Lecture 9

Question 1

Descr the major lobar fissure of the liver

Answer 1

Also referred to as the principle plane or Cantlie line
Divides anatomical right & left liver

Question 2

How are hepatobiliary processes differentiated?

Answer 2

1) Chronicity of symptoms
2) History of:
Alcohol use
Occupational exposures
Viral hepatitis
particularly Hep C in those born between 1945-1965 and Hep B
3) Exam findings

Question 3

Descr 3 choliangiography imaging options

Answer 3

ERCP (endoscopic retrograde cholangiopancreatogram): performed with fluoroscopy
PTC (percutaneous transhepatic cholangiogram): antegrade visualization of biliary tree
IOC (intraoperative cholangiogram): open or laparoscopic via cystic duct or CBD
Visualize bile ducts during GB surgery

Question 4

Cholescintigraphy: Descr HIDA (Hepatic 2,6-dimethyl iminodiacetic acid) or DISIDA (diisopropyl iminodiacetic acid) scan

Answer 4

Acutely ill patients to eval for infection, bile leak, or biliary obstruction
Indicated if diagnosis of cholecystitis remains uncertain following u/s
If cystic duct patent, tracer enters gallbladder leading to its visualization
Evaluate patency of CBD & ampulla

Normal finding: visualization of contrast in CBD & GB within 15-30min and small bowel within 60min

Technetium-labeled HIDA (or DISIDA) injected intravenously, then taken up selectively by hepatocytes & excreted into bile

Question 5

Surgeon’s initial priority with hepatobiliary disease is? Why?

Answer 5

1) Necrotic or infected tissue? (ie, gangrenous GB)
Biliary obstruction with infection? (ie, cholangitis)
Acute liver failure?
2) Potentially life-threatening conditions
May require urgent surgical intervention

Question 6

1) What are some less common indications for hepatic resection?
2) How much is removed?
3) Define major hepatic resection

Answer 6

1) Less common indications: traumatic injury, infection/abscess, & liver donor transplantation
2) 75-80% removal with expected remnant regeneration (normal hepatic function)
3) 3 or more segments

Question 7

Descr the post op course of hepatic resection

Answer 7

Close monitoring for several post-op days
Hemorrhage is the major concern in immediate post-op period
Most patients without cirrhosis ready for discharge by POD 7 or 8
Sr bilirubin often increases
Sr albumin usually falls
PT often increases
Some patients develop ascites
Hypoglycemia not usually a problem
AST & ALT usually increased
Alkaline phosphatase initially normal then increases

Question 8

Hepatic resection:
1) How common are complications?
2) What are the most freq complications?
3) What is another group of complications?

Answer 8

1) Occur in up to 40% patients (most resolve without sequelae)
2) Liver-related (most frequent): perihepatic fluid collections (biloma), relative hepatic insufficiency, hepatic failure
3) Pulmonary: symptomatic pleural effusions or atelectasis, pneumonia (infrequent)

Question 9

Cirrhosis of liver:
1) What is it?
2) Common causes?

Answer 9

1) Represents pathologic end-point of severe hepatic injury
2) HBV & HCV infection, obesity, hepatotoxin exposure (ie, alcohol), metabolic derangements (ie, a1-antitrypsin deficiency, hemochromatosis, Wilson’s disease)

Question 10

Descr the presentation of cirrhosis

Answer 10

Well-compensated & asymptomatic
Encephalopathy, jaundice, coagulopathy (frank hepatic failure)
Complications of portal hypertension (ie, gastroesophageal varices, ascites)
85% caused by cirrhosis
Varices: high death rate

Question 11

Descr how to Tx cirrhosis

Answer 11

1) Most frequently managed medically (underlying causes & complications)
2) Surgical management: Liver transplantation
Complications of portal hypertension: treatment of bleeding/non-bleeding varices & ascites
Surgical diseases affecting non-cirrhotic patients (ie, cholecystitis, appendicitis)

Question 12

Cirrhosis: Acutely bleeding varices:
1) Medical Tx?
2) Non-surgical procedures?

