Surgery Hepatobiliary Flashcards
absolute contraindications for liver biopsy
significant coagulopathy, biliary dilatation, suspicion of hemangioma or echinococcal cyst
common primary site for metastatic liver tumors
colorectal
most common primary malignant tumor
hepatocellular ca
4th most common cancer in the ph
risk factors for hcc
- viral hepatitis (b or c) !!
- (alcoholic) cirrhosis !!
- hemochromatosis !!
- non-alcoholic steatosis hepatitis !!
- schistosomiasis
- chemicals
- aflatoxins (a. flavusi, a fumigatus)
- thorotrast
- male gender
- 50 yo
clinical presentation of hcc
- asymptomatic when small
- when glisson’s capsule is stretched = dull aching ruq associated with fever, malaise, and jaundice
- hepatomegaly
- weight loss
- tender abdominal mass
- cirrhosis
- paraneoplastic syndrome
most common site for metastases
lung and diaphragm
laboratory tests for hcc
afp = elevated
liver function = abnormal but not specific
imaging for hcc
- ct scan and mri
- triphasic ct scan hypervascularity in arterial phase, hypodense in delayed phase
- hepatic ultrasound (cannot asses if <2 cm)
management for hcc
- resection (toc for no cirrhosis and child’s score A, with preserved liver function, without portal hpn)
- transplant
- chemo
- chemoembolization
criteria for transplant
- resection not possible
milan criteria
- one nodule < 5 cm
- 2-3 nodules all < 3 cm
- no gross vascular invasion or extrahepatic spread
algorithm for hcc management
- determine if resection or transplant candidate
- if non resectable: sorafenib or palliative care
2nd most common primary malignancy of the liver
cholangioca (adenoca of bile ducts)
presentation of cholangioca
- painless jaundice !!
- hepatomegaly and palpable mass
- patho: hard grayish mass, metastasizes to liver and regional ln
- uts or ct scan
subclassifications of cholangioca
- peripheral or intrahepatic
- central extrahepatic proximal: hilar cholangioca / klatskin tumor
- central extrahepatic distal can be nodular, scirrhous, diffusely infiltrating, or papillary
what is klatskin tumor
- originates in wall of bile duct at hepatic duct confluence (bifurcation)
- obstructive jaundice
- mgt: neo-adjuvant chemorad
- poor prognosis
bismuth corlette classification for klatskin tumor
I common hepatic duct
II involves bifurcations
III either right or left intrahepatic duct
IV both right and left secondary intrahepatic duct
management for klatskin tumor
- surgical resection (only cure)
- intrahepatic cholangioca = hepatectomy
t/f if primary sclerosing cholangitis is present, surgical resection is still possible
false, there are high recurrence rates
prognosis for cholangioca
- median survival is 32-38 mos
- greatest risk for recurrence: presence of positive margins, ln positive tumors
- most common cause of death: hepatic failure or cholangitis
t/f the liver is the second most common site for all ca of abdomen, and most common site for hematogenous spread
true
negative prognostic factors for hepatic metastasis
- non-breast and non-colorectal origin
- > 60 yo
- disease free interval of <12 mos
- (+) need major hepatectomy
- (+) r2 resection
- (+) extrahepatic metastasis
predictors of poor outcoome
- (+) primary node
- tumor > 1 in location
- > 5 cm
- caa > 200 ng/mL
most common primary malignant liver ca in children
hepatoblastoma
presentation and tx for hepatoblastoma
- abdominal distention, failure to thrive, and high afp
- tx: surgery, liver transplant
what is angiosarcoma / malignant hemangioendothelioma
- highly malignant tumor
- metastasis to spleen and lungs
- associated with chemical agents
- poor prognosis
what is ca of gallbladder
- more in elderly
- aggressive, poor prognosis
- gallstones common
- adenoca common
- indistinguishable from cholecystitis and cholelithiasis
risk factors for ca of gallbladder
- polypoid lesion of the gb (> 10 mm = cholecystectomy and evaluation)
- calcified “porcelain” gb
diagnosis and management of ca of gallblader
- uts, ct scan, mrcp
- surgery
- endoscopic or percutaneously placed stents
prognosis for ca of gallbladder
- 5 year survival 5%
- t1: cholecystectomy
- t2: extended cholecystectomy with lymphadenectomy
