Hepatobiliary Surgery Flashcards
(36 cards)
A 55 year old accountant has jaundice and a temperature of 39oC. He is known to have gallstones. Blood cultures have grown a gram negative bacilli. Imaging shows a bile duct measuring 1.2cm in diameter. What is the best treatment option?
PTC and stent PTC and drain ERCP and stent MRCP USS
ERCP and stent
Note the question states treatment option, this excludes MRCP and USS which are not treatments. Whilst PTC may access the duct, the drains may displace easily and the transduodenal route is the preferred first line access.
A 65 year old man is admitted with jaundice and investigations demonstrate a carcinoma of the pancreatic head. An ERCP is attempted but the surgeon is unable to cannulate the ampulla. What is the best course of action?
Whipples procedure Laparotomy and formation of hepatico-jejunostomy Percutaneous transhepatic cholangiogram and drain External beam radiotherapy Laparotomy and duodenoduodenostomy
Cancer of the pancreatic head will cause obstructive jaundice and intrahepatic duct dilatation. When an ERCP has failed the most appropriate option is to attempt a PTC. This procedure is always preceded by an ultrasound (which presumably this patient has already had or they would not be undergoing an ERCP). Prior to performing the PTC it is important to stage the disease and establish resectability or not. This is because the PTC drains frequently dislodge and fall out. It is usually desirable to pass a stent at the time of doing the PTC to mitigate the effects of this problem.
A 67 year old lady presents with jaundice and abdominal pain. Her investigations show a dilated common bile duct, a carcinoma of the pancreatic head compressing the pancreatic duct. Her liver contains bi-lobar metastasis. What is the most appropriate course of action?
Undertake synchronous resection of liver metastases and pancreatoduodenectomy Resection of liver metastases, chemotherapy and then resection of the primary lesion Insertion of endoscopic biliary stent and consideration of palliative chemotherapy Palliation alone Insertion of PTC and palliation
Insertion of endoscopic biliary stent and consideration of palliative chemotherapy
The presence of metastatic disease in the context of pancreatic cancer renders this incurable and resection of metastatic disease is not appropriate.
A 43 year old lady presents with 24 hour history of generalised right upper quadrant pain. On admission, she is septic and jaundiced and there is tenderness in the right upper quadrant. What is the most likely diagnosis?
Cholecystitis Cholangitis Gallbladder empyema Gallbladder abscess Liver abscess
A combination of sepsis and jaundice generally favors a diagnosis of cholangitis. Conditions such as empyema may cause sepsis but not marked jaundice, the same is also true of the other differentials listed
A 23 year old lady is admitted with right upper quadrant pain. On examination, she is tender in the right upper quadrant. Imaging shows signs of acute cholecystitis due to gallstones. The CBD appears normal. Liver function tests are normal. What is the most appropriate course of action?
Laparoscopic cholecystectomy during the next 24-48 hours Open cholecystectomy during the next 24-48 hours Laparoscopic cholecystectomy 3 months following resolution of the attack Open cholecystectomy 3 months following the attack Laparoscopic cholecystectomy after 5 days of intravenous antibiotics
In most cases the treatment of choice for acute cholecystitis is an acute cholecystectomy performed early in the illness. Delayed surgery particularly around 5- 7 days after presentation is much more technically challenging and is often best deferred. In most cases the procedure can be performed laparoscopically, even when acute inflammation is present.
An 82 year old lady is taken to theatre for a common bile duct exploration. She has a stone impacted at the distal aspect of the common bile duct and despite best efforts it proves impossible to remove it. What is the best course of action?
Close the bile duct over a T Tube and arrange for a stent to be placed Undertake a choledochoduodenostomy Arrange for a repeat ERCP Construct a hepaticojejunostomy Bypass the gallbladder onto the jejunum
If a stone cannot be removed at surgery then the chances of succeeding at ERCP are slim. In this case, its probably best to bypass the distal bile duct and a choledochoduodenostomy is the best way of achieving this. There are long term risks of cholangitis which are less of a concern in older patients.
A 53 year old alcoholic develops acute pancreatitis and is making slow but reasonable progress. He is troubled by persisting ileus and for this reason a CT scan is undertaken. This demonstrates a large pancreatic pseudocyst. This is monitored by repeat CT scanning which shows no resolution and he is now complaining of early satiety. What is the best course of action?
Pancreatectomy Emergency cystogastrostomy Elective cystogastrostomy ERCP Staging laparotomy to assess severity
Elective cystogastrostomy
Drainage of this man’s pseudocyst is required. This could be accomplished radiologically or endoscopically or surgically. As the other options are not on the list this is the best option from those available.
A 40 year old woman is admitted with abdominal pain. She has suffered from repeated episodes of this colicky right upper quadrant pain. On examination, she is pyrexial with right upper quadrant peritonism. Her blood tests show a white cell count of 23. However, the liver function tests are normal. An abdominal ultrasound scan shows multiple gallstones in a thick walled gallbladder, the bile duct measures 4mm. What is the best course of action?
