Hepatobiliary Surgery Flashcards

1
Q

A 55 year old accountant has jaundice and a temperature of 39oC. He is known to have gallstones. Blood cultures have grown a gram negative bacilli. Imaging shows a bile duct measuring 1.2cm in diameter. What is the best treatment option?

	PTC and stent
	PTC and drain
	ERCP and stent
	MRCP
	USS
A

ERCP and stent

Note the question states treatment option, this excludes MRCP and USS which are not treatments. Whilst PTC may access the duct, the drains may displace easily and the transduodenal route is the preferred first line access.

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2
Q

A 65 year old man is admitted with jaundice and investigations demonstrate a carcinoma of the pancreatic head. An ERCP is attempted but the surgeon is unable to cannulate the ampulla. What is the best course of action?

Whipples procedure
Laparotomy and formation of hepatico-jejunostomy
Percutaneous transhepatic cholangiogram and drain
External beam radiotherapy
Laparotomy and duodenoduodenostomy
A

Cancer of the pancreatic head will cause obstructive jaundice and intrahepatic duct dilatation. When an ERCP has failed the most appropriate option is to attempt a PTC. This procedure is always preceded by an ultrasound (which presumably this patient has already had or they would not be undergoing an ERCP). Prior to performing the PTC it is important to stage the disease and establish resectability or not. This is because the PTC drains frequently dislodge and fall out. It is usually desirable to pass a stent at the time of doing the PTC to mitigate the effects of this problem.

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3
Q

A 67 year old lady presents with jaundice and abdominal pain. Her investigations show a dilated common bile duct, a carcinoma of the pancreatic head compressing the pancreatic duct. Her liver contains bi-lobar metastasis. What is the most appropriate course of action?

Undertake synchronous resection of liver metastases and pancreatoduodenectomy
Resection of liver metastases, chemotherapy and then resection of the primary lesion
Insertion of endoscopic biliary stent and consideration of palliative chemotherapy
Palliation alone
Insertion of PTC and palliation
A

Insertion of endoscopic biliary stent and consideration of palliative chemotherapy

The presence of metastatic disease in the context of pancreatic cancer renders this incurable and resection of metastatic disease is not appropriate.

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4
Q

A 43 year old lady presents with 24 hour history of generalised right upper quadrant pain. On admission, she is septic and jaundiced and there is tenderness in the right upper quadrant. What is the most likely diagnosis?

	Cholecystitis
	Cholangitis
	Gallbladder empyema
	Gallbladder abscess
	Liver abscess
A

A combination of sepsis and jaundice generally favors a diagnosis of cholangitis. Conditions such as empyema may cause sepsis but not marked jaundice, the same is also true of the other differentials listed

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5
Q

A 23 year old lady is admitted with right upper quadrant pain. On examination, she is tender in the right upper quadrant. Imaging shows signs of acute cholecystitis due to gallstones. The CBD appears normal. Liver function tests are normal. What is the most appropriate course of action?

Laparoscopic cholecystectomy during the next 24-48 hours
Open cholecystectomy during the next 24-48 hours
Laparoscopic cholecystectomy 3 months following resolution of the attack
Open cholecystectomy 3 months following the attack
Laparoscopic cholecystectomy after 5 days of intravenous antibiotics
A

In most cases the treatment of choice for acute cholecystitis is an acute cholecystectomy performed early in the illness. Delayed surgery particularly around 5- 7 days after presentation is much more technically challenging and is often best deferred. In most cases the procedure can be performed laparoscopically, even when acute inflammation is present.

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6
Q

An 82 year old lady is taken to theatre for a common bile duct exploration. She has a stone impacted at the distal aspect of the common bile duct and despite best efforts it proves impossible to remove it. What is the best course of action?

