Surgery

Hepatobiliary Tract Part 2

Hanisah Guro, MD, FPSGS, FPCS, FPAHPBSI, FACS
August 31, 2020

OUTLINE o Comprised of cholesterol and salts

GALLBLADDER DISEASES ..........................................................................1

Epidemiology .........................................................................................................................1
Clinical Manifestations
Gallstone .................................................................................................................................1 - Most patients will remain asymptomatic from their gallstones
Gallbladder infections ..........................................................................................................1 throughout life
Gallbladder Cancer ...............................................................................................................2
- Postprandial right upper quadrant pain (biliary colic)
BILIARY DUCT DISEASES ............................................................................2 o Other diseases of the biliary tree that also presents with
Obstructive Jaundice............................................................................................................2 biliary colic
Bile duct infections ...............................................................................................................3
Primary Sclerosing Cholangitis ...........................................................................................3 ▪ Choledocholithiasis
▪ Cholangitis
BILE DUCT NEOPLASM ...............................................................................4 ▪ Gallstone pancreatitis
Cholangiocarcinoma .............................................................................................................4
▪ Gallstone ileus
DISEASES OF THE PANCREAS ...................................................................4 ▪ Gallbladder cancer
Acute Pancreatitis .................................................................................................................4
Chronic Pancreatitis .............................................................................................................5
Pancreatic Pseudocyst .........................................................................................................5 Symptomatic Gallstones
Neoplasms of The Endocrine Pancreas..............................................................................6
Clinical Manifestations:
- Typically present with recurrent attacks of pain
- The pain develops when a stone obstructs the cystic duct, resulting
GALLBLADDER DISEASES in a progressive increase of tension in the gallbladder wall as it
Divided into 3 parts: contracts in response to a meal
- Gallbladder stones o It is located in the epigastrium or RUQ and frequently radiates
- Gallbladder infections to the right upper back or between scapulae
- Gallbladder tumors
Diagnosis:
Epidemiology - The diagnosis of symptomatic cholelithiasis or chronic cystitis
depends on the presence of typical symptoms and the
- One of the most common afflictions of the digestive tract demonstration of stones on diagnostic imaging
- Present in between 10% and 15% of adults - Ultrasound (abdominal)
- Risk Factors: o Standard diagnostic test for gallstones as it is noninvasive
o Age over 40 years and highly sensitive
o Multiparous women - CT scan
o Obesity
o Use of oral contraceptives Treatment:
o Hormonal therapy - Surgical cholecystectomy
o Diabetic - Patients with symptomatic cholelithiasis should be offered elective
o Patients with gastrointestinal diseases cholecystectomy
- If surgery has to be postponed, the patient should be advised to
Gallstone avoid dietary fats and meals
Formation - Diabetic patients with symptomatic gallstones → prone to develop
acute cholecystitis – prompt surgery is advised
Decreased bile acid synthesis - Pregnant women with symptomatic gallstones – cholecystectomy
↓ is feasible and, if possible, should be done in the 2nd trimester
Increased cholesterol synthesis in the liver
↓
Gallbladder infections
Super saturation of bile with cholesterol
↓ Acute Cholecystitis
Formation of precipitates - Infection of the gallbladder
↓ - Associated with gallstones in 90% to 95% of cases
Gall stones (CHOLELITHIASIS) - Obstruction of the cystic duct by a gallstone is the initiating event
↓ that leads to gallbladder distention, inflammation, and edema of the
Inflammatory changes (CHOLECYSTITIS) gallbladder wall

Types Clinical Manifestations:

- Biliary colic with relapsing and remitting pain in the RUQ or
- Cholesterol stones
epigastrium that may radiate to the right back or interscapular
o Usually yellow green and made primarily of hardened
area
cholesterol
o In contrast to biliary colic, the pain of acute cholecystitis does
- Pigment stones
not subside, it is unremitting, may persist for several days
o Small, dark stones made of bilirubin
and is usually more severe than the pain in uncomplicated
o The exact cause is unknown
gallstone disease
o They tend to develop in people who have cirrhosis, biliary tract
- Fever
infections, and hereditary blood disorders
- Anorexia
- Mixed stones
- Nausea and vomiting
o Most common type