Administration of broad spectrum intravenous antibiotics and perform a delayed open cholecystectomy in 3 months Arrange a radiological cholecystotomy Undertake a laparoscopic cholecystectomy Undertake an open cholcystectomy Administration of broad spectrum intravenous antibiotics and perform a delayed laparoscopic cholecystectomy in 3 months
This lady has acute cholecystitis and needs an acute cholecystectomy. This operation should usually be performed within 72 hours of admission. Delay beyond this timeframe will usually result in increased operative complications and most surgeons would administer antibiotics and perform and interval cholecystectomy if the early window for an acute procedure is missed. A bile duct measuring 4mm is usually normal.
A 48 year old lady is admitted with attacks of biliary colic and investigations show gallstones. A laparoscopic cholecystectomy is performed. The operation is technically challenging due to a large stone impacted in Hartmans pouch. Following the operation she fails to settle and becomes jaundiced and has bile draining into a drain placed at the surgical site. What is the best course of action?
Arrange an ERCP Undertake a laparotomy Arrange an abdominal USS Arrange an MRCP Arrange an abdominal CT scan
In this scenario it must be assumed that the bile duct has been damaged. In most cases an ERCP is the most appropriate investigation. This can also allow the passage of a stent if this is deemed to be safe and sensible. Other imaging modalities will add little to overall management and simply add delay.
A 73 year old lady undergoes a laparotomy and a gallstones ileus is identified. The gallbladder itself is densely adherent to the duodenum. What is the correct course of action?
Milk the gallstones into the colon and leave the gallbladder Remove the gallstones from the small bowel, resect the gallbladder and close the duodenal defect transversely Remove the gallstones from the small bowel and perform a subtotal cholecystectomy Remove the gallstones from the small bowel and undertake a cholcystostomy Remove the gallstones from the small bowel and leave the gallbladder alone
In gallstone ileus leave the gallbladder alone
The gallstones should always be removed, the enterotomy site is proximal to the site of obstruction.
Which of the following is the most sensitive blood test for diagnosis of acute pancreatitis?
Amylase Lipase C-peptide Trypsin Trysinogen
The serum amylase may rise and fall quite quickly and lead to a false negative result. Should the clinical picture not be concordant with the amylase level then serum lipase or a CT Scan should be performed.
A 72 year old man undergoes a distal gastrectomy for carcinoma of the stomach. He presents with jaundice approximately 8 months post operatively. Ultrasound of the liver and bile ducts shows no focal liver lesion and normal calibre common bile duct with intra hepatic duct dilatation. What is the most likely explanation?
Peri hilar lymphadenopathy Fitz- Hugh Curtis syndrome Gilberts syndrome Mirizzi syndrome Gallstones
Unfortunately metastatic disease is the most likely event. Peri hilar lymphadenopathy would be a common culprit.
A 59 year old man is diagnosed as having carcinoma of the pancreas with two malignant deposits in the right lobe of the liver. What is the most appropriate treatment?
Palliative chemotherapy Liver resection followed by chemotherapy Simultaneous resection of liver metastasis and en bloc segmental pancreatic resection Pancreatic resection followed by liver resection once recovered Radical radiotherapy followed by surgery
Pancreatic cancer has a poor prognosis and most cases have metastatic disease at presentation. There is no role in pancreatic cancer for liver resection together with pancreatic surgery as there is no survival benefit. Most centres will offer palliative chemotherapy which has improved both longevity and quality of life.
A 34 year old lady is admitted with jaundice and undergoes an ERCP. The procedure is technically difficult and she is returned to the ward still jaundiced. Unfortunately she now has severe generalised abdominal pain. What is the best course of action?
Arrange abdominal MRI scan Arrange MRCP Arrange an abdominal CT scan Undertake a laparotomy Undertake a laparotomy and biliary bypass
There are two main differential diagnoses here. One is pancreatitis, repeated trauma to the ampulla and duct (if partially cannulated) is a major risk factor for pancreatitis. The second is the possibility that the duodenum has been perforated. ERCP is performed using a side viewing endoscope, the manipulation of which can be technically challenging for the inexperienced operator in a patient with abnormal anatomy. A CT scan is the best investigation to distinguish between these two differential diagnoses.
A 58 year old woman is admitted with an attack of severe acute pancreatitis. She is managed on the intensive care unit and is making progress. She then deteriorates and a CT scan shows extensive pancreatic necrosis (>40%). There are concerns that this may have become infected. What is the correct course of action?
Undertake a fine needle aspiration of the area Perform a pancreatic necrosectomy Perform a Whipples procedure Arrange an ERCP Perform a distal pancreatectomy
When there are concerns that pancreatic necrosis may have become infected the usual approach is to perform an image guided FNA for culture. There is always the risk of seeding infection with such a strategy so it must be performed with care. Pancreatic necrosectomy is not usually undertaken until the presence of infection is proven.
A 41 year old lady with colicky right upper quadrant pain is identified as having gallstones on an abdominal ultrasound scan. What is the most appropriate course of action?