	Close the bile duct over a T Tube and arrange for a stent to be placed
	Undertake a choledochoduodenostomy
	Arrange for a repeat ERCP
	Construct a hepaticojejunostomy
	Bypass the gallbladder onto the jejunum
A

If a stone cannot be removed at surgery then the chances of succeeding at ERCP are slim. In this case, its probably best to bypass the distal bile duct and a choledochoduodenostomy is the best way of achieving this. There are long term risks of cholangitis which are less of a concern in older patients.

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7
Q

A 53 year old alcoholic develops acute pancreatitis and is making slow but reasonable progress. He is troubled by persisting ileus and for this reason a CT scan is undertaken. This demonstrates a large pancreatic pseudocyst. This is monitored by repeat CT scanning which shows no resolution and he is now complaining of early satiety. What is the best course of action?

	Pancreatectomy
	Emergency cystogastrostomy
	Elective cystogastrostomy
	ERCP
	Staging laparotomy to assess severity
A

Elective cystogastrostomy

Drainage of this man’s pseudocyst is required. This could be accomplished radiologically or endoscopically or surgically. As the other options are not on the list this is the best option from those available.

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8
Q

A 40 year old woman is admitted with abdominal pain. She has suffered from repeated episodes of this colicky right upper quadrant pain. On examination, she is pyrexial with right upper quadrant peritonism. Her blood tests show a white cell count of 23. However, the liver function tests are normal. An abdominal ultrasound scan shows multiple gallstones in a thick walled gallbladder, the bile duct measures 4mm. What is the best course of action?

Administration of broad spectrum intravenous antibiotics and perform a delayed open cholecystectomy in 3 months
Arrange a radiological cholecystotomy
Undertake a laparoscopic cholecystectomy
Undertake an open cholcystectomy
Administration of broad spectrum intravenous antibiotics and perform a delayed laparoscopic cholecystectomy in 3 months
A

This lady has acute cholecystitis and needs an acute cholecystectomy. This operation should usually be performed within 72 hours of admission. Delay beyond this timeframe will usually result in increased operative complications and most surgeons would administer antibiotics and perform and interval cholecystectomy if the early window for an acute procedure is missed. A bile duct measuring 4mm is usually normal.

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9
Q

A 48 year old lady is admitted with attacks of biliary colic and investigations show gallstones. A laparoscopic cholecystectomy is performed. The operation is technically challenging due to a large stone impacted in Hartmans pouch. Following the operation she fails to settle and becomes jaundiced and has bile draining into a drain placed at the surgical site. What is the best course of action?

	Arrange an ERCP
	Undertake a laparotomy
	Arrange an abdominal USS
	Arrange an MRCP
	Arrange an abdominal CT scan
A

In this scenario it must be assumed that the bile duct has been damaged. In most cases an ERCP is the most appropriate investigation. This can also allow the passage of a stent if this is deemed to be safe and sensible. Other imaging modalities will add little to overall management and simply add delay.

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10
Q

A 73 year old lady undergoes a laparotomy and a gallstones ileus is identified. The gallbladder itself is densely adherent to the duodenum. What is the correct course of action?

Milk the gallstones into the colon and leave the gallbladder
Remove the gallstones from the small bowel, resect the gallbladder and close the duodenal defect transversely
Remove the gallstones from the small bowel and perform a subtotal cholecystectomy
Remove the gallstones from the small bowel and undertake a cholcystostomy
Remove the gallstones from the small bowel and leave the gallbladder alone
A

In gallstone ileus leave the gallbladder alone

The gallstones should always be removed, the enterotomy site is proximal to the site of obstruction.

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11
Q

Which of the following is the most sensitive blood test for diagnosis of acute pancreatitis?

	Amylase
	Lipase
	C-peptide
	Trypsin
	Trysinogen
A

The serum amylase may rise and fall quite quickly and lead to a false negative result. Should the clinical picture not be concordant with the amylase level then serum lipase or a CT Scan should be performed.

