Hepatobiliary Surgery Flashcards
What are the functions of the gallbladder?
Bile reservoir
Concentrates bile
Secretes after meal - CKK
Why do surgeons need to be careful when performing surgery on gall bladder?
Anatomical variation
What are some diseases of the gall bladder?
Gallstone disease
Benign - cholesterosis and GB polyps
What is the composition of gallstones?
Mixed - cholesterol and pigment
20% just cholesterol or pigment
What are the risk factors for gall stones?
Age, gender (female), oral contraception pill, cholesterol and pigment
What is the presentation of gall stones?
Asymptomatic
Dyspeptic symptoms
Biliary colic - attack
Acute cholecystitis
Empyema, perforation
Jaundice
Describe choledocholithiasis
Primary - stones developed in bile duct
Secondary - stones jumped into bile duct
Can get post-cholecystectomy pain
What can be caused from choledocholithiasis?
Obstructive jaundice (painful) -pale stools, itching, steatorrhea
Acute pancreatitis
Ascending cholangitis - jaundice, fever, pain and rigors
What are the investigations used for gallstones?
USS, EUS
Radio isotope scan (HIDA)
ERCP
What bloods are done for gallstone investigation?
LFTs, ALT, AST, ALP
Amylase, lipase
WCC
What is the management for asymptomatic gallstones?
Nothing
What are some non-operative treatments for gallstones?
Dissolution - thin out solution, oxycolic acid
Lithotripsy - breaks down stones
What are the operative treatments for gall stones?
Open or mini cholecystectomy
Laparoscopic cholecystectomy is gold standard
NOTES
Single port
Describe laparoscopic cholecystectomy
Best option
Port in umbilicus
Less wound infections
Keyhole surgery
What is used for management of CBD stones?
Expectant treatment - incidental
Lap exploration
Open exploration
ERCP
Transhepatic stone retrieval
What are some congenital benign biliary tract diseases?
Biliary atresia
Choledochal cysts
What are some benign biliary strictures?
Iatrogenic
Gallstone related
Inflammatory
Describe biliary atresia
Born without bile duct
Treated with reconstruction and may need transplant
Describe choledochal cysts
Dilation of BD in different locations
Recommended BD removed and reconstructed
Risk of cancer
Describe Iatrogenic bile duct injuries?
Strasberg classification
Bile duct injury performing cholecystectomy
Management is surgery reconstruction
Describe primary sclerosing cholangitis
Autoimmune condition
Dilation and stones which give beading pattern
Need bio-thinning meds and under observation
Describe biliary enteric fistula
Bile flows along an abnormal connection from the bile ducts into a nearby hollow structure
Can present with air in BD
What are some malignant cancers which cause jaundice?
Cholangiocarcinoma - intra and extrahepatic
Gallbladder cancer
Ampullary cancer
Cancer of head of pancreas
What are the risk factors of cholangiocarcinoma?
PSC, congenital cystic disease, biliary enteric drainage, thorotrast, carcinogens
What are the three types of intrahepatic cholangiocarcinoma?
Mass forming
Peri-ductal
Intra-ductal
What is the treatment for intrahepatic cholangiocarcinoma?
Surgery is only option
What is the presentations of cholangiocarcinoma?
Obstructive jaundice
Itching
Non specific symptoms - weight loss, vomiting
What investigations are used for cholangiocarcinoma?
Lab
Radiology - USS, EUS, CT, MRA, MRCP and PET
ERCP, cholangioscopy
What is the management for cholangiocarcinoma?
Surgical but only 10% of patients can be fit
Palliative
What is the palliative treatment for cholangiocarcinoma?
Surgical bypass, stenting, radiotherapy, chemo, PDT
Describe gallbladder cancer
Aggressive
Poor prognosis
Treatment depends on stage
What are the treatment options for ampullary tumours?
Endoscopic excision
Trans-duodenal excision
Pancreatico-duodenectomy is gold standard
