Hepatobilliary Flashcards
rate of patient’s that develop type 1 diabetes after distal pancreatectomy
10%
location of beta islet cells in pancreas
predominately in the tail of the pancreas
function of beta islet cells in pancreas
produce insulin
in what cells is insulin produced in the pancreas
beta islet cells
when would you perform a Puestow procedure
- pancreatic duct dilation 1-2 cm away from the head of the pancreas
- ductal dilation > 6 mm
another name for the puestow procedure
lateral pancreaticojejunostomy
when would you perform the Frey procedure
for pancreatic obstruction at the head with distal duct dilation
Describe the Frey procedure
pancreatic head resection with a 1 cm remnant at the duodenal margin, with lateral pancreaticojejunostomy to decompress the distal pancreas
Indication for Berger procedure
- pancreatic head inflammatory mass that is NOT cancer
- without distal main duct obstruction/dilation
dissecting out distal portion of pancreas for distal pancreatectomy, you notice blood oozing after you liberate inferior portion of pancreas. What did you injure?
splenic vein
Grey-Turner sign
- discoloration at the flanks secondary to inflammatory extravasation from pancreatitis
Cullen Sign
- periumbilical discoloration secondary to extravasation of inflammatory fluid from pancreatitis
25 year old male recently traveled to Africa, returns with 2 weeks of RUQ pain fever, malaise, and weight loss. US of liver shows fluid collection
Amebic infection
first line treatment for amebic liver abscess
metronidazole
what is one great thing about pancreatic neuroendocrine tumors, if low grade
- great prognosis if all lesions are resected, no need for neoadjuvant chemotherapy
what test do you perform to assess a functional liver remnant prior to hepatic resection
CT with 3D reconstruction
patient with chronic pancreatitis, plan is for palliative surgery to address pain and biopsy shows rare atypical cells…what should you worry about
pancreatic cancer, and therefore this patient requires oncologic resection
most common liver lesion in an otherwise healthy female
hemangioma
liver lesion with peripheral nodular enhancement in the arterial phase with central filling in the delayed phase
hemangioma
liver lesion with arterial enhancement and washout on delayed imaging
hepatocellular carcinoma
liver lesion with rim enhancement on CT scan with contrast
hepatic abscess
indications to operate on a pancreatic pseudocyst
- persistant abdominal pain
- feeding intolerance
- inability to exclude cystic neoplasm
T1a gall bladder cancer
cancer limited to the mucosa
T1b gall bladder cancer
cancer invading the muscularis
gall bladder cancer invading the muscularis is given what T stage
T1b
at what T stage in gall bladder cancer should you pursue hepatic resection of segments IVb and V
T1b and greater
OR
T1a with positive margins on pathology
Branch Duct Intraductal papillary mucinous neoplasm features that would necessitate resection
- obstructive jaundice
- enhancing solid component
- main duct dilation greater than 1 cm
BD-IPMN worrisome features that would necessitate endoscopic imaging and possible resection
- IPMN greater than 3 cm
- non-enhancing mural nodules
- thickened enhancing cyst walls
- main duct 5-9 mm in siz / abrupt caliber change
- lymphadenopathy / pancreatitis
type 1 choledochal cyst
fusiform dilation of the CBD w/o intrahepatic involvement
type 2 choledochal cyst
diverticulum off of the CBD
type 4a choledochal cyst
- single fusiform dilation of the extra hepatic bile ducts
- plus dilation of the intrahepatic ducts
-type 4b choledochal cyst
multiple extra hepatic ductal dilations
type 5 choledochal cyst
- bonus points for eponym
intrahepatic bile duct cysts only
- Caroli disease
what is associated with choledochal cysts and thought to contribute to their development
anomalous pancreatobiliary junction
what metabolic derangements would you expect in a patient with a VIPoma?
- achlorhydria
- hypokalemia
- hypercalcemia
- hyperglycemia
- acidosis
what is achlorhydria, and why is it relevant
- inability of the stomach to secrete HCl
- in VIPomas you see this phenomenon, contributes to acidosis seen in VIPomas
Epynomen for VIPoma
Verner-Morrison Syndrome
What is Verner-Morrisone Syndrome
- Patient with a VIPoma
how long should your lateral pancreatojejunostomy be in a Puestow Procedure?
studies show improved outcomes with an at least 6 cm anastomosis
fluid characteristics of a pancreatic serous cyst
- CEA: low
- Fluid quality: clear
- Amylase: low
- Mucin staining: negative
fluid characteristics of a pancreatic mucinous cyst neoplasm
- CEA: High
- fluid quality: thick
- Amylase: low
- Mucin Staining: Positive
fluid characteristics of a pancreatic IPMN
- CEA: high
- fluid quality: clear and thick
- Amylase: High
- Mucin Staining: positive
fluid characteristics of pancreatic pseudocyst
- CEA: low
- fluid quality: clear
- Amylase: High
- Mucin Staining: negative
which pancreatic lesions have ovarian-type stroma on histopathology?