Answer 12

1) Resuscitation & correction of coagulopathy
Antibiotic prophylaxis & splanchnic vasoconstriction (octreotide to reduce portal pressure)
2) Endoscopic therapy (banding, ligation or sclerotherapy)
(TIPS (salvage therapy of choice )

Question 13

Cirrhosis: Acutely bleeding varices:
1) Mechanical Tx to stabilize before definitive treatment?
2) Operative procedure options?

Answer 13

1) Balloon tamponade
2) Emergency portosystemic surgical shunt & variceal ligation
or
Esophageal transection and re-anastomosis

Question 14

Acutely bleeding varices w cirrhosis: Descr the role of portosystemic shunts

Answer 14

Reduce varices and decrease risk of bleeding
Non-selective & selective
Complications: encephalopathy, difficult transplant, renal failure

Question 15

Non-bleeding varices w cirrhosis:
1) Primary goal?
2) Prophylactic therapy (no h/o bleeding)?
3) Therapeutic therapy (h/o previous bleed)?

Answer 15

1) Prevent bleeding.
2) Expectant management, endoscopic band ligation or sclerotherapy (high risk for bleed), beta blockers (low and high risk)
3) Beta blockers, endoscopic band ligation (both similarly effective in preventing rebleeding and reduce recurrence of varices)
TIPS

Question 16

What are 2 Surgical/Operative approaches for non-bleeding varices w cirrhosis?

Answer 16

Liver transplantation (relatively young pt with cirrhosis)
Portosystemic shunts (if poor transplant candidate)

Question 17

Ascites w cirrhosis:
1) What does it result from?
2) Surgical mgmt?

Answer 17

1) Results from increased formation of lymph, hypoalbuminemia, and salt and water retention of the kidneys
2) liver transplantation
portosystemic (portacaval) shunt

Question 18

Ascites w cirrhosis: Descr medical mgmt

Answer 18

1) Diuretics (spironolactone initial treatment)
2) Dietary sodium restriction (2g max)
3) Avoidance of excessive fluid intake
4) Paracentesis (should be performed before therapy started)
5) TIPS

Question 19

Cirrhosis: Descr surgical therapy for indications unrelated to underlying liver disease (ie, cholecystitis, perforated viscus, abdominal wall hernias)

Answer 19

Severity of liver disease estimated by Child’s class or MELD score to quantify surgical risk
Consider preoperative evaluation for liver transplant prior to elective procedures

Question 20

Hemangioma: What is it? Explain

Answer 20

Most common benign hepatic tumor
Mass of blood vessel cells; thought to be congenital vascular malformations
Frequently incidental CT or MRI finding (also used for diagnosis)

Question 21

Hemangioma:
1) S/Sxs?
2) Tx?

Answer 21

1) Most small, solitary asx
Abdominal pain or discomfort possible with lesions >10 cm
2) Majority should be managed with observation (no surgery) unless significant symptoms
Rarely require surgery (rare bleeding or symptoms)
Surgical treatment is enucleation (most common) or resection (ie, lobectomy) if symptomatic

Question 22

Simple hepatic cysts:
1) Are they common? What imaging?
2) Are they malignant?
3) Do you always need to Tx?

Answer 22

1) Common incidental finding on abdominal imaging
U/S (most helpful first test): If internal septations, fenestrations, calcifications, should be evaluated with CT abd W IV contrast or MRI abd WWO (MRI better to assess character)
2) No malignant potential, but must distinguish from cystadenoma which is pre-malignant
3) No intervention required for asymptomatic patients

Question 23

Focal Nodular Hyperplasia (FNH):
1) Who does it affect?
2) What must you distinguish from? How?

Answer 23

1) Affects young women of reproductive age (avg ~40yo)
2) Hepatic adenoma (similar CT findings)
MRI most reliable imaging to differentiate
CT: central stellate scar (does not enhance w contrast)

Question 24

Focal Nodular Hyperplasia (FNH):
What are some features?

