Hepatobiliary Flashcards
When concerned about a bile duct injury, when to go straight to PTC instead of ERCP
if transection is definitely suspected. Otherwise, if concerned about cystic duct stump, hepatic bed, or incomplete transection, ERCP first is reasonable.
Bismuth Strasberg A
Cystic duct stump leak or duct of luska leak
Bismuth Stransburg B
LIgaiton and division of anomylous right sided segmental hepatic duct
(present as late pain, not reliably diagnosed with ERCP since both right and left main ducts opacity. Presents with persistent pain, diagnosed with MRCP.)
Bismuth Strasburg C
Same as B, but proximal duct leaks freely into abdomen.
Bismuth Strasburg D
lateral injury to extrahepatic bile duct, cautery injury or otherwise.
Bismuth Strasburg E
Disruption of biliary-enteric continuity. Will require PTC
- Greater than 2 cm from confluence
- Less than 2 cm from confluence
- Injury at confluence
- Separation of right and left hepatic ducts
- Ligation below confluence with associated ligation of right posterior duct.
Bismuth strasburg classification
Repair is HJ for all but type A (maybe Type D if no stricture)
Contraindications to immediate reapir of bile duct injury
- Inexperience
- Extensive thermal injury
- Massive blood loss
- HD instability
- Major vascular injury
Latest time to consider early repair for bile duct injury in patient doing well
72 hours. (otherwise external and internal drainage followed by elective repair 6-8 weeks)
Preoperative considerations before biliary enteric reconstruction after bile duct injury
Bile re-feeding
nurtiion
Fat soluble vitamin replacement, especially vitamin K (likely parenteral needed)
Position of right hepatic artery in relation to hepatic duct
directly posterior (principle of anterior only dissection on biliary reconstruction)
Differential for liver mass
Annual incidence of HCC in cirrhosis
3-4% per year.
Risk factors for cholangiocarcinoma
- Primary sclerosing cholangitis
- Hepatic parasitic infection (schistosomiasis)
- Hx of choledochal cysts
- Hx of choledochal stones
- cirrhosis
Most common liver mets
- far away CRC
- Second far away NET
- rare ones include breast, adrenal, sarcoma, renal, melanoma, reproductive tract
work up for liver mass
- CBC, BMP, INR, LIver profile
- Hepatitis panel
- CEA, AFP, CA19-9
- U/S and Triphasic CT
- Dodatate scan if hx of NET
Imaging for liver mass with biomarkers should be sufficient, but if a biopsy is necessary - markers to help differentiate
- Lung - TTF-1
- Breat - ER/PR
- Colon - CK-20
- Pancreaticobiliary - CK-7
LIver lesion imaging characteristics
cholangiocarcinoma (characteristics)
delayed venous enhancement.
Milan criteria
- 1 lesion less than 5 cm
- 3 less than 3 cm
- No vascular invasion or extrahepatic involvement
Screening for HCC (population and frequency)
Cirrhotics of any kind
LIver U/S and AFP every 6-12 months.
HCC imaging characteristics
arterial enhancement with venous washout
Childs pugh score
Childs A could undergo resection (except those with portal hypertension) (poor mans test - platelet count < 100k)
Childs B - only limited resection
Childs C - not suitable for resection
Future liver remnant requirements
- 20% normal patient
- 30% s/p chemotherapy
- 40% cirrhosis
Survival after resection for HCC
approximately 70% (both resection or transplant) 5 year survival
Other modes of treatment for HCC
- Radiofrequency or microwave ablation
- Chemoembolization
- Sorafenib
Key steps for liver resection for HCC
- Need central and arterial access, low CVP strategy
- Intraoperative U/S to define vascular anatomy and surveil for other lesions
- Look for distant mets
- Encircle porta for possible Pringle maneuver
- Parenchymal transection with control of bile and vascular structures.
- Post resection U/S
CRC mets appearance
hypointense lesions in portal venous phase
Causes of hyperbilirubinemia
Prior to cholecystectomy for gallstone ileus, need this imaging work up
Evaluation of CBD in case of Mirrizzi syndrome element - MRCP or ERCP
Usually can close the duodenum with transverse closure.
Surgical procedure for gallbladder cancer
- cholecystectomy
- Segment 4B and 5 resection
- portal lymphadenectomy
- bile duct resection to achieve negative margins.
Indications for prophylactic cholecystectomy
Porcelein gallbladder
Gall bladder polyps > 1 cm
Distant nodes in gallbladder cancer that make it metastatic disease
celiac or aortocaval nodes
Simple cholecystectomy appropriate for this T stage gallbladder CA
T1a
Work up for gallbladder CA
- LFTs
- multiphasic CT C/A/P
- CEA, CA19-9
- Consider staging laparoscopy
- If jaundices, MRCP
T staging for gallbladder CA
- T1a invades lamina propria
- T1b invades the muscular layer
- T2 Perimuscular connective tissue (no serosa or liver)
- T3 Invades serosa or liver or other organ)
- T4 portal vein or hepatic artery or 2 other structures
Work up for extrahepatic cholangiocarcinoma
- Multiphase CT c/a/p
- LFTs
- CEA, CA19-9
- MRCP
- IGg4
6.
Bismuth-corlette classification of hilar cholangiocarcinoma
- Common hepatic duct below level of bifurcation
- Klatskin (Altemeier) tumors at bifurcation of right and left
- A. confluence and right hepatic duct, B confluence and left hepatic duct
- Confluence and both right and left hepatic ducts
- Stricture at common and cystic duct.
prinicples of resection for hilar cholangiocarcinoma
- Must have artrial inflow
- Must have portal inflow
- Must have venous outflow
- Must have biliary drainage.
- Must have enough liver (FLR)
Is portal vein or hepatic artery invovlement a contraindication to resection for extrahepatic cholagnio
NO
Candidate for transplant for extrahepatic cholangio
tumor < 3 cm
No nodal disease
No intrahepatic or extrahepatic metastatic diasease.
5 types of choledochal cysts and their treatments
- fusiform dilation of CBD; resection, chole, HJ
- saccular cyst off of CBD; resection and closure
- distal CBD; sphincterotomy and endoscopic unroofing (low risk of cancer, so resection not always performed)
- Intra and extrahepatic dilations; resection which may involve hepatectomy, chole, and HJ
Thickness of gallbladder wall associated with cholecystitis
> 4mm
Diameter of dilated CBD
> 6 mm
Young pateint without cirrhosis with HCC - type? and marker?
Fibrolemmelar variant
Neurotensin
Most common cause of pyogenic liver abscesses
cholangitis
Most effective imaging modality to detect small liver mets
Intraoperative U/S (MRI and CT are equivalent)
Most common implicated etiology of Budd Chiari
myeloproliferatrive disorders
Most common cause of acute liver failure in the USA
Acetaminophen toxicity (followed by inderminate)
Order of operations for partial hepatectomy
cholecystectomy, ligation of artery, portal vein, the hepatic vein
Examples of 2 liver flukes
Clonorchis, Opisthorchis
Hepatic pressure gradients and their clinical correlates
Normal
Portal HTN
Varices
Variceal bleeding and ascites
6-9 mm Hg
9-12 mm Hg
> 12 mm Hg
Contraindication to percutaneous drainage of liver abscess
massive ascites
