Transcript QUESTION - Mount Sinai St. Luke's Roosevelt Hospital

Question
• Injury to the common bile duct during
laparoscopic cholecystectomy is most likely to
occur as a result of
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A. use of a 30 degree scope
B. lateral retraction of the infundibulum
Dissection of the cystic duct-gallbladder junction
Dissection of the triangle of Calot
Intraoperative cholangiography
Question
• Injury to the common bile duct during
laparoscopic cholecystectomy is most likely to
occur as a result of
–
–
–
–
–
A. use of a 30 degree scope
B. lateral retraction of the infundibulum
Dissection of the cystic duct-gallbladder junction
Dissection of the triangle of Calot
Intraoperative cholangiography
Question
• Injury to the common bile duct during
laparoscopic cholecystectomy is most likely to
occur as a result of
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–
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A. use of a 30 degree scope
B. lateral retraction of the infundibulum
C. Dissection of the cystic duct-gallbladder junction
D. Dissection of the triangle of Calot
E. Intraoperative cholangiography
ANATOMY
• Triangle of Calot
– Common Hepatic duct
– Cystic duct
– Inferior surface of the Liver
– Cystic Artery is within
– Anatomic variants
• Cystic Duct may be absent, short, posterior, low or
anterior to CBD, or directly from the RHD
• Cystic artery may arise from gastroduodenal artery
ANATOMY
• Injuries (Causes)
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Failure to occlude duct
Too deep a dissection plane
Thermal Injury
Tenting injury
Misidentification
• CBD thought to be cystic duct
• Injury of aberrant duct
ANATOMY
• Injuries (Bismuth classification)
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Type A Cystic duct leaks/Liver bed duct injury
Type B/C Aberrant Right hepatic ducts
Type D Lateral injury to major duct
Type E Transection/Ligation
– Immediate referral is preferred
– 1-6 weeks – Drain/stent & operate in 3months
ANATOMY
• Portahepatis (Hepatoduodenal lig)
– Portal vein posterior
– Common hepatic artery to left anterior
– CBD to the right anterior
PHYSIOLOGY
• Bile
– Lecithin
– Bile Salt
– Cholesterol
• Gallbladder Contraction
– Cholecystokinin
• Fatty acid
• Amino acid
CHOLELITHIASIS
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10-20% of population
Female age obesity family hx
Crystallization-contraction of bile salt pool
1-2% develop symptoms
Types
– Cholesterol
– Pigmented
• Brown/Black
Asymptomatic Stones
• Prophylactic cholecystectomy not indicated
• Exceptions
– Transplant
• Renal- NO
• Cardiac -YES
– Chronic TPN -Probably YES
• 35 develop stones
• Develop symptoms more than expected
– Bariatrics-NO
– Hemoglobinopathy -YES
• 50 develop complication
• Crisis mimics biliary colic
Asymptomatic Stones
• Incidental cholecystectomy
– During laparotomy stones are discovered
– Over 70 -higher incidence of sepsis/MSOF when CCY
NOT done
ACUTE CHOLECYSTITIS
• Signs and Symptoms
• Labs
– Leukocytosis
– Bilirubin
• Choledocholithiasis
• Mirizzi syndrome
– Amylase
• Radiographic
– Ultrasound
– CT
– HIDA
ACUTE CHOLECYSTITIS
• Treatment
– Antibiotics-broad spectrum
• Ecoli, Klebsiella, Clostridium, Proteus, Enterobacter
– CBD stones
• Preop -ERCP
• Intraop
– CBDE
– Postop ERCP
• Surgery
– Expose Calot triangle
• Fundus superior
• Infundibulum lateral/inferior
• Critical view of safety
• Avoid electrocautery
ACUTE CHOLECYSTITIS
– Cholangiogram
• Anatomy
• LFT elevation
• H/O pancreatitis/jaundice
• Injury
• Timing
– Early is better
• Complications of AC
– Gangrene.empyema.perforation
– Male, older, T>38,WBC>18
– Mortality 20%
ACUTE CHOLECYSTITIS
• Complications of LC
– Bile duct injury - 0.3%
• Manage w/ERCP/stent
• T-tube
• Hepaticojejunostomy
– Stone spillage 10%
• Abscess
ACUTE CHOLECYSTITIS
• Acute acalculous cholecystitis
– 4-8% of AC cases
– M>F/Critically ill
– Trauma/surgery/burns
– Childbirth
– Mult transfusions
– Shock/sepsis
– TPN/narcotics
– SLE/Sarcoidosis/Polyart nodosa
Acute acalculous cholecystitis
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Dx usually delayed
HIDA, US., CT
High risk of gangrene
Treatment
– Percutaneous cholecystostomy
– Cholecystectomy
Critically Ill
• Cholecystostomy 95-100% successful
• Facilitates delayed LC
• No change in mortality vs conservative
therapy.
• Higher conversion, complication rate during
subsequent lap chole
PREGNANCY
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0.04% develop AC
Conservative Rx if poss
7% develop preterm labory
Positioning
– L side down ( take pressure off IVC)/ Rev Trend
– SCD’s
– Low pneumoperitoneum
– Supraumbilical trocar w/ Hasson technique
– US for CBDE/Lead shielding for cholangiogram
– Monitor fetus pre/post-op
Pregnancy
• If possible (and necessary) surgery should be done
in 2nd trimester
– 1st trimester – open and lap assoc w/ spontaneous
abortion
– 3rd trimester – injury to uterus and premature labor
– Control symptoms – wait for 2nd trimester or delivery.