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o May be reluctant to move as the inflammatory process o Suspected before surgery
creates focal peritonitis - Asymptomatic in early stage
- Tenderness and guarding are in the RUQ o When there is an associated symptom, GB cancer tends to
- Murphy’s sign – an inspiratory arrest with deep palpation in the present in a similar manner to biliary colic or chronic
right subcostal area, is characteristic of acute cholecystitis cholecystitis
- In general:
Diagnosis: o Abdominal discomfort
- Mild to moderate leukocytosis (12,000-15,000 cells/mm3) o RUQ pain
- Ultrasound o Nausea & vomiting
o Most useful initial radiologic test for diagnosing acute o Jaundice
cholecystitis, with a sensitivity and specificity of 70-90% o Weight loss
o Effective at documenting the presence of absence of stones, o Anorexia
and it can show gallbladder wall thickening and o Ascites
pericholecystic fluid
- CT Scan Diagnosis
o Can demonstrate thickening of the gallbladder wall, - Ultrasound
pericholecystic fluid, and the presence of gallstones but is o 70% to 100% sensitivity
somewhat less sensitive than ultrasonography o Thickened, irregular GB wall (>3mm) with hypervascularity
or a mass replacing the gallbladder
Treatment: o It may also visualize tumor invasion of the liver,
- IV fluids lymphadenopathy, or a dilated biliary tree
- Broad-spectrum antibiotics - CT Scan
o Should cover gram-negative enteric organisms as well as o Identifying a GB mass
anaerobes o Evaluating for nodal spread or local invasion into adjacent
- Analgesia organs or vasculature
- Cholecystectomy → definitive treatment - MRCP (If questions about local invasion remain)
o Laparoscopic Cholecystectomy o Allows for complete assessment of biliary, vasculature, nodal,
o Open Cholecystectomy hepatic, and adjacent organ involvement
- Endoscopic Ultrasound (EUS)
Gallbladder Cancer o Useful tool in staging and evaluating for focal invasion, as well
- Rare as obtaining tissue diagnosis through FNA
- Most common of biliary tract malignancy - PTC/Endoscopic cholangiogram
- 5th most common among malignant neoplasms of the digestive tract o Helpful to delineate the extent of biliary tree involvement
- Highly fatal disease with poor prognosis - PET Scan
- Late presentation, often with disseminated disease, overall dismal o Can be utilized in both staging and surveillance
prognosis, and lack of effective systemic therapy
- Has a tendency to spread early via lymphatics, hematogenous, Treatment
and peritoneal metastases and also has a unique ability to implant - Surgical approach (resection) – only curative option
along biopsy tracts and wounds o Re-op for incidental GB cancer after cholecystectomy
- 5-year survival rate for GB cancer: o Beyond stage 1 (T2 and T3)
o Resectable disease – 20% with median survival of just 16 ▪ Central liver resection
months ▪ Hilar lymphadenopathy
o Advanced, untreated GB cancer – median survival of 2-5 ▪ Evaluation of cystic duct stump
months, long term survival is exceedingly rare - Radical resection for advanced disease