Answer 24

Well-circumscribed, firm, tan, usually subcapsular mass (2-3cm diameter)
Most asxatic. If sxatic (RUQ discomfort), >10cm
Rare hemorrhage
Not hormonally responsive
Not associated with malignant change
LFTs and AFP WNL
Must distinguish from hepatic adenoma (similar CT findings)

Question 25

Focal Nodular Hyperplasia: 1) What is it? 2) Tx?

Answer 25

1) Nodules (aggregates) of hepatocytes 2) Most FNH treated non-surgically (serial imaging) Resection indicated for symptomatic lesions or if imaging fails to define lesion

Question 26

Hepatic adenoma: 1) Who does it affect? 2) What is it assoc with? 3) Labs?

Answer 26

1) Affects young women of reproductive age 2) Most likely associated with OCP use 3) LFTs and AFP usually WNL

Question 27

Hepatic adenoma: Features?

Answer 27

Some lesions have hemorrhage; appear hypervascular compared to surrounding liver parenchyma (contrast-enhanced CT or MRI) Rare progression to HCC (~5%) May enlarge with high levels of circulating hormones

Question 28

Hepatic adenoma: Tx?

Answer 28

observation with serial imaging (< 5 cm); surgical resection (> 5 cm) Avoid OCPs permanently

Question 29

Liver metastasis: 1) What imaging? 2) Where does this cancer usually originate?

Answer 29

1) Best images of liver and extrahepatic spread: contrast-enhanced helical CT of the C/A/P MRI may also be used; distinguishes benign from malignant 2) Most common malignant hepatic neoplasms are metastatic tumors from primary cancers of GI tract, breast, lung, GU system, ovary, & uterus

Question 30

Liver metastasis: 1) When does it usually present? 2) Tx?

Answer 30

1) Condition often advanced at presentation (precluding surgery) 2) Chemotherapy is only treatment option for most patients (palliative) Exception: metastatic colorectal cancer (~20% cure rate with hepatic resection)

Question 31

Primary liver cancer/ Hepatocellular carcinoma (HCC): 1) Is it common? Causes? 2) Imaging? What else to Dx?

Answer 31

1) Most common primary liver cancer; chronic Hep B or C 2) CT w contrast C/A/P provides best images *For all possible liver cancers, a core biopsy should be pursued if suspicion is high

Question 32

Primary liver cancer/ Hepatocellular carcinoma (HCC): Descr the 3 main Tx options

Answer 32

1) Partial hepatectomy: resection TOC in some patients minimum criteria: disease confined to liver and amenable to a complete resection 2) Liver transplantation: treats malignancy and underlying cirrhosis (Milan criteria, living donors adopted as means to increase donor pool) > 80% patients are not candidates for transplant or resection 3) Non-operative liver-directed therapy: advanced disease & advanced cirrhosis (local ablative therapies) After treatment, followed with periodic physical exams, blood work to assess liver function, AFP (if elevated before resection), imaging studies. Recurrence = 70% (5yrs)

Question 33

Primary liver cancer/ Intrahepatic cholangiocarcinoma: 1) Risk factors? 2) Presentation?

Answer 33

1) Risk factors: cirrhosis, chronic liver disease 2) Generally, presents as a large mass within the liver without jaundice Clinically distinct from cholangiocarcinoma arising from the extrahepatic biliary tree. First symptom often is pain 2/2 size of tumor

Question 34

Primary liver cancer/ Intrahepatic cholangiocarcinoma: Descr the 2 main Tx options

Answer 34

1) Resectable disease: Complete resection (laparotomy) with negative margins is TOC 2) Unresectable disease (metastasis, locally advanced tumors, & multiple intrahepatic lesions or satellite tumors): embolic treatment + chemo Transplantation rarely indicated

Question 35

Extrahepatic cholangiocarcinoma: Descr the 2 main Tx options

Answer 35

1) Resectable disease: Complete resection with negative margins (radical pancreaticoduodenectomy) 2) Unresectable disease (metastasis, locally advanced tumors, & multiple intrahepatic lesions or satellite tumors): Stent placement

Question 36

Gallbladder adenocarcinoma: 1) Epidemiology? Outcome? 3) Tx options?

