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CHAPTER 32
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The Gallbladder and Extrahepatic Biliary System
1. The arterial supply of the common bile duct is derived
from:
A. The left hepatic artery.
B. The right hepatic artery.
C. The gastroduodenal artery.
D. The right hepatic and gastroduodenal arteries.
E. The left hepatic and gastroduodenal arteries.
2. Relaxation of the sphincter of Oddi in response to a meal
is largely under the control of which hormone?
A. Gastrin
B. Cholecystokinin (CCK)
C. Motilin
D. Secertin
E. Ghrelin
Answer: D
The majority of the blood flow to the human common bile
duct originates from the right hepatic artery and gastro duodenal arteries, with major trunks running along the medial
and lateral aspects of the common duct (often referred to as
the 3 o’clock and 9 o’clock positions). (See Schwartz 11th ed.,
p. 1396.)
Answer: B
The sphincter of Oddi is a complex structure that is functionally independent from the duodenal musculature and creates
a high-pressure zone between the bile duct and the duodenum. The sphincter of Oddi is about 4 to 6 mm in length
and has a basal resting pressure of about 13 mm Hg above
the duodenal pressure. On manometry, the sphincter shows
phasic contractions with a frequency of about four per minute and an amplitude of 12 to 140 mm Hg. The spontaneous
motility of the sphincter of Oddi is regulated by the interstitial cells of Cajal through intrinsic and extrinsic inputs from
hormones and neurons acting on the smooth muscle cells.
Relaxation occurs with a rise in CCK, leading to diminished
amplitude of phasic contractions and reduced basal pressure,
allowing increased flow of bile into the duodenum. During
fasting, the sphincter of Oddi activity is coordinated with the
periodic partial gallbladder emptying and an increase in bile
flow that occurs during phase II of the migrating myoelectric
motor complexes. (See Schwartz 11th ed., pp. 1397–1398.)
3. Acute cholecystitis is considered:
A. A primary infectious process with secondary
inflammation.
B. A sterile primary inflammatory process.
C. A primary inflammatory process with occasional
bacterial contamination.
D. A primary autoimmune process.
Answer: C
Obstruction of the cystic duct by a gallstone is the initiating
event that leads to gallbladder distention, inflammation, and
edema of the gallbladder wall. Why inflammation develops
only occasionally with cystic duct obstruction is unknown. It
is probably related to the duration of obstruction of the cystic
duct. Initially, acute cholecystitis is an inflammatory process,
probably mediated by the mucosal toxin lysolecithin, a product of lecithin, as well as bile salts and platelet-activating factor.
Increase in prostaglandin synthesis amplifies the inflammatory
response. Secondary bacterial contamination is documented
in 15% to 30% of patients undergoing cholecystectomy for
acute uncomplicated cholecystitis. In acute cholecystitis, the
gallbladder wall becomes grossly thickened and reddish with
subserosal hemorrhages. Pericholecystic fluid often is present.
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The mucosa may show hyperemia and patchy necrosis. In
severe cases, about 5% to 10%, the inflammatory process progresses and leads to ischemia and necrosis of the gallbladder wall. More frequently, the gallstone is dislodged and the
inflammation resolves. (See Schwartz 11th ed., p. 1405.)
4. Appropriate management of a patient with cirrhosis secondary to sclerosing cholangitis includes:
CHAPTER 32
A. Systemic immunosuppression with corticosteroids
and calcineurin inhibitors.
B. Anti-TNF monoclonal antibodies (infliximab).
C. Consideration for transplantation.
D. Ursodeoxycholic acid.
E. Excision of the extrahepatic biliary tree (Kasai
procedure).
The Gallbladder and Extrahepatic Biliary System
5. Over a 10-year period, what percentage of patients with
asymptomatic gallstones will remain symptom-free?
A. 10%
B. 25%
C. 50%
D. 66%
E. 90%
Answer: C
Sclerosing cholangitis (primary or secondary) is an uncommon disease characterized by inflammatory strictures involving the intrahepatic and extrahepatic biliary tree. It is a
progressive disease which can lead to biliary cirrhosis. Medical therapy has long been attempted with immunosuppressants, antibiotics, steroids, and ursodeoxycholic acid, and has
been disappointing. Surgical management with resection of
the extrahepatic biliary tree and hepaticojejunostomy has
produced reasonable results in patients with extrahepatic
and bifurcation strictures, but without cirrhosis or significant
hepatic fibrosis. In patients with sclerosing cholangitis and
advanced liver disease, liver transplantation is the only option.
It offers excellent results, with overall 5-year survival as high
as 85%. Primary sclerosing cholangitis recurs in 10% to 20%
of patients and may require retransplantation. (See Schwartz
11th ed., p. 1417.)
