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GS50 General Surgery and Thoracic Surgery Biliary Tract Toronto Notes 2019 Carcinoma of the Gallbladder
Courvoisier’s Sign
Palpable, nontender distended gallbladder due to CBD obstruction. Present in 33% of patients with pancreatic carcinoma. The distended gallbladder could not be due to acute cholecystitis or stone disease because the gallbladder would actually be scarred and smaller, not larger
Risk Factors
• chronicsymptomaticgallstones(70%ofcases),oldage,female,gallbladderpolyps,porcelain gallbladder, chronic infection (Salmonella, Helicobacter), and abnormal pancreaticobiliary duct junction
Clinical Features
• majorityareadenocarcinoma
• maybeincidentalfindingonelectivecholecystectomy(~1%ofopencholecystectomiesOR0.1%in
laparoscopic cholecystectomies)
• manypatientsareasymptomaticuntillate
• local:non-specificRUQpain,±palpableRUQmass
• Courvoisier’sgallbladder:anenlarged,oftenpalpablegallbladderinapatientwithcarcinomaofthe
head of the pancreas; associated with jaundice due to obstruction of the CBD
• systemic: jaundice (50%) due to invasion of CBD or compression of CBD by pericholedochal nodes,
weight loss, malaise, anorexia
• earlylocalextensiontoliver,mayextendtostomach,duodenum • earlymetastasiscommontoliver,lung,bone
Investigations
• U/S:muralthickening,calcification,lossofinterfacebetweengallbladderandliver,andfixedmass
• endoscopicU/S(EUS):goodfordistinguishingcarcinomasfromotherdiagnosessuchaspolyps,good
for staging, allows sampling of bile for cytology
• abdominal CT: polypoid mass, mural thickening, liver invasion, nodal involvement, and distant
Treatment
Efficacy of Neoadjuvant Chemoradiation,
Followed by Liver Transplantation, for Perihilar
Cholangiocarcinoma at 12 US Centres
Gastroenterology 2012;143:88-98
Purpose: To determine the effectiveness of neoadjuvant
chemoradiation and liver transplantation for unresectable
perihilar cholangiocarcinoma and to determine the
appropriateness of the United Network of Organ Sharing/
Organ Procurement and Transplantation Network (UNOS/
OPTN) criteria for model of end-stage liver disease (MELD)
exception for patients with this disease.
Methods: Study conducted from 1993-2010 in 12 transplant
centres. 287 patients included.
Results: Median follow-up was 2.5 yr. 43% of patients
(n=122) died after a median of 1.2 yr from presentation, and Prognosis of these, 60 died pretransplant. Post-transplant, 43 patients
had recurrences and 62 died. Recurrence-free survival at
2, 5, and 10 yr were 78%, 65%, and 59%, respectively.
Intention-to-treat survival rates at 2 and 5 yr were 68% and
53%, respectively. 25% of patients left the waiting list after
a median of 4.6 mo. The waiting list drop-out rate increased
by an average of 11.5% every 3 mo. Patients who received
transplantation outside of the criteria for MELD exception or Definition who had a malignancy within 5 yr had significantly worse
recurrence-free survival compared to those who met the
criteria (HR=2.98, 95% CI 1.79, 4.95). Recurrence-free
survival at 5 yr was shorter for patients with tumours >3 cm
vs. ≤3 cm (p<0.001).
Conclusions: Neoadjuvant chemoradiation and liver
transplantation are effective treatments for unresectable
perihilar cholangiocarcinoma. Furthermore, the UNOS/OPTN
criteria for MELD exception appear to be appropriate.
metastases
• MRI/MRCP:goodfordistinguishingbenignandmalignantpolyps
• if carcinoma of the gallbladder is suspected pre-operatively, an open cholecystectomy should be considered to avoid tumour seeding of the peritoneal cavity
• confinedtomucosa(rare):cholecystectomy
• beyondmucosa:cholecystectomy,enblocwedgeresectionof3-5cmunderlyingliver,anddissectionof
hepatoduodenal lymph nodes
Cholangiocarcinoma
• malignancyofextra-orintrahepaticbileducts
Risk Factors
Clinical Features
• majorityareadenocarcinomas
• gradualsignsofbiliaryobstruction:jaundice,pruritus,darkurine,andpalestools
• anorexia,weightloss,RUQpain,Courvoisier’ssign(ifCBDobstructed),hepatomegaly
• earlymetastasesareuncommon,butcommonlytumourgrowsintoportalveinorhepaticartery • Klatskintumour:cholangiocarcinomalocatedatbifurcationofcommonhepaticduct
Investigations
• LFTsshowobstructivepicture
• U/S, CT: bile ducts usually dilated, but not necessarily • ERCPorPTC:todetermineresectability,forbiopsies • CXR,bonescan:formetastaticworkup
Treatment
• ifresectable:biliarydrainageandwideexcisionmargin • intra-hepaticlesions:liverresection
■ upper third lesions: duct resection + Roux-en-Y hepaticojejunostomy, ± liver resection ■ middle third lesions (uncommon): duct resection + Roux-en-Y hepaticojejunostomy
■ lower third lesions: Whipple procedure
• unresectablelesions:stentorcholedochojejunostomy(surgicalbypass) • chemotherapy±radiotherapy
• rolefortransplantationinselectedpatientswithKlatskinstumours
Prognosis
• overall5yrsurvival:15%
• poor5yrsurvival(10%)asgallbladdercarcinomaisoftendetectedlate • betteroutcomeswhendetectedincidentallyfollowingcholecystectomy
• age50-70,gallstones,ulcerativecolitis,primarysclerosingcholangitis,choledochalcyst,Clonorchis sinensis infection (liver fluke), chronic intrahepatic stones (hepatolithiasis)
Obstructive jaundice is the most common presenting symptom for cholangiocarcinoma