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12
Q

A 72 year old man undergoes a distal gastrectomy for carcinoma of the stomach. He presents with jaundice approximately 8 months post operatively. Ultrasound of the liver and bile ducts shows no focal liver lesion and normal calibre common bile duct with intra hepatic duct dilatation. What is the most likely explanation?

	Peri hilar lymphadenopathy
	Fitz- Hugh Curtis syndrome
	Gilberts syndrome
	Mirizzi syndrome
	Gallstones
A

Unfortunately metastatic disease is the most likely event. Peri hilar lymphadenopathy would be a common culprit.

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13
Q

A 59 year old man is diagnosed as having carcinoma of the pancreas with two malignant deposits in the right lobe of the liver. What is the most appropriate treatment?

Palliative chemotherapy
Liver resection followed by chemotherapy
Simultaneous resection of liver metastasis and en bloc segmental pancreatic resection
Pancreatic resection followed by liver resection once recovered
Radical radiotherapy followed by surgery
A

Pancreatic cancer has a poor prognosis and most cases have metastatic disease at presentation. There is no role in pancreatic cancer for liver resection together with pancreatic surgery as there is no survival benefit. Most centres will offer palliative chemotherapy which has improved both longevity and quality of life.

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14
Q

A 34 year old lady is admitted with jaundice and undergoes an ERCP. The procedure is technically difficult and she is returned to the ward still jaundiced. Unfortunately she now has severe generalised abdominal pain. What is the best course of action?

	Arrange abdominal MRI scan
	Arrange MRCP
	Arrange an abdominal CT scan
	Undertake a laparotomy
	Undertake a laparotomy and biliary bypass
A

There are two main differential diagnoses here. One is pancreatitis, repeated trauma to the ampulla and duct (if partially cannulated) is a major risk factor for pancreatitis. The second is the possibility that the duodenum has been perforated. ERCP is performed using a side viewing endoscope, the manipulation of which can be technically challenging for the inexperienced operator in a patient with abnormal anatomy. A CT scan is the best investigation to distinguish between these two differential diagnoses.

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15
Q

A 58 year old woman is admitted with an attack of severe acute pancreatitis. She is managed on the intensive care unit and is making progress. She then deteriorates and a CT scan shows extensive pancreatic necrosis (>40%). There are concerns that this may have become infected. What is the correct course of action?

	Undertake a fine needle aspiration of the area
	Perform a pancreatic necrosectomy
	Perform a Whipples procedure
	Arrange an ERCP
	Perform a distal pancreatectomy
A

When there are concerns that pancreatic necrosis may have become infected the usual approach is to perform an image guided FNA for culture. There is always the risk of seeding infection with such a strategy so it must be performed with care. Pancreatic necrosectomy is not usually undertaken until the presence of infection is proven.

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16
Q

A 41 year old lady with colicky right upper quadrant pain is identified as having gallstones on an abdominal ultrasound scan. What is the most appropriate course of action?

	Laparoscopic cholecystectomy
	Open cholecystectomy
	Liver function tests
	MRCP
	ERCP
A

Liver function testing is part of the core diagnostic work up of biliary colic and surgical planning cannot proceed until this (and the diameter of the CBD on USS) are known.

17
Q

A 34 year old lady is undergoing a laparoscopic cholecystectomy for cholecystitis. She has been unwell for the past 10 days. On attempting to dissect the gallbladder (which is distended), all that can be seen are the gallbladder fundus and dense adhesions make it difficult to dissect Calots triangle. What is the best course of action?

Perform an operative cholecystostomy
Dissect the adhesions off Calots triangle and continue with the cholecystectomy
Dissect out the bile duct and perform a cholangiogram
Arrange an ERCP
Arrange a PTC
A

If only the fundus can be seen, then it may be difficult to even proceed with a sub total cholecystectomy. Therefore, a cholecystostomy can be performed and this will usually allow the situation to settle. Definitive surgery can then be undertaken in more favourable circumstances.

