe in hilar cholangiocarcinoma?
should generally resect, has direct communication with the bile duct at the bifurcation.
NCCN surgical principles for SMV
since desmoplasia and invasion are hard to differentiate, data supports aggressive approach to resection.
Things to do before closing if you are aborting a pancreatic cancer as unresectable?
Make sure you get a tissue biopsy for diagnosis
consider gastrojejunostomy
consider biliary bypass v metal stent
celiac plexus neurolysis
follow-up after resection of HCC?
Imaging and AFP every 3-6 months
length of induction chemotherapy for locally advanced PDAC?
4-6 months
after 6months would try RT
Metachronous CRC mets with no previous chemo?
OK to go straight to resection if simple case/fit patients
Unresectable hilar cholangiocarcinoma?
invades the secondary biliary radicals bilaterally.
When to do a segment 4b/5 resection
Tb gallbladder cancer (invades the muscular layer)
only when on hepatic side
NCCN definition of high volume pancreatic facility
15-20 cases yearly
En-bloc left adrenalectomy for distal pancreatectomy?
Go for it! May be necessary for R0 in up to 40% of resections.
[NCCN guidelines]
LIGRO RCT
randomized patients to PVE v ALPS
complete resection higher with ALPS (~90 v 60%)
mortality similar
PVE may have been poor quality
How do you do a portal lymph node dissection?
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.
Measurement of Kinetic Growth Rate after PVE?
% change in liver volume/weeks since PVE
ESPAC-3 trial
no difference between adjuvant gem or adjuvant 5FU for resectable PDAC (median OS 23 v 23.6 mo)
Need to reconstruct portal vein and cannot get ends to reach?
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
PDAC contact with variant arterial anatomy?
NCCN borderline resectable
BILCAP trial?
supports adjuvant capecitabine for resected bile duct cancer
Preop moves for Intrahepatic cholangiocarcinoma?
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.
GB cancer presents with jaundice and positive nodes?
Gem/Cis
IR transgastric drainage of a distal pancreatic leak?
mixed opinions. Would stent the pancreatic duct first. would not do in early post-operative setting.
Can’t find the pancreatic duct?
do a dunking anastomosis into the posterior wall of the stomach
Vessels to check on PDAC scan?
Look at relation to the SMA/SMV down to 1st jejunal branches.
Look at IMV, (if distal)
look for replaced arteries.
Level of evidence for not doing routine preoperative stenting of PDAC?
Level I RCT in NEJM 2010s
LAP07 trial
No added survival benefit to doing chemoradiation and gemcitabine alone for pancreatic cancer. [JAMA 2016]
NCCN biliary stent recommendations
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)
Childs C with HCC?
only option is transplant
NCCN position on neoadjuvant therapy for PDAC?
limited evidence to recommend a specific regimen outside a clinical trial or high volume center for resectable or borderline resectable disease.
Poor performance status and PDAC progression after neoadjuvant?
single agent chemotherapy or palliative RT
Interstage management of ALPPS?
last one week monitor for infection/biloma ensure good nutrition evaluate FLR with a HIBA consider futility
nodal radiation for borderline PDAC?
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.
What must you do before placing an enteral stent for PDAC?
ensure biliary drainage
Adjuvant chemo for bile duct cancer?
R0/R1 - capecitabine (BILCAP)
R2 - Gem/cis (ABC-02)
Caudate biliary dilation implies obstruction of which side of liver?
Proximal left
Surgical planning for a Klatskin tumor?
- look at arterial phase to determine sidedness.
- Look for ductal dilation.
- Look for patency of the portal vein.
- Look for atrophy.
Would you check your SMA margin?
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.
Who gets FOLFIRINOX as adjuvant after PDAC?
ECOG 0-1 status only
Intrahepatic Cholangiocarcinoma operation?
always start with diagnostic lap
Formal lobectomy with LND is probably the safer answer even though some are doing non-anatomic.
Adjuvant therapy for resected bile duct tumors?
Gemcitabine plus cisplatin
extrapolation on the basis of ABC-02 which was a RCT proving survival benefit in Stage IV.
RT for resected bile duct tumors?
no
additional systemic option besides traditional chemotherapy for unresectable PDAC?
consider testing for MSI for immunotherapy
Give RT for metastatic PDAC?
only for palliative purposes
No change in imaging of locally advanced PDAC and stable or smaller CA19-9
consider resection anyway or refer to a high volume center.
Factors that substantially increase risk of post-op liver failure after PVE/major resection?
Chemo> 8 cycles DM+obesity+irinotecan Age >75 LArge droplet steatosis Shock (pringle and do a good operation)
CONKO 001 trial
OS benefit for adjuvant gem v observation for resectable PDAC
stent SMV for pancreatic cancer?
some think is palliative for ascites
Traditional cutoffs for future liver remnant
Normal patient 20%
Extensive chemo (>8cycles) 70%
Childs A cirrhosis 60%
Is there any level I evidence that additional chemotherapy after complete resection of colorectal cancer to NED status improves survival?
No
Positive peritoneal cytology for PDAC,
NCCN statement
should be considered M1, even if resection is done.
Best standardized measurement of liver size after PVE?