Answer 36

1) Uncommon; occurs in elderly; F>M Associated with gallstones (length of time present) Persistent RUQ pain/biliary colic 1yr survival = 15% 2) Procedure depends on timing of identification & extent of disease: a) Cholecystectomy *1 case of gallbladder cancer prevented with every 100 cholecystectomies b) + Resection  (adjacent normal liver and LNs) c) + Bile duct resection *Prophylactic cholecystectomy: Patients with GB polyp(s) > 1 cm

Question 37

Acute cholecystitis: 1) What is it? 2) What testing?

Answer 37

1) Persistent obstruction of bile flow from gallbladder (calculous) Also in very ill pts or pts on TPN with biliary stasis: acalculous 2) RUQ u/s (first test of choice; may be only test required) then HIDA if more information required

Question 38

Acute cholecystitis: Tx?

Answer 38

Definitive Treatment: laparoscopic cholecystectomy within 24-72 hours of admission for most pts with symptoms + supportive care Persistent cystic duct obstruction may lead to perforation or necrosis = life-threatening surgical emergency

Question 39

Acute cholecystitis: 1) Mainstay of therapy? 2) Timing & approach to biliary decompression depends on what three factors?

Answer 39

1) IVF, abx, biliary decompression 2) -Establishing diagnosis -Length of disease at presentation -Pt’s pre-existing health to undergo surgery

Question 40

What are the 3 main Tx options for acute cholecystitis?

Answer 40

Urgent laparoscopic cholecystectomy Percutaneous cholecystostomy – patient not good surgical candidate Abx +/- Interval cholecystectomy

Question 41

Cholelithiasis: When should you consider prophylactic cholecystectomy?

Answer 41

In asymptomatic patients found to have gallstones on imaging for the following findings: a) Stones > 1 cm diameter b) Calcified gallbladder c) Enlarging or > 1 cm gallbladder polyps

Question 42

Cholelithiasis: What should you do for most symptomatic pts? Explain

Answer 42

Elective cholecystectomy indicated (laparoscopic preferred) Intraoperative cholangiography also completed to evaluate for common duct stones

Question 43

Choledocholithiasis: 1) What is it? 2) Tx?

Answer 43

1) Common bile duct stones; gallbladder u/s may show dilation of bile duct 2) -Typical patient (mild cholangitis + gallstones): Laparoscopic cholecystectomy with laparoscopic exploration of CBD >May need ERCP prior to cholecystectomy -CBD stones with previous cholecystectomy: endoscopic sphincterotomy (allows stones to pass from the duct to the duodenum) -If cholangitis (bacterial infection of biliary ducts), + IV abx  ERCP with sphincterotomy and bile duct decompression

Question 44

Cystic duct stump leak: 1) Cause? 2) Typical presentation? 3) Dx? 4) Tx?

Answer 44

1) Complication of laparoscopic cholecystectomies -Surgical clip slips off (inaccurately placed) = Results in biloma 2) Abdominal pain, fever, + vomiting 3 days after procedure 3) HIDA (identify biliary leak) or ERCP (identify leak, location, and allow for treatment with CBD stent) 4) ERCP stenting of CBD & percutaneous drainage of biloma ->90% leaks seal after CBD stenting without further surgery

Question 45

Gallstone ileus: 1) What is it? 2) TOC? 3) What is pathognomonic?

Answer 45

1) Mechanical intestinal obstruction caused by a large gallstone lodged in the ileal lumen 2) CT (TOC) 3) Pneumobilia (pathognomonic)

Question 46

Gallstone ileus: Descr Tx

Answer 46

Emergency laparoscopy (or laparotomy) with removal of obstructing stone: -Proximal intestine inspected for 2nd stone -Gallbladder left undisturbed -Delayed elective cholecystectomy (once pt recovered and if chronic gallbladder symptoms; 30% patients) -Fistula closes spontaneously in most patients