18
Q

A 63 year old man is admitted to ITU with an attack of severe gallstone pancreatitis. He requires ventillatory support for ARDS. Over the past few days he has become more unwell and a CT scan is organised. This demonstrates an area of necrosis, culture from this area shows a gram negative bacillus. His CRP is 400 and WCC 25.1. What is the best course of action?

	Whipples procedure
	Distal pancreatectomy
	Pancreatic necrosectomy
	Pylorus preserving pancreatoduodenectomy
	ERCP
A

This man requires necrosectomy as he has infected pancreatic necrosis and is haemodynamically unstable. A radiological drainage procedure is unlikely to be sufficient.

19
Q

A 41 year old lady is admitted with colicky right upper quadrant pain. On clinical examination she has a mild pyrexia and is clinically jaundiced. An ultrasound scan is reported as showing gallstones and the patient is taken to theatre for an open cholecystectomy. At operation, Calots triangle is almost completely impossible to delineate. What is the most likely explanation?

	Mirizzi syndrome
	Carcinomatosis
	Bile duct strictures
	Fitz - Hugh Curtis syndrome
	Carcinoma of the head of the pancreas
A

In Mirizzi syndrome the gallstone becomes impacted in Hartmans pouch. Episodes of recurrent inflammation occur and this causes compression of the bile duct. In severe cases this then progresses to fistulation. Surgery is extremely difficult as Calots triangle is often completely obliterated and the risks of causing injury to the CBD are high.

20
Q

A 42 year old female presents with symptoms of biliary colic and on investigation is identified as having gallstones. Of the procedures listed below, which is most likely to increase the risk of gallstone formation?

	Partial gastrectomy
	Jejunal resection
	Liver lobectomy
	Ileal resection
	Left hemicolectomy
A

Bile salt reabsorption occurs at the ileum. Therefore cholesterol gallstones form as a result of ileal resection

21
Q

A 43 year old woman is admitted with acute cholecystitis and fails to settle. A laparoscopic cholecystectomy is being performed. At operation, the gallbladder has evidence of an empyema and Calots triangle is inflamed and the surgeon suspects that a Mirizzi syndrome has occurred. What is the best course of action?

Undertake an operative cholecystostomy
Perform a sub total cholecystectomy
Perform a laparotomy
Perform an exploration of the common bile duct
Continue to explore Calots triangle and complete the operation
A

This will address the acute sepsis and resolve the situation. Attempts at completing the surgery at this stage, even in expert hands carries a very high risk of bile duct injury.

22
Q

A 68 year old man with type 2 diabetes is admitted to hospital unwell. On examination, he has features of septic shock and right upper quadrant tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder. What is the most likely diagnosis?

	Acute calculous cholecystitis
	Acute acalculous cholecystitis
	Cholangitis
	Mirizzi syndrome
	Sphincter of oddi dysfunction
A

This is the classic description of acalculous cholecystitis and its commonest in patients with type 2 diabetes. If you answered it incorrectly, ensure that you were not caught out by the acute calculous cholecystitis as this is a common exam mistake if options are mis read in a rush.

23
Q

A 43 year old male with long standing chronic hepatitis is being followed up. Recently his AFP is noted to be increased and an abdominal USS demonstrates a 2cm lesion in segment V of the liver. What is the most appropriate course of action?

	PET CT scan
	Liver MRI
	USS guided liver biopsy
	Laparoscopic biopsy
	Segmental resection of segment V
A

Liver MRI

Liver lesions that are suspicious of HCC should be scanned prior to resection as there is a risk of multifocal lesions that would either preclude or otherwise affect the decision to proceed with segmental resection.

24
Q

A 45 year old man presents with an episode of alcoholic pancreatitis. He makes slow but steady progress. He is reviewed clinically at 6 weeks following admission. He has a diffuse fullness of his upper abdomen and on imaging a collection of fluid is found to be located behind the stomach. His serum amylase is mildly elevated. Which of the following is the most likely explanation?