Laparoscopic cholecystectomy Open cholecystectomy Liver function tests MRCP ERCP
Liver function testing is part of the core diagnostic work up of biliary colic and surgical planning cannot proceed until this (and the diameter of the CBD on USS) are known.
A 34 year old lady is undergoing a laparoscopic cholecystectomy for cholecystitis. She has been unwell for the past 10 days. On attempting to dissect the gallbladder (which is distended), all that can be seen are the gallbladder fundus and dense adhesions make it difficult to dissect Calots triangle. What is the best course of action?
Perform an operative cholecystostomy Dissect the adhesions off Calots triangle and continue with the cholecystectomy Dissect out the bile duct and perform a cholangiogram Arrange an ERCP Arrange a PTC
If only the fundus can be seen, then it may be difficult to even proceed with a sub total cholecystectomy. Therefore, a cholecystostomy can be performed and this will usually allow the situation to settle. Definitive surgery can then be undertaken in more favourable circumstances.
A 63 year old man is admitted to ITU with an attack of severe gallstone pancreatitis. He requires ventillatory support for ARDS. Over the past few days he has become more unwell and a CT scan is organised. This demonstrates an area of necrosis, culture from this area shows a gram negative bacillus. His CRP is 400 and WCC 25.1. What is the best course of action?
Whipples procedure Distal pancreatectomy Pancreatic necrosectomy Pylorus preserving pancreatoduodenectomy ERCP
This man requires necrosectomy as he has infected pancreatic necrosis and is haemodynamically unstable. A radiological drainage procedure is unlikely to be sufficient.
A 41 year old lady is admitted with colicky right upper quadrant pain. On clinical examination she has a mild pyrexia and is clinically jaundiced. An ultrasound scan is reported as showing gallstones and the patient is taken to theatre for an open cholecystectomy. At operation, Calots triangle is almost completely impossible to delineate. What is the most likely explanation?
Mirizzi syndrome Carcinomatosis Bile duct strictures Fitz - Hugh Curtis syndrome Carcinoma of the head of the pancreas
In Mirizzi syndrome the gallstone becomes impacted in Hartmans pouch. Episodes of recurrent inflammation occur and this causes compression of the bile duct. In severe cases this then progresses to fistulation. Surgery is extremely difficult as Calots triangle is often completely obliterated and the risks of causing injury to the CBD are high.
A 42 year old female presents with symptoms of biliary colic and on investigation is identified as having gallstones. Of the procedures listed below, which is most likely to increase the risk of gallstone formation?
Partial gastrectomy Jejunal resection Liver lobectomy Ileal resection Left hemicolectomy
Bile salt reabsorption occurs at the ileum. Therefore cholesterol gallstones form as a result of ileal resection
A 43 year old woman is admitted with acute cholecystitis and fails to settle. A laparoscopic cholecystectomy is being performed. At operation, the gallbladder has evidence of an empyema and Calots triangle is inflamed and the surgeon suspects that a Mirizzi syndrome has occurred. What is the best course of action?
Undertake an operative cholecystostomy Perform a sub total cholecystectomy Perform a laparotomy Perform an exploration of the common bile duct Continue to explore Calots triangle and complete the operation
This will address the acute sepsis and resolve the situation. Attempts at completing the surgery at this stage, even in expert hands carries a very high risk of bile duct injury.
A 68 year old man with type 2 diabetes is admitted to hospital unwell. On examination, he has features of septic shock and right upper quadrant tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder. What is the most likely diagnosis?
Acute calculous cholecystitis Acute acalculous cholecystitis Cholangitis Mirizzi syndrome Sphincter of oddi dysfunction
This is the classic description of acalculous cholecystitis and its commonest in patients with type 2 diabetes. If you answered it incorrectly, ensure that you were not caught out by the acute calculous cholecystitis as this is a common exam mistake if options are mis read in a rush.
A 43 year old male with long standing chronic hepatitis is being followed up. Recently his AFP is noted to be increased and an abdominal USS demonstrates a 2cm lesion in segment V of the liver. What is the most appropriate course of action?
PET CT scan Liver MRI USS guided liver biopsy Laparoscopic biopsy Segmental resection of segment V
Liver MRI
Liver lesions that are suspicious of HCC should be scanned prior to resection as there is a risk of multifocal lesions that would either preclude or otherwise affect the decision to proceed with segmental resection.
A 45 year old man presents with an episode of alcoholic pancreatitis. He makes slow but steady progress. He is reviewed clinically at 6 weeks following admission. He has a diffuse fullness of his upper abdomen and on imaging a collection of fluid is found to be located behind the stomach. His serum amylase is mildly elevated. Which of the following is the most likely explanation?
Early fluid collection Pancreatic abscess Peripancreatic necrosis Pseudocyst Sterile necrosis
Pseudocysts are unlikely to be present less than 4 weeks after an attack of acute pancreatitis. However, they are more common at this stage and are associated with a raised amylase.
