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Surgical Management of Benign and Malignant conditions of Biliary Tree. Houssam G. Osman, M.D. HPB surgery Associate Director, HPB Fellowship Methodist Dallas Medical Center, Dallas ACOS: In-Depth Review - 2014 Kansas city, MO. CHOLECYSTITIS. Acute cholecystitis

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surgical management of benign and malignant conditions of biliary tree

Surgical Management of Benign and Malignant conditions of Biliary Tree

Houssam G. Osman, M.D.

HPB surgery

Associate Director, HPB Fellowship

Methodist Dallas Medical Center, Dallas

ACOS: In-Depth Review - 2014

Kansas city, MO

cholecystitis
CHOLECYSTITIS
  • Acute cholecystitis
  • Achalculouscholecystitis
  • Gangrenous cholecystitis
  • Emphysematous cholecystitis

Imaging: US

Treatment options:

  • Antibiotics
  • Cholecystectomy
  • Percutaneous cholecystotomy tube
choledocholithiasis
CHOLEDOCHOLITHIASIS
  • Secondary 85%
  • Primary 15%

- benign biliary strictures

- sclerosing cholangitis

- choledochalcysts.

- parasitic infections

choledocholithiasis1
CHOLEDOCHOLITHIASIS

Conditions

  • Painful jaundice
  • Cholangitis
  • Gallstone pancreatitis
  • Silent CBD stone
choledocholithiasis2
CHOLEDOCHOLITHIASIS
  • Probability of CBD stone

American Society of Gastrointestinal Endoscopy Standards of Practice Committee Maple JT, et al.: The role of endoscopy in the evaluation of suspected choledocholithiasis. GastrointestEndosc. 71 (1):1-9 2010

choledocolithiasis
CHOLEDOCOLITHIASIS

Imaging

Ultrasound

  • 1st line
  • Jaundice + CBD > 10 mm -> stone in 90% of cases
  • Maybe able to visualize stone

MRCP

  • Most sensitive non invasive study (decreased sensitivity for stones < 5 mm)
  • Intermediate probability or when ERCP is not feasible
choledocolithiasis1
CHOLEDOCOLITHIASIS

ERCP

  • ? Therapeutic more than diagnostic?

EUS

  • Comparable efficacy to ERCP but ? less complication

I.O.C

  • Routine Vs selective
choledocolithiasis2
CHOLEDOCOLITHIASIS

Treatment approaches

  • ERCP
  • PTC
  • CBDE
bile duct injury
BILE DUCT INJURY
  • Incidence during open cholecystectomy 0.2 – 0.3 %
  • Incidence during laparoscopic cholecystectomy 0.3 – 0.6%
bile duct injury1
BILE DUCT INJURY

Causes of laparoscopic biliary injury

  • Misidentification of the bile ducts as the cystic duct
  • Misidentification of the CBD as the cystic duct
  • Misidentification of the aberrant right sectoral hepatic duct as the cystic duct
  • Improper techniques of ductal exploration
  • Failure to occlude the cystic duct securely
  • Plane of dissection away of gallbladder wall into liver bed
  • Excessive retraction of cystic duct with tenting of CBD
  • Injudicious use of electrocautery
  • Injudicious use of clips

Modified from Strasberg SM et al, 1995: An analysis of problem of biliary injury during laparoscopic cholecystectomy. J Am CollSurg 180: 101-125

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

bile duct injury2
BILE DUCT INJURY

Classification of laparoscopic biliary injury

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

bile duct injury3
BILE DUCT INJURY

Injury recognized at time of surgery

  • Stop!
  • Consider your expertise and ask for help
  • Leave a drain and transfer to HPB surgeon

What is HPB surgeon going to do?

  • Quick return to OR - open approach (likely)
  • Identify injury and assess concomitant vascular injury
  • Cholangiogram
  • Repair:

-Roux en Y hepatojejunostomy

-Direct repair over T tube

bile duct injury4
BILE DUCT INJURY

You are doing a tough laparoscopic cholecystectomy and suspect Mirizzi syndrome, what do you do?

  • Proceed with subtotal cholecystectomy

Or

  • Place cholecystotomy tube
bile duct injury5
BILE DUCT INJURY

Hold on a second! How can suspect Mirizzi syndrome??

  • Long standing gallstone disease
  • Contracted gallbladder
  • Jaundice or cholangitis
bile duct injury6
BILE DUCT INJURY

You are doing a tough laparoscopic cholecystectomy and suspect Mirizzi syndrome and you perform partial cholecystectomy. You encounter a gush of bile!

what is going on?