	Early fluid collection
	Pancreatic abscess
	Peripancreatic necrosis
	Pseudocyst
	Sterile necrosis
A

Pseudocysts are unlikely to be present less than 4 weeks after an attack of acute pancreatitis. However, they are more common at this stage and are associated with a raised amylase.

25
Q

A 34 year old lady is admitted with pancreatitis. The aetiology is unclear and it is classified as an attack of moderate severity according to the Glasgow criteria. Her imaging shows no gallstones and fluid around the pancreas. Which of the following is the most appropriate initial management option?

	Laparotomy
	Laparoscopy
	Radiological aspiration of the fluid
	Active observation
	Administration of octreotide
A

Acute early fluid collections are seen in 25% of patients with pancreatitis and require no specific treatment. Attempts at drainage may introduce infection and result in pancreatic abscess formation.

26
Q

A 63 year old man is admitted with obstructive jaundice that has developed over the past 3 weeks. He was previously well and on examination has a smooth mass in his right upper quadrant. What is the most likely underlying diagnosis?

	Mirizzi syndrome
	Bile duct stones
	Carcinoma of the pancreas
	Benign bile duct stricture
	Chronic cholecystitis
A

Carcinoma of the pancreas (Courvoisiers law!). The development of jaundice in association with a smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy. A bile duct stricture would not present in this way, all the other choices are related to gallstones.

27
Q

A 43 year old lady presents with an attack of acute pancreatitis. It is classified as a mild attack on severity scoring. Imaging identifies gallstones but a normal calibre bile duct, and a peripancreatic fluid collection. Which of the following management options is most appropriate?

Intravenous octreotide
Cholecystectomy once the attack has settled
Nasogastric tube drainage of the stomach
Insertion of a radiological drain
Avoidance of enteral feeding
A

Patients with gallstone pancreatitis should undergo early cholecystectomy.
Enteral feeding helps minimise gut bacterial translocation and should be given to most patients with pancreatitis. Many studies have evaluated the role of octreotide in reducing pancreatic secretions and shown no benefit (Uhl W et al Gut 1999 45:97-104, McKay C et al. Int J Pancreatol 1997; 21: 13-19).
The use of antibiotics in pancreatitis is controversial. However, a Cochrane review has presented reasonable evidence in favor of administration of imipenem to prevent infection in established necrosis.

28
Q

A surgeon is undertaking a cholecystectomy for cholecystitis secondary to gallstones. The operation is difficult and views of Calots triangle are poor. Unfortunately the distal aspect of the bile duct is transected. What is the most appropriate course of action?

Perform a primary sutured repair
Repair the defect over a T tube
Place drains and close the wounds and discuss with a hepatobiliary surgeon
Repair the defect with a Roux en Y choledochojejunostomy
Repair the defect with a choledochoduodenostomy
A

Bile duct injuries have worse outcomes if the repair is performed by the surgeon who created the injury and also if the surgeon is not an HPB surgeon.

29
Q

A 43 year old lady with repeated episodes of abdominal pain is admitted with small bowel obstruction. A laparotomy is performed and at surgery a gallstone ileus is identified. What is the most appropriate course of action?

Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Leave the gallbladder in situ.
Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Remove the gallbladder.
Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Perform a choledochoduodenostomy.
Remove the gallstone from an enterotomy at the site of the obstruction and leave the gallbladder in situ.
Remove the gallstone from an enterotomy at the site of the obstruction and remove the gallbladder.
A

Gallstone ileus occurs as a result of the fistula developing between the gallbladder and the duodenum. These tend to become impacted somewhat proximal to the ileocaecal valve and cause small bowel obstruction. The correct management is to remove the gallstone from an enterotomy proximal to the site of stone impaction. The bowel at the site of impaction itself may not heal well and an enterotomy performed at this site may well result in the need for a resection. The standard surgical teaching is that under almost all circumstances the gallbladder should be left in situ, as the anatomy in this area is often hostile and unpredictable. Disconnecting it from the duodenum leaves a large defect that is difficult to close.

