BILIARY TRACT

Question 1

Managment of perc chole tube

Answer 1

• repeat cholecystogram in 3-6 weeks and remove catheter if cystic duct is patent
• plan for interval / delayed chole after recovery - not necessary for acalculous cholecystitis

Question 2

Diagnostic test for biliary dyskinesia?

Answer 2

CCK-stimulated HIDA (EF < 35%)

Question 3

Treatment for biliary dyskinesia?

Answer 3

Elective cholecystectomy (can observe if asymptomatic or minimally symptomatic)

Question 4

Treatment for strawberry gallbladder (cholesterolosis)?

Answer 4

Cholecystectomy

Question 5

Treatment for adenomyomatosis?

Answer 5

Cholecystectomy

Question 6

Treatment for porcelain gallbladder:
- Asymptomatic and complete calcification?
- Symptomatic or selective calcification?

Answer 6

• Asymptomatic and complete calcification: Serial imaging
• Symptomatic or selective calcification: Cholecystectomy

Question 7

Treatment of gallbladder polyp:
- < 1 cm and asymptomatic?
- > 1 cm and symptomatic?

Answer 7

• < 1 cm and asymptomatic: Monitor with US
• > 1 cm and symptomatic: Cholecystectomy

Question 8

Treatment of gallbladder adenocarcinoma:
- T1a (mucosa)?
- >/ T1b (invades mucosa)?

Answer 8

• T1a (mucosa): Open chole
• > / T1b (invades mucosa): Extended chole (nonanatomic resection into gallbladder fossa) and portal lymphadenectomy

Question 9

What do you do if T1b gallbladder adenocarcinoma is found on postop pathology?

Answer 9

Return to OR and complete resection

Question 10

What do you do if T1b gallbladder adenocarcinoma is found on postop pathology - extending to CBD or positive cystic duct margin?

Answer 10

CBD resection and hepaticojejunostomy

Question 11

What do you do if T1b gallbladder adenocarcinoma is found intraoperatively?

Answer 11

Abort procedure and complete staging prior to return to OR

Question 12

SURGICAL APPROACH for choledocholithiasis?

Answer 12

1. Start with IOC
2. If stone is seen: give 1 mg glucagon, wait 2 min and flush with 100-200 cc saline, if fails repeat x1, if fails x2 - CBDE

Question 13

What are the options if a CBDE fails?

Answer 13

• Leave T-tube
• Postop ERCP
• Transduodenal sphincteroplasty
• Biliary-enteric drainage (side to side choledochoduodenostomy or hepaticojejunostomy)

Question 14

Management of a T tube

Answer 14

1. Repeat cholangiogram at 24-48 hours; if normal clamp and flush bid; if obstructed / retained stone leave open to drain
2. Repeat cholangiogram at 10-14 days; if normal remove tube vs clamp 1-2 weeks; if obstructed / retained stone then ERCP vs IR via T tube

Question 15

Management of Sphincter of Oddi dysfunction:
- With abnormal LFTs and/or dilated CBD?
- With normal LFTs and CBD?

Answer 15

• Abnormal LFTs and/or dilated CBD: ERCP w/ sphincterotomy
• Normal LFTs and CBD: CCBs or Ursodiol

Question 16

What is the initial management of gallstone ileus?

Answer 16

Enterolithotomy via PROXIMAL enterotomy
- open longitudinally and close transversely
- inspect bowel for additional stones

Question 17

What is the eventual / definitive management of gallstone ileus?

Answer 17

Cholecystectomy and fistula closure 6-8 weeks after recovery from initial treatment

Question 18

What is the management of bile duct injury discovered intraoperatively:
- <50% circumference?
- >/ 50% circumference?

Answer 18

• <50% circumference: Primary repair over T tube or ERCP w/ stent
• > / 50% circumference: Hepaticojejunostomy

*if limited resources or inexperienced: stop dissection, leave drains, transfer to higher level of care

Question 19

What is the management of a bile duct injury discovered postoperatively:
- With biloma?
- With leak or partial injury / stricture?
- With complete transection / occlusion?

Answer 19

• With biloma: Perc drain
• With leak or partial injury / stricture: ERCP with stent
• With complete transection / occlusion: Hepaitcojejunostomy (immediate repair if 3-7 days postop; delayed 6-8 wk repair if >7 days postop and manage with perc drain / decompression)

Question 20

Todani classification of choledochal cysts:

Answer 20

I: Extrahepatic (fusiform / saccular)
II: Diverticula
III: Intraduodenal (choledochocele)
IV: Multiple (IVa both; IVb extrahepatic only)
V: Intrahepatic (Caroli’s disease)

Question 21

What is the treatment for each class of choledochal cyst?

Answer 21

I: CBD resection with RYHJ
II: Diverticulectomy
III: <3 cm: ERCP marsupialization; >3 cm: Transduodenal excision / sphincteroplasty
IVa: CBD resection with RYHJ vs possible OLT
IVb: CBD resection with RYHJ
V: Supportive vs resection (+/-) vs OLT

Question 22

Bismuth-Corlette classification of cholangiocarcinoma

Answer 22

I: CBD or common hepatic duct
II: Bifurcation (Klatskin tumor)
III: Invades unilateral hepatic duct
IV: Bilateral hepatic ducts

Question 23

What are unresectable features of cholangiocaricnoma?

