HPB

Question 1

Bismuth-Corlette Classification of cholangiocarcinoma

Answer 1

type I
limited to the common hepatic duct, below the level of the confluence of the right and left hepatic ducts

type II
involves the confluence of the right and left hepatic ducts

type IIIa
type II and extends to involve the origin of the right hepatic duct (confluence of the right posterior and anterior sectoral ducts)

type IIIb
type II and extends to involve the origin of the left hepatic duct (confluence of the 2nd, 3rd and 4th segmental ducts)

type IV
extending to and involving the origins of both right and left hepatic ducts (i.e., combination of types IIIa and IIIb)
or
multifocal involvement

type V
stricture at the junction of common bile duct and cystic duct

Question 2

Blumgart clinical staging for peri-hilar cholangiocarcinoma

Answer 2

· T1
o unilateral extension to 2nd-order biliary radicles
· T2
o unilateral extension to 2nd-order biliary radicles AND ipsilateral portal vein involvement +/- hepatic lobar atrophy
· T3
o bilateral extension to 2nd-order biliary radicles
o unilateral extension to 2nd-order biliary radicles AND contralateral portal vein involvement +/- hepatic lobar atrophy
main or bilateral portal vein involvement

Question 3

Courvoisier’s sign

Answer 3

Painless jaundice and a palpable gallbladder

Question 4

Staging for cholangiocarcinoma

Answer 4

“Biochemical markers, local and distant imaging with possible biopsy if diagnostic uncertainty or tissue diagnosis needed for neoadjuvant or palliative treatment”

LFTs
CEA and CA 19-9
Triple phase CT - can look at disease as well as vessel involvement
MRCP - define strictures
ERCP and brushings - can be therapeutic for stenting, brushings only 30% sensitive due to dense fibroblastic reaction
Spyglass and biopsy - sens/spec >90%
PET - can change management in up to 30% of cases by detecting occult mets

Question 5

Factors when deciding if patient is eligible for curative treatment in cholangiocarcinoma

Answer 5

Patient, and tumours factors.

Patient
- fitness for surgery
- presence of concurrent liver disease, adequate functional liver remnant

Tumour
PERI-HILAR
- presence of metastatic disease (distal LNs, lung, peritoneal mets)
- extent within biliary tree (involvement of second order biliary radicles bilaterally)
- extension into second order radicles unilaterally with CONTRALATERAL unreconstructable portal vein involvement

INTRA-HEPATIC
- mets, as above
- similar to HCC criteria for resection, need FLR

EXTRA-HEPTIC
- mets, as above
- unreconstructable PV or SMA/CHA involvement

Question 6

Role of liver transplant in cholangiocarcinoma

Answer 6

Mayo clinic protocol
- peri-hilar cholangioca not resectable
- tumour <3cm
- no intra- or extra-hepatic metastases

Undergo neoadjuvant chemoradiation with 5FU and capecitabine

Restaging including staging laparoscopy. Regional or distant lymph nodes mets preclude transplant.

~55% survival at 5 years.

Question 7

Palliative management options for cholangiocarcinoma

Answer 7

Biliary stenting and supportive care
- ERCP stent if distal vs PTC and stent

Surgical bypass
- intra-hepatic biliary enteric bypass (esp if unable to proceed during planned major resection and bile duct already transected)
- hepaticojej for distal tumours

Radiotherapy
- usually EBRT

Chemotherapy
- some QOL improvement and short term survival improvement

Question 8

Differentials for “gallbladder polyps” seen incidentally on ultrasound

Answer 8

BENIGN
- Cholesterol polyps ~60% (lipid accumulation in wall of GB)
- Adenomyomas ~25% (mucosal overgrowth, thickening of the muscle wall and development of intramural diverticulae. May be polypoid projections into lumen)
- Inflammatory polyps (granulomatous and fibrous tissue containing plasma cells and lymphocytes)
- Adenomas (benign glandular tumours comprised of biliary epithelium). Malignant potential related to size (6% if <1 cm, 37% if 1-2cm)

Other: lipomas, fibromas, leiomyomas.

MALIGNANT
- adenocarcinomas/cholangioca
- SCC

Question 9

Recommended surveillance for gallbladder polyps

Answer 9

Question 10

Indications for surgery for GB polyps

Answer 10

• polyp size >1cm
• smaller polyps with concurrent gallstones
• polyps of any size with PSC
• polyps with biliary symptoms

Question 11

Risk factors for gallbladder cancer

Answer 11

Gallstones
- Present in up to 90% of patients with GBC → one of the strongest RFs
- Overall incidence of GBC in patients with gallstones 0.5%
→ Greatest with larger stones (>3cm) or long duration (>40yrs)

Porcelain gallbladder
- Associated with chronic cholecystitis → intramural calcification
- Incidence of GBC = 2-3% in more recent data

Gallbladder (adenomatous) polyps
- Increased risk if:
o Size >1cm
o Age >50yo
o Multiple polyps

Primary sclerosing cholangitis

Chronic infection
- Chronic Salmonella Typhi carriage -> 1-4% of acutely infected become chronic asymptomatic carriers -> more common in pts with gallstones -> gallstones through to be nidus for ongoing infection

Anomolous pancreatico-biliary junction
- Pancreatic duct drains into CBD → long common channel (usually >2cm)
- Predisposes to reflux of pancreatic fluid into biliary tree

Obesity
Smoking
Diabetes -> modest association, mediated in part by obesity and higher rates of gallstones

Cholecysto-enteric fistula

Question 12

Staging and associated management of gallbladder cancer

Answer 12

T1aN0M0 - managed by simple cholecystectomy alone

T1b and above - requires “radical cholecystectomy with en bloc resection of Seg 4b/5 of liver and portal/hepatoduodenal lymphadenectomy” Aiming for 2cm margin of normal liver. Aiming for >6 LN harvest. Frozen section of cystic duct margin.

T3/4 - may be possible for radical en bloc resection of surrounding involved organs if R0 resection achievable.

N2 - equivalent to metastatic disease, therefore not for curative surgery.

N2/M1/T3/T4 and not resectable - palliative radiation or chemotherapy VS best supportive care and stenting if jaundiced.