30
Q

A 42 year old lady presents with right upper quadrant pain and a sensation of abdominal fullness. An ultrasound scan demonstrates a 6.5 cm hyperechoic lesion in the right lobe of the liver. Serum AFP is normal. What is the most likely underlying lesion?

	Liver cyst
	Haemangioma
	Hepatocellular carcinoma
	Liver metastasis
	Liver cell adenoma
A

A large hyperechoic lesion in the presence of normal AFP is likely to be a haemangioma. An HCC of equivalent size will almost always result in rise in AFP.

31
Q

Following an uncomplicated laparoscopic cholecystectomy a patient is found to have a bile leak. An ERCP is performed and leakage is noted from the cystic duct. What is the most appropriate course of action?

Undertake a sphincterotomy and place a stent in the common bile duct
Undertake a laparoscopy and place a T tube into the bile duct
Start the patient on TPN and keep them nil by mouth
Transfer the patient for a biliary bypass procedure
Place a transhepatic biliary stent
A

Undertake a sphincterotomy and place a stent in the common bile duct

Cystic stump leaks following cholecystectomy can be managed with ERCP and stent

32
Q

A 43 year old lady presents with jaundice and is diagnosed as having a carcinoma of the head of the pancreas. Although she is deeply jaundiced, her staging investigations are negative for metastatic disease. What is the best method of biliary decompression in this case?

	ERCP and sphincterotomy alone
	ERCP alone
	ERCP and placement of stent
	Cholecystostomy
	Choledochoduodenostomy
A

A stent is the best option for biliary decompression in resectable disease. Surgical bypasses have no place in the management of operable malignancy as a bridge to definitive surgery.

33
Q

A 34 year old women is admitted with cholangitis. Her bilirubin is 180 and alkaline phosphatase is 348. She becomes progressively more unwell and develops abdominal pain. The F1 checks her amylase which is elevated at 1080. Standard treatment is initiated and her Glasgow score is 3. What is the most appropriate course of action?

	ERCP
	PTC
	Laparotomy
	Pancreatic necrosectomy
	Cholecystectomy
A

She requires urgent decompression of her biliary system. An ERCP is the conventional method of performing this. It is important to ensure that her coagulation status is normalised prior to performing this procedure

34
Q

A 22 year old teacher is admitted with severe epigastric pain. Serum amylase is normal. You wish to exclude a perforated viscus, and determine whether pancreatitis is present. What is the best course of action?

Order an erect CXR and plain abdominal film
Request an abdominal USS
Request a CT scan of the abdomen and pelvis with intravenous contrast
Request a non contrast CT scan of the abdomen and pelvis
Request a magnetic resonance cholangiopancreatography scan
A

A CT scan with IV contrast is needed, without contrast only the perforated viscus question can be answered.

35
Q

What proportion of patients presenting for cholecystectomy for treatment of biliary colic due to gallstones will have stones in the common bile duct?

	10%
	30%
	2%
	50%
	25%
A

Up to 10% of all patients may have stones in the CBD. Therefore, all patients should have their liver function tests checked prior to embarking on a cholecystectomy.

36
Q

Which of the following is false during the pre operative preparation for surgery in pancreatic cancer?

IV antibiotics should be given intra operatively
Endotoxaemia can be reduced with lactulose
Subcutaneous heparin should be avoided
Endotoxaemia can be reduced with IV mannitol
There is a higher risk of complications if the bilirubin is greater than 150
A

Vitamin K should be given to correct abnormal clotting initially, however there is still a risk of thrombosis so low molecular weight heparin should be used. Bile salts can also be given to reduce endotoxaemia. Biliary obstruction should be relieved. In the case of biliary obstruction, if a stent is used it should be a made of plastic. Metallic stents will become embedded and may compromise attempts at resection.