Recurrence 50-75%
– If pain intractable or course worsens – cholesystostomy
is reasonable until 2nd trimester/ delivery is reached.
Question
• A 27 yo woman who is 16 weeks pregnantpresents with 12
hours of RUQ abdominal pain and vomiting. She is afebrile and
stable hemodynamically. She has a WBC of 13,200 and normal
LFT’s. Ultrasound reveals cholelithiasis and distention, but no
pericholecystic fluid or thickening.
• Antibiotics and IV fluids are started, but after 12 hours her
symptoms and exam worsen and her T=100.5
• The best management would be:
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A. Magnesium sulfate
B. percutaneous cholecystostomy
C. Laparoscopic cholecystectomy
D. ERCP
E. Broaden antibiotic coverage
Question
• A 27 yo woman who is 16 weeks pregnantpresents with 12
hours of RUQ abdominal pain and vomiting. She is afebrile and
stable hemodynamically. She has a WBC of 13,200 and normal
LFT’s. Ultrasound reveals cholelithiasis and distention, but no
pericholecystic fluid or thickening.
• Antibiotics and IV fluids are started, but after 12 hours her
symptoms and exam worsen and her T=100.5
• The best management would be:
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A. Magnesium sulfate
B. percutaneous cholecystostomy
C. Laparoscopic cholecystectomy
D. ERCP
E. Broaden antibiotic coverage
Acute Cholangitis
• ETIOLOGY
– Bile Stasis
– Growth of bacteria
• Stones
• Papillary stenosis
• Mirizzi syndrome
• Choledochal cyst
• Sclerosing cholangitis
• Parasites/viral
• Iatrogenic
Acute Cholangitis
• Charcot Triad
– Abdominal pain
– Fever
– Jaundice
• Reynolds Pentad - ADD:
– Shock
– Altered mental status
Common Duct Stones
• PRE-OP
– ERCP
• 70-90% effective
• 40-60% no stones
• Morbidity 5-19%
• Mortality 1.9%
• Longer LOS
– Lap CBDE
– 70-90% effective
Common Duct Stones
Intraop
– Small stones
• Glucagon to relax Oddi
• Flush
– LCBDE
– OCBDE
• Unable to do LCBDE
• ERCP not possible
• Impacted stone
• Longer LOS/higher morbidity
– ERCP/ES
• Postop
– ERC/ES
Open CBDE
• Contraindication
– Small duct w/ small stones– risk of stricture
– Portal HTN
– Severe inflammation
– Cholangitis w/shock
Open CBDE
• Steps
– Flush/milk
– Fogarty balloons
– Choledochoscope
– Baskets
• If unsuccessful:
• Transduodenal sphincterotomy
– Anterior 10-11 oclock
• avoid PD
– Close if >10mm
• Choledochoduodenostomy
Question
– The most effective long term treatmentfor extrahepatic
choledochal cysts is
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Antibiotics and Urodeoxycholic acid
Placements of self expanding stents
Resection
Laser ablation
Endoscopy/ES
– The most common form of choledochal cyst is
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Extrahepatic diffuse
Extrahepatic saccular
Intraduodenal (choledochocele)
Intra- and Extrahepatic
Intrahepatic only (Caroli’s)
Choledochal Cysts
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Type I
Extrahepatic and fusiform (MOST COMMON)
Type II Extrahepatic and saccular
Type III Intraduodenal (choledochocele)
Type IV Extrahepatic and Intrahepatic (Next M.C.)
Type V Intrahepatic only (Caroli’s disease)
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Uncommon in West, but incidence increasing
Triad of Symptoms: RUQ mass, pain, jaundice is RARELY EVIDENT
Adults usually present w pancreatitis or cholecystitis
Dx: Imaging U/s, MRCP/CT/ERCP
Choledochal Cysts
– Complications
• Stone formation
• Recurrent sepsis
• MALIGNANT DEGENERATION (10%)
– Treatment
• Cyst excision w/ hepaticojejunostomy
• Jejunal interposition may be better for surveillance
Question
– A 33 yo woman presents w 4 weeks of anorexia, weight
loss, fatigue and jaundice. Evaluation including ERCP
reveals primary scleerosisng cholangitis (PSC)
• PSC
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Occurs mostly in women
Has a known etiology
Is associated with retroperitoneal fibrosis
More oftern assoiated with Crohn’s disease than Ulcerative colitis
Lacks pathogomatic signs
Question
– A 33 yo woman presents w 4 weeks of anorexia, weight
loss, fatigue and jaundice. Evaluation including ERCP
reveals primary scleerosisng cholangitis (PSC)
• PSC
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Occurs mostly in women
Has a known etiology
Is associated with retroperitoneal fibrosis
More oftern assoiated with Crohn’s disease than Ulcerative colitis
Lacks pathogomatic signs
Question
– A 33 yo woman presents w 4 weeks of anorexia, weight
loss, fatigue and jaundice. Evaluation including ERCP
reveals primary scleerosisng cholangitis (PSC)
– The most definitive treatments would be
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Long term antibiotics
Urodeoxycholic acid
Long term steroids
Roux-en-Y choledochoduodenotomy
Hepatic transplantation