Epidemiology BILIARY DUCT DISEASES

- Women: 2-4x more often than men Obstructive Jaundice
o Higher rate of cholelithiasis and inflammation in women - Most biliary duct diseases would present as obstructive jaundice
- Age: most common in 7th decade of life - Jaundice, or icterus, is yellowish discoloration of tissue resulting
- Chilean Mupache Indian women (27.3 cases / 100,000 annually) from the deposition of bilirubin
- India (22 cases / 100,000 annually) - Tissue deposition of bilirubin occurs only in the presence of serum
- North America (7.1 cases / 100,000 annually)
hyperbilirubinemia and is a sign of either liver disease or less
often, a hemolytic disorder
Risks
- Causes:
- The most consistently implicated etiologic factor in the o Intrahepatic
development of GB cancer is cholelithiasis o Extrahepatic
o Of GB cancer 75%-90% occur in the setting of cholelithiasis ▪ Intraductal
- Larger stones (>3cm) are associated with a 10-fold increased risk ▪ Extraductal
of cancer
- Higher in symptomatic gallstones
- Polyploid lesion ~10mm Choledocholithiasis
- Calcified “porcelain” gallbladder ~20% incidence of GB cancer - Common bile duct stones
- Patients with Choledochal cyst - 6-12% of patients with stones in the gallbladder
- Sclerosing cholangitis - 20-25% of patients >60 of age with symptomatic gallstones have
- Anomalous pancreatico-biliary duct junction stones in the common bile duct as in the gallbladder
- Exposure to carcinogens (azotuluene, nitrosamines)
Clinical Manifestations:
Clinical Manifestations - May be silent and often discovered incidentally
- May cause obstruction
- Common clinical scenarios:
o Identified by final pathology after routine cholecystectomy - May manifest with cholangitis or gallstone pancreatitis
o Discovered intraoperatively
Diagnosis:
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- Ultrasonography o Charcot’s triad +
o Useful in documenting stones in the gallbladder as well as o septic shock
determining the size of the common bile duct o mental status change
- MRC (Magnetic Resonance Cholangiography) - Abdominal examination is indistinguishable with Acute
o Gives an excellent anatomic detail Cholecystitis
o 95% sensitivity; 89% specificity
o 5% morbidity (cholangitis & pancreatitis) Diagnosis:
- Endoscopic Cholangiography - Presence of the ff supports the diagnosis of cholangitis
o “Gold standard” o Leukocytosis
o Distinct advantage of providing a therapeutic option at the o Hyperbilirubinemia
time of diagnosis o Elevated Alkaline phosphatase
o 5% morbidity (cholangitis& pancreatitis) → same w/MRC o Elevated transaminases
- Endoscopic Ultrasound - Ultrasonography
o As good as ERCP in detecting CBD stones o document the presence of gallbladder stones, demonstrate
o 91% sensitivity; 100% specificity dilated ducts, and possibly pinpoint the site of obstruction
- CT Scan & MRI = show pancreatic and ampullary masses if present
o Lacks therapeutic intervention
in addition to the ductal dilatation
- Percutaneous Transhepatic Cholangiography (PTC)
o However, abdominal imaging will barely elucidate the exact
o Rarely needed in patients with secondary CBD stones cause of cholangitis
o Frequently performed for both diagnostic and therapeutic o Initial diagnosis is made clinically
reasons in patients with primary bile duct stones - ERCP: definitive diagnostic test

Treatment Management:
- Patients with symptomatic gallstones suspected CBD stones will - IV antibiotics
have: - Fluid resuscitation
Preoperative endoscopic cholangiography - Biliary decompression: endoscopic or percutaneous transhepatic
↓ route or surgery
Sphincterotomy & ductal clearance of stones - Definitive operative therapy should be deferred until the
cholangitis has been treated
↓
- Mortality is approximately 5%
Laparascopic cholecystectomy
o Intraoperative cholangiogram
o Laparoscopic common bile duct exploration Primary Sclerosing Cholangitis
o Open common bile duct exploration, T-tube insertion - Uncommon disease characterized by inflammatory strictures
- Stones Impacted in the ampulla involving the intrahepatic and extrahepatic biliary tree
o Cholechoduodenostomy - It is a progressive disease that eventually results in secondary
o Roux en Y choledochojejunostomy biliary cirrhosis
- Retained stones / recurrent stones after cholecystectomy - No clear attributing causes
o RETAINED – deliberately left in place at the time of surgery - Most patients are symptomatic when diagnosed, and may complain
or diagnoses shortly after cholecystectomy of intermittent jaundice, fatigue, weight loss, pruritus, or abdominal
▪ endoscopic retrieval or via the T-tube tract once it as pain
matured (2-4weeks) - Of the patient with sclerosing cholangitis, 10%-15% will develop
o RECURRENT – diagnosed months or years later cholangiocarcinoma
▪ endoscopic sphincterotomy to allow stone retrieval o Cholangiocarcinoma in the setting of PSC frequently follows
as well as spontaneous passage of retained stones an aggressive course

Bile duct infections Diagnosis:

