HPB Flashcards
Replaced right hepatic artery
Accessory RHA
Replaced left hepatic artery
Relation between RHA and common hepatic duct
Cystic artery origin
- replaced RHA: comes off SMA
- RHA off PHA and accessory branch off SMA
- LHA off left gastric a
RHA passes posterior to the common hepatic duct
RHA gives off the cystic artery at the triangle of Calot
% of pts with ASx stones develop symptoms within 20 years
- require operation
- complications
- 20% to 30% of patients with asymptomatic stones will develop symptoms within 20 years
- 10-18% of those with silent gallstones develop biliary pain and approximately 7% require operative intervention
- 1-4% of those with gallstones develop complications, such as acute cholecystitis, gallstone pancreatitis, and choledocholithiasis
Tokyo Guidelines
Tokyo Guidelines: Severity Grading for Acute Cholecystitis
Grade 1 (Mild): Acute cholecystitis that does not meet the criteria for a more severe grade. Mild gallbladder inflammation, no organ dysfunction.
Grade 2 (Moderate): The presence of one or more of the following:
Elevated white blood count (> 18,000 cells per cubic millimeter)
Palpable tender mass in the right upper quadrant
Duration of complaints > 72 hours
Marked local inflammation, including biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis
Grade 3 (Severe): The presence of one or more of the following:
Cardiovascular dysfunction (hypotension requiring treatment with dopamine ≥ 5 µg per kilogram of body weight per minute, or any dose of dobutamine) Neurological dysfunction (decreased level of consciousness) Respiratory dysfunction (ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen < 300) Renal dysfunction (oliguria, creatinine > 2.0 mg/dL) Hepatic dysfunction (prothrombin-time–international normalized ratio > 1.5) Hematologic dysfunction (platelet count < 100,000 per cubic millimeter)
Complications of cholecystectomy
and rate
- biliary injury: 0.26 %–0.6% of cases
- lost stones: 20% to 40%
- retained stones: retained CBD stones, or secondary common duct stones, can be identified for up to 2 years after cholecystectomy
When to remove cholecystostomy tube and perform cholecystectomy
Most patients do not need cholecystectomy after resolution of acute illness
- ~3-8 weeks tract is formed and tube can be removed
- 6-12 weeks perform cholecystectomy
Prior to tube removal, perform tube study to confirm patency of cystic duct, no retained stones, and tract maturation
What to do if a CBD injury is suspected
If injury is suspected, IOC should be performed to assess the surrounding anatomy and plan for repair—closure over a T tube, end-to-end anastomosis, duodenal re-implantation (must perform a Kocher maneuver), or hepaticojejunostomy.
Options when CBD stones are encountered
- Ductal irrigation with glucagon to relax the sphincter of Oddi (this also works if there is no passage of dye into the duodenum)
- A balloon catheter or wire basket can be passed under fluoroscopic guidance to extract the stone
- Open or laparoscopic CBD exploration
- Transcystic CBD exploration with the aid of choledochoscopy for stone removal
- Choledochotomy with choledocoscopy for stone removal
- Laparoscopic endobiliary stent placement via the cystic duct with postoperative ERCP
- ERCP during or after cholecystectomy
Eval of patient p/w jaundice after lap chole
- US-eval for collection of bile and biliary tree
- labs
- CT is more useful as it allows for eval of vasculature; 20% of CBD injuries have associated vascular injury
- HIDA–incapable of precise anatomic delineation but can confirm the presence of obstruction or leak
- ERCP-assess the biliary anatomy, type and level of injury, and treat identified pathology.
IOC use in preventing bile duct injury and identifying injuries
- Limited data suggests that IOC may prevent bile duct injury.
- IOC is associated with a 90% success rate of identifying injuries and allows for therapeutic intervention
Blood supply biliary tree
- arterial, not the portal system
- The distal CBD (below the level of the duodenal bulb) is supplied by the posterosuperior pancreaticoduodenal and gastroduodenal arteries. The supraduodenal CBD and common hepatic duct are supplied by the right hepatic and cystic artery.
- The blood supply runs along the 3- and 9-o’clock positions of the extrahepatic bile duct.
Primary choledocolithiasis
- Stones form within the biliary tree
- Recurrent pyogenic cholangitis can develop and is usually seen in East Asian populations
- Pathogens, such as Clonorchis sinensis and Ascaris lumbricoides, enter the biliary tract and secrete enzymes that hydrolyze bilirubin glucuronides to form free bilirubin, which precipitates to form brown pigment stones .
Benign biliary strictures
Result from ischemia, inflammation from recurrent choledocholithiasis or cholangitis, and other inflammatory conditions including PSC
Choledochal cysts
Thought to result from an anomalous pancreaticobiliary junction that allows reflux of pancreatic secretions into the bile duct, causing inflammation and damage to the biliary tree
Mirizzi syndrome
- Bile duct is obstructed from external compression by a stone within the cystic duct.
- Can be associated with cholecystocholedochal fistula formation
Lemmel syndrome
- Rare cause of biliary obstruction
- Periampullary duodenal diverticulum that causes compression of the intrapancreatic portion of the CBD