  • Mirizzi syndrome type 2: cholecystocholedochal fistula

What do you do?

  • Cholecystocholedochoduodenostomy, or
  • Hepatojejunostomy

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

bile duct injury7
BILE DUCT INJURY

Injury recognized postoperatively

  • Bile leak
  • Biloma and infection
  • Juandice

Workup

  • ERCP - diagnostic and therapeutic
  • MRCP
  • CT – assess vascular injury and fluid collection
  • PTC if needed
bile duct injury8
BILE DUCT INJURY

Injury recognized postoperatively

  • Control bile leak
  • Drain fluid collection
  • Treat infection
  • Volume resuscitation
  • Electrolyte replacement
  • Delayed repair
bile duct cyst
BILE DUCT CYST

Classification

Chijiiwa K, Koga A: Surgical management and long-term follow-up of patients with choledochal cysts. Am J Surg 165:238-242, 1993

bile duct cyst1
BILE DUCT CYST

Presentation – Adulthood

  • Asymptomatic (majority)
  • Biliary colic like symptoms and mild jaundice
  • Pancreatitis
  • Liver cirrhosis
  • Malignancy ( weight loss)

Incidence of malignancy 2.5 – 28 %

bile duct cyst2
BILE DUCT CYST

Treatment

  • Type I : Excision + Roux en Y hepatojejunostomy vs. hepatoduodenostomy
  • Type II: Excision
  • Type III: Trans-duodenal excision vs. endoscopic sphinterotomy
  • Type IV A: Bile duct and hepatic resection and hepatojejunostomy
  • Type IV B: Excision + Roux en Y hepatojejunostomy vs. hepatoduodenostomy +/- sphincteroplasty
  • Type V: Liver resection vs. transplant

Cyst excision does not eliminate risk of malignancy

primary sclerosing cholangitis
PRIMARY SCLEROSING CHOLANGITIS
  • Associated with IBD mainly UC
  • Risk of cholangiocarcionoma 1% per year

Presentation

  • Asymptomatic
  • Liver cirrhosis
  • Cholangitis – uncommon
primary sclerosing cholangitis1
PRIMARY SCLEROSING CHOLANGITIS

Diagnosis

  • Cholangiography / MRCP
  • Multifocal strictures

Treatment

  • Asymptomatic : Observe
  • Stricture : ERCP vs resection
  • Liver cirrhosis: Transplant
  • Cholangiocarcinoma: Resection
extra hepatic cholangiocarcinoma
EXTRA-HEPATIC CHOLANGIOCARCINOMA

Risk factors

  • Primary sclerosing cholangitis
  • Bile duct cysts
  • Biliary parasites; Clonorchissinensis, Opisthorchisviverrini
  • ?? sphincterotomy
extra hepatic cholangiocarcinoma1
EXTRA-HEPATIC CHOLANGIOCARCINOMA

Classification

  • Perihilar
  • Mid bile duct

- hepatic confluence to cystic duct

- rare

  • Distal bile ducy

- distal to cystic duct confluence

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

extra hepatic cholangiocarcinoma2
EXTRA-HEPATIC CHOLANGIOCARCINOMA

Presentation

  • Jaundice and pruritus
  • Abnormal LFT
  • Non specific symptoms and weight loss
extra hepatic cholangiocarcinoma3
EXTRA-HEPATIC CHOLANGIOCARCINOMA
  • Distal cholangiocarcinoma

- treat like periampullary tumor

- whipple

  • Mid duct cholangiocarcinoma

- very rare

- ? Gallbladder / cystic duct base cancer

- bile duct resection and cholecystectomy

- assess need to treat like GB cancer; segment 4,5 liver resection

extra hepatic cholangiocarcinoma4
EXTRA-HEPATIC CHOLANGIOCARCINOMA
  • Perihilarcholangiocarcinoma - Classification

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

extra hepatic cholangiocarcinoma5
EXTRA-HEPATIC CHOLANGIOCARCINOMA
  • Perihilarcholangiocarcinoma – Work up

- CT

- MRCP

- ERCP

- PTC

Tissue diagnosis is not required in patient with potentially resectable

extra hepatic cholangiocarcinoma6
EXTRA-HEPATIC CHOLANGIOCARCINOMA
  • Perihilarcholangiocarcinoma – Treatment
      • Resectable

- bile duct resection

- achieving R0 resection almost always require partial hepatectomy

- hepatojejunostomy

- adjuvant treatment

      • Unresectable

- palliative

- transplant in selected cases preceded by neoadjuvanet chemotherapy (Mayo clinic)