Cholangitis - ERCP
o Revealing multiple dilatations and strictures (beading) of the
- One of the main complications of choledochal stones
intra and extrahepatic biliary tree confirms the diagnosis
- ACUTE CHOLANGITIS – ascending bacterial infection in
o The hepatic duct bifurcation is often the most severely
association with partial or complete obstruction of the bile ducts
affected segment
- Positive bile cultures are common
- Liver biopsy
o E. coli
o To determine the degree of hepatic fibrosis and the presence
o K. pneumoniae
of cirrhosis
o S. faecalis
o Enterobacter spp
o B. fragilis Treatment:
- Gallstones are the most common causes of obstruction in - No known curative treatment for primary sclerosing cholangitis and
cholangitis medical management is largely supportive
- Patients with extrahepatic and bifurcation strictures, but without
Clinical Presentation: cirrhosis or significant hepatic fibrosis
- May present from mild, self-limiting episodes to fulminant, potentially- o Surgical management with resection of the extrahepatic
life threatening biliary tree and hepaticojejunostomy has produced
- Typically, older and female reasonable results
- CHARCOT’S TRIAD: - Patients with primary sclerosing cholangitis and advanced liver
o Fever disease
o Epigastric o Liver transplantation is the only option
o RUQ pain and jaundice
- REYNOLD’S PENTAD:
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BILE DUCT NEOPLASM - Choledochoscopy
Cholangiocarcinoma o May be able to improve diagnosis rates but is only available
in specialized center
- Rare tumor arising from the biliary epithelium and may occur
anywhere along the biliary tree
- Risk factors: Treatment
o Primary Sclerosing Cholangitis - Surgical excision – only potentially curative treatment
o Choledochal cysts - Resectable disease should first undergo diagnostic laparoscopy
o Ulcerative colitis o Curative resection – the location and local extension of the
o Hepatolithiasis tumor dictates the extent of the surgery required
▪ Distal bile tumors – pancreaticoduodenectomy
o Biliary-enteric anastomosis
(Whipple procedure)
o Biliary tract infections with Clonorchis
- Unresectable on surgical exploration
o Liver flukes infection o Roux-en-y hepaticojejunostomy
o Dietary nitrosamines o Cholecystectomy
o Thorotrast, Dioxin o Gastrojejunostomy
- Bismuth- Corlette Type I and II no signs of vascular involvement
Pathology o Local tumor excision with portal lymphadenectomy,
- 95% of bile duct cancers are ductal adenocarcinomas cholecystectomy, common bile duct excision, and bilateral
Roux-en-Y hepaticojejunomies
- About half of all cholangiocarcinomas are located in the perihilar
- Bismuth-Corlette Type IIIa or IIIb
region
o Right or left hepatic lobectomy
- 40% occuring more distally in the common bile duct - Type IV Klatskin tumors
- Perihilar cholangiocarcinomas, also referred to as Klatskin tumors o With more extensive involvement of both hepatic ducts and
o KLATSKIN TUMOR intrahepatic spread
▪ Bismuth-Corlette classification o Often considered unresectable
o Liver transplantation
- Nonoperative biliary decompression can be performed for patients
with unresectable disease on initial presentation
- Adjuvant chemotherapy
o No proven role
- Adjuvant radiation therapy
o Not been shown to increase quality of life or survival in resected
patients
- Palliative chemotherapy
o Unresectable disease

DISEASES OF THE PANCREAS

Acute Pancreatitis
- an inflammatory disorder of the pancreas that is characterized by
edema and, when severe, necrosis
- Alcohol being the most common etiology
- Occurs in various degrees of severity, the determinants of which
are multifactorial

Figure 1. Bismuth-Corlette Classification

Etiology
Clinical Manifestations
- Painless jaundice
- Pruritus
- Mild right upper quadrant pain
- Anorexia
- Fatigue
- Weight loss
- Cholangitis

Diagnosis
- Tumor markers
o CA 19-9 – 79% sensitivity; 98% specificity if the serum value is
>129U/mL
- Ultrasound/CT scan
o Dilatation of the intrahepatic biliary tree
- ERCP
o Detailed evaluation of the biliary anatomy and the tumor
- PTC
o Proximal extent of the tumor remains in question
o To determine resectability
- Tissue Diagnosis Diagnosis
o Fine-needle aspiration (percutaneous or endoscopic) and - Typical abdominal pain
biliary brushings - 3x or greater elevation in serum lipase and/or amylase
▪ Low sensitivity in detecting malignancy (15%-60%)
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- Confirmatory findings on CT scan

G – gallbladder
P – Pancreas
Arrows - Necrosis

Management
- Severe pancreatitis carries a mortality rate of 80%
- Interventions in the first 24hrs can help minimize the morbidity
and mortality Chronic Pancreatitis
- IV fluids Incurable, chronic inflammatory condition that is multifactorial in its
- Relief of pain – analgesics etiology, highly variable in its presentation, and a challenge to treat
- Antibiotics successfully.
- Nutritional support
- There are many other approaches to predicting severity. Etiology
o At 24 hours after admission an APACHE II score of 8 or more - genetic mutations
or a serum C-reactive protein level of >150 mg/dL has a - alcohol exposure
similar accuracy in predicting severity as Ranson’s criteria - duct obstruction due to trauma
- gallstones
- tumors
- metabolic diseases - hyperlipidemia, hyperparathyroidism
- auto-immune disease

