Lecture 9 highlights

Question 1

Most common indications for hepatic resection are?

Answer 1

Primary & secondary malignant tumors
+
symptomatic benign tumors

Question 2

HIDA:
1) Why may it be done for acutely sick pts?
2) With what diagnoses is it indicated?

Answer 2

1) Infection, bile leak, or biliary obstruction
2) If cholecystitis remains uncertain following u/s

Question 3

1) Cirrhosis is a _______ contraindication for partial hepatectomy
2) What predicts mortality after hepatic resection in pts with cirrhosis?
3) What assesses liver function in patients undergoing resection?

Answer 3

1) relative
2) Child-Pugh classification (ascites, encephalopathy, albumin, total bilirubin, prothrombin time)
3) MELD score (bilirubin, Sr sodium, INR, Sr creatinine, dialysis)

Question 4

1) What is the major concern in immediate post-op period of hepatic resection?
2) Hepatic resection: Most patients without cirrhosis ready for discharge by POD ____ or ___
3) Is hypoglycemia a concern?

Answer 4

1) Hemorrhage
2) 7 or 8
3) Hypoglycemia not usually a problem

Question 5

1) What is a main cause of cirrhosis?
2) Main Sxs?

Answer 5

1) Alcohol
2) Encephalopathy, jaundice, coagulopathy, portal hypertension

Question 6

List the main points of cirrhosis Tx

Answer 6

Most frequently managed medically (underlying causes & complications)
Surgical management: Liver transplantation

Question 7

Acutely bleeding varices w cirrhosis:
1) What is the salvage therapy of choice?
2) What is a main operative procedure?

Answer 7

1) TIPS
2) Emergency surgical shunt + variceal ligation

Question 8

What is the most common benign hepatic tumor?

Answer 8

Hemangioma

Question 9

Main Tx for Hemangioma?

Answer 9

Observation (surgical = enucleation or resection)

Question 10

Simple hepatic cyst:
1) What premalignant condition must you distinguish from?
2) Who do you need to Tx?

Answer 10

1) Cystadenoma
2) Symptomatic pts

Question 11

Focal Nodular Hyperplasia (FNH):
1) What is the best imaging to differentiate from hepatic adenomas?
2) Tx?

Answer 11

1) MRI
2) Usually just serial imaging; resection if needed

Question 12

Who must Avoid OCPs permanently? (important)

Answer 12

Hepatic adenoma pts

Question 13

Descr general Tx for:
1) Hemangioma
2) Simple hepatic cysts

Answer 13

1) Observation for most; rare enucleation or resection (lobectomy)
2) No intervention if asymptomatic; drainage, deroofing, and or resection for symptomatic patients

Question 14

Descr general Tx for:
1) Hepatic adenoma
2) FNH

Answer 14

1) Observation for asymptomatic lesions < 5 cm; resection for symptomatic lesions and asymptomatic lesions > 5 cm
2) No intervention if asymptomatic; resection for symptomatic patients and to differentiate from adenoma or malignancy

Question 15

Liver metastasis:
1) Best images of liver and extrahepatic spread?
2) What may also be used?
3) What is the only Tx option for most pts?
-What is the exception?

Answer 15

1) Contrast-enhanced helical CT of the C/A/P
2) MRI
3) Chemotherapy; metastatic colorectal cancer

Question 16

Primary liver cancer/ Hepatocellular carcinoma (HCC):
1) Best imaging?
2) 3 main Tx optoins?

Answer 16

1) CT w contrast C/A/P
2) Partial hepatectomy; liver transplant; non-op liver directed therapy

Question 17

What are the types of primary liver cancers?

Answer 17

1) HCC
2) Intrahepatic cholangiocarcinoma
3) Extrahepatic cholangiocarcinoma

Question 18

Primary liver cancer/ Intrahepatic cholangiocarcinoma:
1) Main presentation?
2) 2 Tx options?

Answer 18

1) Large mass within the liver without jaundice; 1st Sx is pain
2) Resectable = Complete resection (laparotomy) is TOC
Unresectable = embolic Tx + chemo

Question 19

Acute cholecystitis:
1) First test of choice? What other test?
2) What is the definitive Tx?
3) What should you do if pt not a good surgical candidate?

Answer 19

1) RUQ U/S = TOC (HIDA if needed)
2) Laparoscopic cholecystectomy
3) Percutaneous cholecystotomy

Question 20

Cholelithiasis:
1) What tx is usually indicated for symptomatic pts?
2) What is also done?

Answer 20

1) Elective cholecystectomy (laparoscopic preferred)
2) Intraoperative cholangiography

Question 21

Choledocholithiasis:
1) What is the Tx for the Typical patient (mild cholangitis + gallstones)?
2) What abt for CBD stones with previous cholecystectomy?
3) What if there’s cholangitis?

Answer 21

1) Laparoscopic cholecystectomy with laparoscopic exploration of CBD
2) Endoscopic sphincterotomy
3) + IV abx -> ERCP with sphincterotomy and bile duct decompression

Question 22

1) Name a Complication of laparoscopic cholecystectomies
2) What are the 2 main ways to Dx?

Answer 22

1) Cystic duct stump leak
2) HIDA or ERCP

Question 23

Gallstone ileus:
1) TOC?
2) What is another Tx?

Answer 23

1) CT
2) Emergency laparoscopy (or laparotomy) with removal of obstructing stone + Delayed elective cholecystectomy