HPB

Question 1

What are risk factors for gallbladder cancer?

Answer 1

Modifiable:
- obesity
- smoking
- EtOH
- H. Pylori or salmonella chronic infections

Unmodifiable:
- Ethnicity - south asian esp Indian, central and south american and eastern european
- Females > Males 3:1
- PSC
- Chronic cholecystitis
- Porcelain gallbladder
- Gallbladder polyps
- Congenital biliary cysts
- Lynch syndrome
- Abnormal pancreatic/ bile duct junction

Question 2

What are the concerning features for a gallbladder polyp?

Answer 2

• > 10mm
• rapidly growing
• associated with gallstones
• sessile or focal wall thickening >4mm
• patients >50yo
• Indian ethnicity
• ## background of PSC

Question 3

When do you recommend a cholecystectomy for gallbladder polyps vs surveillance vs discharge?

Answer 3

Algorithim as follows:
In the otherwise fit patient for chole…

Chole:
>10mm&raquo_space; cholecystectomy
PSC any size&raquo_space; cholecystectomy
Polyp + symptomatic&raquo_space; cholecystectomy

Surveillance:
Those with risk factors:
<6mm surveil at 1y, 2y, 4y DC
6-9mm surveil at 6m, 1y,2y,4y DC

Those without risk factors:
6-9mm surveil at 1y,3y DC

If during surveillance polyp grows >2mm or reaches 10mm then cholecystectomy

Discharge:
<6mm no risk factors&raquo_space; discharge

Question 4

What is the TNM staging for gallbladder cancer?

Answer 4

Tis - tumour cells retained in epithelial layer.
T1a into lamina propria
T1b into muscularis
T2 into perimuscular connective tissue
T3 through the wall and may be into one other organ e.g. the liver, stomach, bowel or pancreas
T4 through the wall and into 2 or more organs outside the liver or into the liver including a main blood vessel e.g. portal vein or hepatic artery.

Question 5

What TNM stage gallbladder cancers can be managed surgically with cholecystectomy alone i.e no hepatic resection or nodal surgery?

Answer 5

Tis (usually picked up incidentally having already performed the cholecystectomy)
T1a i.e. into lamina propria but not the muscularis.

Question 6

What is the Barcelona clinic liver staging system?

Question 7

What are the Kyoto guidelines for IPMNs

Answer 8

https://ars.els-cdn.com/content/image/1-s2.0-S1424390323018835-gr3.jpg

Question 9

What classification system do you use for biliary anatomical variations?

Answer 9

Huang for PSD insertion
Cystic duct = low insertion, insertion to left side
parallel insertion
Counaid Blumgert

Question 10

What are the causes of pancreatitis?

Answer 10

I GET SMASHED

Idiopathic

Gallstones
Ethanol
Trauma

Steroids
Mumps
Autoimmune
Scorpion sting
Hypercalcaemia, hypertriglyceridaemia
ERCP
Drugs e.g. diuretics, azathiprine, asparagine

Question 11

What is the relevance of haemolytic conditions to gallstone disease?

Answer 11

Calcium bilirubinate stones (pigment stones) are at increased risk in haemolytic disorders due to increased bilirubin released during haemolysis.

In some haemolytic conditions e.g. hereditary spherocytosis when a splenectomy may be considered electively in a patient with symptomatic gallstone disease a combined case of cholecystectomy and splenectomy may be considered. Similarly when a person is undergoing a cholecystectomy for symptomatic gallstone disease and they have moderate- severe symptomatic haemolysis the addition of splenectomy may be considered.

Question 12

What is Wernickes encephalopathy?