Answer: D
Gallstones in patients without biliary symptoms are commonly diagnosed incidentally on ultrasonography, computed
tomography (CT) scans, or abdominal radiography or at
laparotomy. Several studies have examined the likelihood of
developing biliary colic or developing significant complications of gallstone disease. Approximately 3% of asymptomatic
individuals become symptomatic per year (ie, develop biliary colic). Once symptomatic, patients tend to have recurring
bouts of biliary colic. Complicated gallstone disease develops
in 3% to 5% of symptomatic patients per year. Over a 20-year
period, about two-thirds of asymptomatic patients with gallstones remain symptom-free. (See Swartz 11th ed., p. 1401.)
6. The most common type of gallbladder cancer is:
A. Oat cell.
B. Adenocarcinoma.
C. Adenosquamous.
D. Anaplastic.
E. Squamous cell.
7. The gallbladder lymphatics drain into which of the
following liver segments?
A. III and IV
B. V and VI
C. IV and V
D. III and V
E. I and IV
Answer: B
Between 80% and 90% of the gallbladder tumors are adenocarcinomas. Squamous cell, adenosquamous, oat cell, and
other anaplastic lesions occur rarely. The histologic subtypes
of gallbladder adenocarcinomas include papillary, nodular,
and tubular. Less than 10% are of the papillary type, but these
are associated with an overall better outcome, as they are
most commonly diagnosed while localized to the gallbladder.
(See Schwartz 11th ed., p. 1421.)
Answer: C
Lymphatic flow from the gallbladder drains first to the cystic
duct node (Calot’s), then the pericholedochal and hilar nodes,
and finally the peripancreatic, duodenal, periportal, celiac,
and superior mesenteric artery nodes. The gallbladder veins
drain directly into the adjacent liver, usually segments IV and
V, where tumor invasion is common. (See Schwartz 11th ed.,
p. 1421.)
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8. Adequate treatment for a gallbladder lesion involving the
lamina propria of the gallbladder includes:
A. Cholecystectomy followed by adjuvant chemotherapy.
B. Neoadjuvant chemo-XRT followed by surgical
resection.
C. Segemental liver resection and lymphadenectomy
alone.
D. Cholecystectomy alone.
E. Extended right hepatectomy.
9. The best initial imaging test for evaluating suspected
cholangiocarcinoma includes:
A. Percutaneous cholangiography.
B. Endoscopic retrograde cholangiopancreatography.
C. Ultrasound.
D. Magnetic resonance cholangiopancreatography
(MRCP).
E. Hepatobiliary iminodiacetic acid (HIDA) scan.
Answer: D
Tumors limited to the muscular layer of the gallbladder (T1)
are usually identified incidentally, after cholecystectomy for
gallstone disease. There is near universal agreement that
simple cholecystectomy is an adequate treatment for T1
lesions and results in a near 100% overall 5-year survival rate.
(See Schwartz 11th ed., p. 1422.)
Answer: C
The initial tests are usually ultrasound or computed tomography (CT) scan. A perihilar tumor causes dilatation of the
intrahepatic biliary tree, but normal or collapsed gallbladder
and extrahepatic bile ducts distal to the tumor. Distal bile
duct cancer leads to dilatation of the extra- and intrahepatic
bile ducts as well as the gallbladder. Ultrasound can establish
the level of obstruction and rule out the presence of bile duct
stones as the cause of the obstructive jaundice. It is usually difficult to visualize the tumor itself on ultrasound or on a standard CT scan. Either ultrasound or spiral CT can be used to
determine portal vein patency. The biliary anatomy is defined
by cholangiography. Papillary thyroid cancer (PTC) defines
the proximal extent of the tumor, which is the most important
factor in determining resectability. Endoscopic retrograde
cholangiopancreatography (ERCP) is used, particularly in
the evaluation of distal bile duct tumors. For the evaluation
of vascular involvement, celiac angiography may be necessary.
With the newer types of magnetic resonance imaging (MRI), a
single noninvasive test has the potential of evaluating the biliary anatomy, lymph nodes, and vascular involvement, as well
as the tumor growth itself. (See Schwartz 11th ed., p. 1423.)
CHAPTER 32
The Gallbladder and Extrahepatic Biliary System
10. Patients with a history of choledochal cysts are at
increased risk of developing biliary cancer:
A. In the gallbladder alone.
B. Predominantly intra-hepatic portions of the biliary
tree.
C. In the distal common bile duct.
D. At the site of the previous cyst.
E. Throughout the biliary tree.
11. What is the best initial management for an intraoperatively identified minor lateral injury to the common bile
duct?