Answer 23

• Extrahepatic organ invasion
• LN beyond hepatoduodenal ligament (periarotic, celiac)
• Mets or disseminated disease
• Invades main portal vein or hepatic artery

Question 24

What is the procedure of choice for cholangiocarcinoma in the following locations?
- Distal CBD?
- Perihilar?
- Intrahepatic?

Answer 24

• Distal CBD: Whipple
• Perihilar: En bloc resection with RYHJ
• Intrahepatic: Hepatic resection

*Also consider adjuvant chemo and radiation

Question 25

How is PSC diagnosed?

Answer 25

MRCP or ERCP and immediate colonoscopy to evaluate for IBD

Question 26

What is the temporizing treatment for PSC?

Answer 26

ERCP with stent for dominant extrahepatic stricture

Question 27

What is the definitive treatment for PSC?

Answer 27

Liver transplant

Question 28

PROCEDURE STEPS: Cholecystectomy

Answer 28

1. Expose gallbladder 2. Expose critical view of safety - only 2 structures entering gallbladder - Clear Triangle of Calot of all tissue - Lower third of gallbladder separated from liver 3. Diide cystic duct and artery 4. Dissect gallbladder from liver bed and remove 5. If approaching a zone of significant risk - finish via a safe method: - Encourage liberal use of IOC - Conversion to open - Subtotal after removal of all stones - Cholecystostomy tube - Low threshold for calling in help of other experienced surgeons

Question 29

PROCEDURE STEPS: Subtotal fenestrating cholecystectomy

Answer 29

1. Gallbladder opened at fundus 2. Bile, stones, and debris removed 3. Gallbladder incision extended posteriorly around gallbladder neck - cystic duct and artery NOT dissected - all dissection done superior to Rouviere's sulcus 4. Anterior wall of gallbladder completely removed 5. Remnant mucosa ablated by acutery or argon beam 6. May consider pursestring closure of cystic duct from inside if feasible 7. Leave drain near stump to drain the presumed bile leak

Question 30

PROCEDURE STEPS: IOC

Answer 30

1. Obtain critical view of safety 2. Place clip proximal to cystic duct 3. Make transverse incision through cystic duct 4. Milk back duct contents 5. Introduce cholangiocatheter and clamp around ductomoty 6. Inject contrast under continuous fluoro visualization 7. Close ductal stump with Endoloop

Question 31

What are the requirements for appropriate IOC visualization?

Answer 31

1. Correct biliary anatomy 2. Free flow into the duodenum 3. No evidence of filling defects 4. Retrograde filling of the right and left hepatic ducts

Question 32

PROCEDURE: Open CBDE

Answer 32

1. Complete cholecystectomy 2. Give glucagon 3. Wide Kocher 4. Place stay sutures of 3-O silk low on choledochus 5. Incise between stays with #15 scalpel 6. Culture CBD bile 7. Extend choledochotomy with Pott's scissors 1.5-2 cm 8. Look inside for floating stones 9. Irrigate CBD with red rubber proximally and distally 10. Look inside with choledochoscope using pressurized irrigation 11. Basket retrieval of stones if needed 12. Look proximally and distally - should see duodenal mucosa 13. If no choledochoscope: 14. Pass Fogarty proximally and distally 15. Randall stone forceps / Biliary scoops / Bakes Dilators? - All dangerous 16. Choose T-tube: largest that will comfortably fit opening (16F most common); trim transverse limbs to 3-4 cm and cut off back of tube 17. Insert tube into CBD and close around tube with 3-O or 4-O absorbable suture 18. Flush T-tube with saline to assure patency and absence of leak 19. T-tube cholangiogram!!!! 20. Exteriorize tube and connect bile drainage bag 21. Suction drain in a dependent position (Morrison's Pouch) 22. Close

Question 33

Contraindications to transcystic CDBE approach:

Answer 33

- Friable cystic duct - Narrow or tortuous cystic duct - Large stones > 1 cm - Multiple stones > 8 - Common hepatic duct stones

Question 34

PROCEDURE: Transduodenal sphincteroplasty

Answer 34

1. Kocher maneuver to mobilize duodenum 2. Longitudinal duodenotomy on lateral side 3. Insert soft catheter, probe, or right angle into CBD through Ampulla of Vater 4. Use Pott's scissors or scalpel to cut papilla at 11 o'clock position, 1.5 cm 5. Clear CBD stone 6. Suture bile duct wall to duodenal mucosa - Start with apical suture and continue along sides in interrupted fashion - Use 4-O or 5-O absorbable monofilament suture 7. Close duodenotomy transversely

Question 35

PROCEDURE: Hepaticojejunostomy

Answer 35

1. Midline incision 2. Complete cholecystectomy 3. Isolage portal structures and divide the common hepatic duct 4. Transect the jejunum 30-50 cm distal to the LoT 5. Create a jejunostomy 60-100 cm distally 6. Create an end-to-end anastomosis of the common hepatic duct to the jejunum end 7. Close