Liver volume (CT scan) to body surface area ratio
three methods for enlarging the future liver remnant
PVE
double embolization (faster)
ALPS
LIRADS M
Highly likely to be an intrahepatic cholangiocarcinoma
Solitary liver lesion
intense homogenous enhancement
central scar with delayed enhancement
Focal Nodular Hyperplasia
Multiple hyperintense Liver lesions?
Most likely metastatic disease
T1b GB cancer?
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
Management by LIRADS score
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
Makuuchi algorithm for extent of hepatectomy?
Uncontrolled ascites -> no resection V Bilirubin >2 -> no resection Bilirubin 1-2 -> very limited wedges Bilirubin <1 -> use IcG functional study to determine extent
recurrence of PDAC at <6months of completion of primary therapy?
switch from gem based therapy to 5Fu based therapy
or vice-versa
When would you do a portal vein ligation?
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
Portal lymph node dissection for fibrolamellar variant of HCC?
would always do given high risk for locoregional recurrence (retrospective data)
Safe time length of Pringle?
normal liver - 1 hour
cirrhotic liver - 30 mins.
Total vascular exclusion of the liver?
Do a pringle
Also dissect under the IVC and place a Rommel tourniquet around it.
Still evidence of arterial bleeding after a pringle?
“Milk down” the tourniquet
Check for a replaced left artery
Things to do in a liver case before closing?
check for bile leak
repeat ultrasound
place drains
reattache falciform ligament
What pressure do you set the ERBE to?
40 bar
Difficulty getting around the right portal vein in dissection?
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.
How low do you want CVP for parenchymal transection?
3 mm Hg
How to you repair a bile leak?
figure-of-eight 5-0 PDS suture
Relationship between right hepatic artery and duct?
duct passes over the artery.
Need to take ducts before starting an anatomic liver dissection?
OK to wait until after parenchymal transection since anatomy becomes more apparent afterwards.
Difficulty during dissection of hepatic veins?
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!
How to do a trisectionectomy?
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
How to identify the s4 pedicle? (left anterior pedicle)
1st branches of the left PV, left HA.
clamp and confirm with ultrasound.
How to identify the s5/8 pedicle? (right anterior pedicle)
1st branches off the right PV and right HA
clamp and confirm with ultrasound
major contraindications to laparoscopic liver resection?
tumors >5cm
tumors close to hilum or outflow
Operative pearls for cryoablation of liver tumors?
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.
Labs to perform second stage of ALPPs?
trend LFTS do not do until bilirubin and INR are normal.
futile if MELD goes above 10
Trying to microwave ablate a liver tumor near a major vessel?
Do a pringle and clamp during ablation to avoid heat sink
Known gallbladder cancer, what to check on CT?
look for patency of the right hepatic artery.
may need to do a right lobe.
Parapancreatic lymph node involvement with GB cancer?
Considered N2/metastatic disease, but many centers have reported non-zero 5 year survival while taking so can take in highly selected patients.
How to identify boundaries of seg5/4b?
use ultrasound to identify R hepatic vein and follow that line down for seg 5
trying to get a roux limb to a right liver?
can go retrocolic and retro gastric for shortest length
multiple bile ducts for biliary anastomosis?
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
How to do a palliative biliary bypass?
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
Pancreas tumor attached to SMV?
Mobilize the venous confluence and complete the SMA dissection
Save the SMV resections/reconstruction for last.
Persistent pancreatic fistula?
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.
How to do surgical enteric drainage of persistent pancreatic fistula?
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.
pancreatic cyst with clear thin fluid
mucin negative
glycogen positive
CEA low
serous cystadenoma
pancreatic cyst with PAS-positive globules and cellular aspirates?
solid pseudopapillary neoplasm
pancreatic cyst with high amylase?
IPMN v pancreatic pseudocyst
pancreatic cyst with high cea?
mucinous cystic neoplasm v IPMN
eosinophilic pancreatic tumor with arthralgias and fat necrosis?
Acinar Cell Carcinoma
very rare (1%)
prognosis a little better than PDAC
treat same as PDAC given lack of other data
ruptured HCC?
bland embolization
work up and take for resection if candidate once stable
pancreatic cyst with central calcifications/central scar?
highly likely to be a benign serous cystadenoma.
serial imaging alone.
arterial phase enhancing pancreatic lesion?
PNET»_space; PDAC
When do you do liver volumetrics after PVE?
4-8 weeks
When to resect hepatocelular adenomas?
all in men
all growing or >5cm in females
stop contraceptives but don’t get pregnant
Management of solid pseudo-papillary tumor of the pancreas?
occur in young women
prognosis is excellent
retrospective data also supports metastasectomy.
Treatment for high grade stage IV PNET?
cisplatin etoposide
Bismuth classification of bile duct tumors
I - below the bifurcation
II - at the bifurcation
III - invades either the left or right duct
IV - multicentric or invades both ducts
multicystic pancreatic lesion with central scar
serous cystic neoplasm
septated pancreatic cyst with eccentric calcifications
mucinous cystic neoplasm
When to EUS a pancreatic cyst?
If not definitively identified on initial MRCP then:
Size > 1.5
Solid component
symptomatic
main duct 0.5-1cm
