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GS48 General Surgery and Thoracic Surgery Biliary Tract Toronto Notes 2019
Mirizzi Syndrome
Extrinsic compression of the common hepatic duct by a gallstone in the cystic duct or Hartmann’s pouch. Impacted gallstone may erode into the CHD or CBD, creating a cholecystohepatic or cholecystocholedochal fistula; Mirizzi syndrome has an association with gallbladder cancer
Rouviere’s Sulcus
Fissure between right lobe and caudate process of liver; keeping dissection anterior to this landmark prevents bile duct injury
Critical View of Safety
Decreases risk of injury to CBD during laparoscopic cholecystectomy
Hepatocystic triangle (space between the gallbladder and liver) cleared of any structures other than the cystic artery
Laparoscopic vs. Open Cholecystectomy Laparoscopic Cholecystectomy
• Shorter operating time
• Shorter length of stay
• Shorter sick leave
• Shorter time to return to daily activities
• Less post-operative pain
• Decreased use of post-operative analgesia
• Decreased reduction in pulmonary
function*
• Fewer pulmonary complications
• Decreased acute phase response
• Less impairment in intestinal motility* Open Cholecystectomy
• Lower conversion rates to open surgery
(for mini-laparotomies) *NOTE:
Pulmonary function = O2 consumption, spirometric parameters, ABG, and acid-base balance
Intestinal motility = auscultating intestinal peristalsis, abdominal circumference measurement, and time interval to restitution of defecation
American Society of Gastrointestinal Endoscopy 2010 Predictors for Risk of CBD Stones
Very strong
• CBD stone on U/S
• Clinical ascending cholangitis
• Bilirubin >68 μmol/L
Strong
• CBD dilated >6 mm on U/S
• Bilirubin 31-68 μmol/L
Moderate
• Abnormal liver test (besides bilirubin) •Age>55yr
• Clinical gallstone pancreatitis
• cholecystectomy
■ early (within 72 h) vs. delayed (after 6 wk)
◆ equal morbidity and mortality
◆ early cholecystectomy preferred: shorter hospitalization and recovery time, no benefit to
delaying surgery
◆ emergent OR indicated if high risk, e.g. emphysematous
■ laparoscopic is standard of care (convert to open for complications or difficult case)
◆ laparoscopic: reduced risk of wound infections, shorter hospital stay, reduced post-operative
pain, and increased risk of bile duct injury • intra-operativecholangiography(IOC)
■ indications: clarify bile duct anatomy, history of biliary pancreatitis, small stones in gallbladder with a wide cystic duct (>15 mm), and jaundice
• percutaneouscholecystostomytube:criticallyillorifgeneralanestheticcontraindicated
Acalculous Cholecystitis
Definition
• acuteorchroniccholecystitisintheabsenceofstones
Pathogenesis
• typicallyduetogallbladderischemiaandstasis
Risk Factors
• DM,immunosuppression,ICUadmission,traumapatient,TPN,andsepsis
Clinical Features
• seeAcuteCholecystitis,GS47
• occursin20%ofcasesofacutecholecystitis
Investigations
• U/S:showssludgeingallbladder,otherU/Sfeaturesofcholecystitis(seeAcuteCholecystitis,GS47) • CTorHIDAscan
Treatment
• broad-spectrumantibiotics,cholecystectomy • ifpatientunstable→cholecystostomy
Choledocholithiasis
Definition
• stonesinCBD
Clinical Features
• 50%asymptomatic
• oftenhavehistoryofbiliarycolic
• tendernessinRUQorepigastrium
• acholicstool,darkurine,andfluctuatingjaundice • primaryvs.secondarystones
■ primary: formed in bile duct, indicates bile duct pathology (e.g. benign biliary stricture, sclerosing cholangitis, choledochal cyst, and CF)
■ secondary: formed in gallbladder (85% of cases in U.S.)
Investigations
• CBC:usuallynormal;leukocytosissuggestscholangitis
• LFTs: increased AST, ALT early in disease, increased bilirubin (more sensitive), Alkaline phosphatase
(ALP), gamma glutamyltransferase (GGT) later
• amylase/lipase:toruleoutgallstonepancreatitis
• U/S:intra-/extra-hepaticductdilatation;differentialdiagnosisischoledochalcyst • MRCP (90% sensative)
■ visualization of ampullary region, biliary and pancreatic anatomy
■ non-invasive diagnostic test of choice • ERCP
■ CBD stones in periampullary region
■ diagnostic and therapeutic; removal of stones and sphincterotomy possible
■ complications: retained stones, ERCP pancreatitis (1-2%), pancreatic or biliary sepsis
Percutaneous Transhepatic Cholangiography
• percutaneousapproachtotheproximalbiliarytree(i.e.intra-hepaticbiliarysystem)viathehepatic parenchyma
• usefulforproximalbileductobstructionorwhenERCPfailsornotavailable