Diagnosis
- depends on the clinical presentation, a limited number of indirect
measurements that correlate with pancreatic function, and
selected imaging studies
- ERCP → most sensitive radiologic test
- CT scan → sensitive for the diagnosis of when calcification, duct
dilatation, or cystic disease is present however not accurate in the
absence of these findings
- EUS → highly reliable in ruling out pancreatic carcinoma when CT
findings are normal or equivocal

Management
- choice of operation and the timing of surgery are based on each
patient’s pancreatic anatomy
- Sphincteroplasty
- Drainage procedures
- Distal pancreatectomy
- Total pancreatectomy

Pancreatic Pseudocyst
Role of surgery:
- Collection of fluid around the pancreas
- Cholecystectomy should be performed as soon as the patient has
recovered, and the acute inflammatory process has subsided - The fluid in the cyst is usually pancreatic juice that has leaked out
- A second role for surgery in pancreatitis is to debride pancreatic of a damaged pancreatic duct
necrosis (Necrosectomy) - Arise after Acute Pancreatitis or Chronic Pancreatitis
- May develop soon after attack of AP
- Can present many weeks or months after recovery

Clinical Presentation
- Abdominal pain
- Feeling of bloating or poor digestion of food
- Deep ache in the abdomen
- Complications related to the pseudocyst such as infection of the
pseudocyst with a pancreatic abscess, bleeding onto the
pseudocyst or blockage of parts of the intestine by the pseudocyst

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Diagnosis o Triple phase CT
- Persistently elevated serum amylase ▪ 90% accurate at finding lesions
- Ultrasound – 75-90% sensitivity
- CT Scan – most accurate 90-100% sensitivity

Management
- All cysts do not require treatment
- In a significant number of patients the cyst will resolve (>50%)
- In a patient with a small (<6cm) cyst, no symptoms – careful
observation of the cyst with periodic CT scan is indicated
- But, if a pseudocyst is persistent over many months or causing
symptoms, then treatment is required

Intervention
- Percutaneous drainage
- Endoscopic drainage
- Surgical drainage
- External drainage
- Surgical Options
o tail of gland and along with proximal stricture
▪ distal pancreatectomy and splenectomy
o head of gland with strictures of pancreatic or bile ducts
▪ Pancreaticoduodenectomy
- Indications for drainage:
o Presence of symptoms (>6 weeks)
o Enlargement of pseudocyst (>6 cm)
o Complications (bleeding, abscess)
o Suspicion of malignancy

Neoplasms of The Endocrine Pancreas

- Insulinoma – most common
- Noninsulinoma Hyperinsulinemia Hypoglycemia Syndrome
- Gastrinoma
- Vasoactive Intestinal Peptide-Secreting Tumor
- Glucagonoma
- Somatostatinoma
- Nonfunctioning Pancreatic Endocrine Tumors

Pancreatic Cancer
- 10th most common cancer
- 4th leading cause of cancer death
- 80% of cases are adenocarcinomas from exocrine pancreas - Endoscopic ultrasound
- Median diagnosis is 70 years old o help find lesion not seen on CT
o help determine resectability
Risk factors o excellent way to get biopsy
- Smoking
- Low vegetables and fruits
- High red meat
- Chronic pancreatitis
- Diabetes
- Obesity
- Genetics

Clinical Presentation
- Non-specific symptoms
- Tumors of the body and tail (25%)
o pain and weight loss
- Tumors of the head (75%)
o jaundice, steatorrhea, weight
loss, pain
- Increased liver function tests
- Elevated CA 19-9 - ERCP
o therapeutic as well as diagnostic
Diagnosis
- Ultrasound – bile duct distention, mass
- CT scan with IV contrast

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o Removal of
▪ Distal stomach,
▪ Duodenum and proximal jejunum
▪ Head of pancreas
▪ Gallbladder
▪ Common bile duct

- Tumors of the body and tail:

- Distal pancreatectomy
o Removal of body and tail of pancreas
o Spleen

- Stage I prognosis – 20% 5yr Over-all survival rate; 70% relapse

- Stage II – 10% 5yr OS
- Stage III – 2.5% 5yr OS
- Stage IV – 1.6% 5yr OS

Treatment
- Head of the pancreas
- Whipple procedure
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Summary of Treatment:
- Resection is the only chance for a cure
- resectable patients should undergo surgery without delay
followed by adjuvant therapy
- Borderline resectable patients may benefit from neoadjuvant
therapy and then surgery
- Unresectable patients may benefit from chemotherapy or
chemoradiation
- Metastatic disease may benefit from chemotherapy or other
palliative treatments

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