A. Placement of a T-tube through the site of injury in
the duct
B. Primary oversew of the injury intra-operatively
C. Resection of the injured portion of the duct with end-
to-end anastomosis
D. Intraoperative placement of endoscopic biliary stent
E. Resection of the bile duct and a roux-en-Y hepatico-
jejunostomy reconstruction
Answer: E
Patients with choledochal cysts have an increased risk of
developing cancer anywhere in the biliary tree, but the incidence is highest in the gallbladder. Sclerosing cholangitis,
anomalous pancreaticobiliary duct junction, and exposure
to carcinogens (azotoluene, nitrosamines) also are associated with cancer of the gallbladder. (See Schwartz 11th ed.,
p. 1417.)
Answer: A
Lateral injury to the common bile duct or the common
hepatic duct, recognized at the time of surgery, is best managed with a T-tube placement. If the injury is a small incision
in the duct, the T-tube may be placed through it as if it were
a formal choledochotomy. In more extensive lateral injuries,
the T-tube should be placed through a separate choledochotomy and the injury closed over the T-tube end to minimize
the risk of subsequent stricture formation. (See Schwartz
11th ed., pp. 1419–1420.)
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12. After identification of a postoperative biliary stricture,
what is the best initial management?
A. Operative resection of the involved biliary segment
and reconstruction with an end-to-end roux-en-Y
hepatico-jejunostomy
B. Endoscopic retrograde cholangiopancreatography
(ERCP) with sphincterotomy and stenting of the
pancreatic duct
CHAPTER 32
C. Transhepatic catheter placement for biliary
decompression
D. Hepatobiliary iminodiacetic acid (HIDA) scan
E. Operative placement of a T-tube at site of biliary
stricture
The Gallbladder and Extrahepatic Biliary System
13. In the early postoperative period, what is the most common presentation of a patient with a biliary injury?
A. Fever
B. Abdominal pain
C. Steatorrhea
D. Elevated transaminases
E. Nausea
Answer: C
Patients with bile duct stricture from an injury or as a sequela
of previous repair usually present with either progressive
elevation of liver function tests or cholangitis. The initial
management usually includes transhepatic biliary drainage
catheter placement for decompression as well as for defining
the anatomy and the location and the extent of the damage.
These catheters will also serve as useful technical aids during subsequent biliary enteric anastomosis. An anastomosis
is performed between the duct proximal to the injury and a
Roux loop of jejunum. Balloon dilatation of a stricture usually
requires multiple attempts and rarely provides adequate longterm relief. Self-expanding metal or plastic stents, placed
either percutaneously or endoscopically across the stricture,
can provide temporary drainage and, in the high-risk patient,
permanent drainage of the biliary tree. (See Schwartz 11th ed.,
pp. 1420–1421.)
Answer: D
In the early postoperative period, patients present either
with progressive elevation of liver function tests due to an
occluded or a stenosed bile duct, or with a bile leak from an
injured duct. (See Schwartz 11th ed., pp. 1419–1420.)
14. The gallbladder wall layers include:
A. Mucosa, muscularis, adventitia, serosa.
B. Mucosa, submucosa, muscularis, adventitia, serosa.
C. Mucosa, submucosa, muscularis mucosa, muscularis,
adventitia, serosa.
D. Mucosa, muscularis mucosa, muscularis, adventitia,
serosa.
15. The most commonly encountered arterial anomaly seen
related to the gallbladder is:
A. Replaced cystic artery.
B. Duplicated cystic artery.
C. Accessory right hepatic artery.
D. Replaced right hepatic artery.
Answer: A
The gallbladder differs histologically from the rest of the gastrointestinal (GI) tract in that it lacks a muscularis mucosa
and submucosa. The muscular layer has circular, longitudinal, and oblique fibers, but without well-defined layers.
The adventitia contains connective tissue, nerves, vessels,
lymphatics, and adipocytes. The gallbladder is covered by
serosa except where the gallbladder is embedded in the liver.
(See Schwartz 11th ed., p. 1393.)
Answer: D
Anomalies of the hepatic artery and the cystic artery are quite
common, occurring in as many as 50% of cases. While the
right hepatic artery usually originates from the proper hepatic
branch of the celiac trunk, up to 20% of patients will have a
replaced right hepatic artery coming off the superior mesenteric artery. In about 5% of cases, there are two right hepatic
arteries, one from the proper hepatic artery and the other
from the superior mesenteric artery (accessory right hepatic
artery). While the right hepatic artery typically runs posterior
to the bile ducts, variations may allow it to course anterior to
the common duct, making it vulnerable during surgical procedures, particularly if it runs parallel to the cystic duct or in
the mesentery of the gallbladder. The cystic artery arises from
the right hepatic artery in about 90% of cases, but it may arise
from the left hepatic, common hepatic, gastroduodenal, or
superior mesenteric arteries. (See Schwartz 11th ed., p. 1396.)