Mucinous cystic neoplasms
how do you adequately examine an abdomen to determine resectability of a pancreatic cancer
evaluate the following
- liver
- bowel
- abdominal wall
- enter lesser sac via gastrocolic ligament to look at pancreas and LNs
What is sump syndrome
complication of a side-to-side choledochoduodenostomy in which food, stones, or other debris accumulate in the CBD and thereby obstruct normal biliary drainage
what must you include in an oncologic distal pancreatectomy
the spleen
what should one do with all choledochal cysts?
excise them all because of the risk of malignancy
when is it acceptable to enucleate a pancreatic insulinoma
- < 2cm
- at least 2mm from duct
most common functional pancreatic neuroendocrine tumor in MEN1
gastrinoma (54%)
How would you manage a pancreatic leak that has gone on for 7 days
- NPO
- TPN
- Somatostatin
- beyond that can consider ERCP and stent if it persists
how many grades of pancreatic fistulas exist
Three
A, B, C
Grade A pancreatic fistula
biochemical leak of no clinical significance, not actually a fistula
Grade B pancreatic fistula
fistula that requires a change in post-operative management (e.g. drain placement)
Grade C pancreatic fistula
fistula that leads to reoperation, organ failure and/or death
what scan would you use to diagnose pancreatic divisum
secretin-enhanced MRCP
Liver lesion with lack of sulfur colloid uptake
hepatic adenoma
recommended FLR for healthy person getting hepatic resection
20%
recommended FLR for person with some liver dysfunction getting hepatic resection
30%
recommended FLR for person with cirrhosis getting hepatic resection
40%
how do you induce growth in FLR prior to liver resection
portal vein embolization of segments planned for resection
hepatic abscess < 5 cm in size, how should you drain
percutaneous aspiration, if accessible
hepatic abscess > 5 cm in size, how should you drain
percutaneous drain placement, if accessible
which vein in the liver joins the middle vein to form a common trunk prior to dumping into the vena cava
- left hepatic vein joins the middle hepatic vein
Depression
Diabetes
Dermatitis
DVTs
what should you think about
Glucagonoma
chemotherapy used for gall bladder carcinoma
Gemcitabine and cisplatin
62M with CT CAP showing a lobulated multicystic mass in the body of the pancreas with a sunburst appearance, what is most likely to be
serous cystic neoplasm
At what size would you excise a serous cystic neoplasm of the pancreas
consider it when it is greater than 4cm
clinical course is harder to predict at that size or greater (sampling bias if biopsied)
How much do you dilate the cystic duct before a Choledochoscopy
5-8 mm
How do you close the cystic duct after choledochoscopy?
with an endo-loop
How do you treat a type 1 choledochal cyst
excision with hypaticojejunostomy
How do you treat a type 2 choledochal cyst
diverticulectomy and primary repair
how do you treat a type 3 choledochal cyst
endoscopic sphincterotomy vs transduodenal excision and sphincterplasty
How do you treat a type 4 choledochal cyst
hepaticojejunostomy with partial hepatectomy if disease involves one lobe
how do you treat a type 5 choledochal cyst
liver transplant
How do you know you’re done with a Kocher Maneuver?
Anterior surface of the aorta and left renal vein
treatment for type 1 choledochal cyst
excision and hepaticojejunostomy
treatment for type 2 choledochal cyst
diverticulectomy and primary repair
treatment for type 3 choledochal cyst
endoscopic sphincterotomy vs transdoudenal excision and sphincterplasty
treatment for type 4 choledochal cyst
hepaticojejunostomy with partial hepatectomy if disease involves one lobe
treatment for type 5 choledochal cyst
liver transplant
What kind of process causes hydatid cyst within the liver
Echinococcal infection
Patient hydatid cysts, what is first line treatment?
Albendazole
how do you distinguish portal vein from hepatic veins when using intra-operative ultrasound?
portal vein has hyperechoic layer secondary to Glisson’s capsule
How is CA 19-9 used in pancreatic cancer
used to monitor response to therapy, not useful for diagnosis
What can cause a falsely elevated CA 19-9
biliary obstruction, as CA 19-9 is held within cells lining biliary tree
patient with 2 cm “honeycomb” lesion at head of pancreas…EUS with low amylase and low CEA
Serous Cystadenoma
how do you diagnose Primary Sclerosing Cholangitis
MRCP
Most common type of biliary injury that occurs during a lap chole
Complete biliary transection at or below hepatic bifurcation