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16. ___% of bile acids are reabsorbed in the body with the
majority of absorption occurring within the ___.
A. 95; ileum and colon
B. 95; duodenum and ileum
C. 80; ileum and colon
D. 80; duodenum and ileum
17. What constitutes as normal filling times in a fasting subject when utilizing a hepatobiliary iminodiacetic acid
(HIDA) scan?
A. Liver uptake within 15 minutes, and gallbladder, bile
duct, and duodenum uptake within 60 minutes
B. Liver uptake within 15 minutes, and gallbladder, bile
duct, and duodenum uptake within 45 minutes
C. Liver uptake within 10 minutes, and gallbladder, bile
duct, and duodenum uptake within 45 minutes
D. Liver uptake within 10 minutes, and gallbladder, bile
duct, and duodenum uptake within 60 minutes
18. A 36-year-old woman presents with several days of right
upper quadrant (RUQ) abdominal pain; which of the
following findings would best support a diagnosis acute
cholecystitis?
A. Cholelithiasis on ultrasound with a 2 mm gallbladder
wall
B. Delayed gallbladder filling on hepatobiliary
iminodiacetic acid (HIDA)
C. Lack of gallbladder filling on HIDA
D. Decreased ejection fraction (EF) on HIDA
Answer: A
About 80% of the secreted conjugated bile acids are reabsorbed in the terminal ileum. The remainder is dehydroxylated (deconjugated) by gut bacteria, forming the secondary
bile acids deoxycholate and lithocholate. These are absorbed
in the colon and can then be transported back to the liver.
Eventually, about 95% of the bile acid pool is reabsorbed,
the so-called enterohepatic circulation. Only a small amount
(5%) is excreted in the stool, allowing the relatively small
quantity of bile acids produced to have maximal effect. (See
Schwartz 11th ed., Chapter 32, pp. 1396–1397.)
Answer: D
99m
Technetium-labeled derivatives of iminodiacetic acid are
injected intravenously, taken up by the Kupffer cells in the
liver, and excreted in the bile. Uptake by the liver is usually
detected within 10 minutes, and the gallbladder, bile ducts,
and duodenum are typically visualized within 60 minutes in
fasting subjects. (See Schwartz 11th ed., p. 1399.)
Answer: C
The primary use of biliary scintigraphy is in the diagnosis of
acute cholecystitis, which appears as a nonvisualized gallbladder, with prompt filling of the common bile duct and duodenum. The lack of gallbladder filling is due to inflammatory
closure of the cystic duct preventing bile backflow into the
gallbladder (Fig. 32-1). Evidence of cystic duct obstruction on
biliary scintigraphy is highly diagnostic for acute cholecystitis. The sensitivity and specificity for the diagnosis are about
95% each. (See Schwartz 11th ed., p. 1399.)
CHAPTER 32
The Gallbladder and Extrahepatic Biliary System
FIG. 32-1. HIDA scanning. A. Normal HIDA scan showing filling of the extrahepatic
biliary tree and gallbladder (white arrow). B. HIDA scan in a patient with acute
cholecystitis showing no filling of the gallbladder.
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19. A 26-year-old who is 25 weeks pregnant presents to the
emergency department (ED) with several days of right
upper quadrant (RUQ) associated with meals and ultrasound (US) concerning for acute cholecystitis, what is
the best plan to proceed?
A. Observation with antibiotics, elective cholecystec-
tomy after delivery
B. Antibiotics and supportive care
CHAPTER 32
The Gallbladder and Extrahepatic Biliary System
C. Antibiotics and laparoscopic cholecystectomy this
admission
D. Antibiotics and laparoscopic cholecystectomy after
28 weeks of pregnancy
20. A 76-year-old man who is medically unfit for surgery
presents to the emergency department (ED) with right
upper quadrant (RUQ) tenderness and ultrasound (US)
findings concerning for acute cholecystitis, what is the
best course of action?
A. Antibiotics, endoscopic retrograde cholangiopancrea-
tography (ERCP), lap chole when stable this admission
B. Antibiotics, lap chole when stable this admission
C. Antibiotics, cholecystostomy tube, lap chole this
admission
D. Antibiotics, cholecystostomy tube, lap chole in 6 to
8 weeks if able
Answer: C
Pregnant women with symptomatic gallstones who cannot
be managed expectantly with diet modifications can safely
undergo laparoscopic cholecystectomy. The operation should
be performed during the second trimester if possible. (See
Schwartz 11th ed., 1405.)
Answer: D
When patients are medically unfit for surgery due to the
severity of their illness or medical comorbidities, they can
be treated with antibiotics and biliary decompression with
cholecystostomy tube placement, which is usually effective in
stabilizing the patient. For those who do recover after cholecystostomy, the tube can be removed once the track is mature
(approximately 4 weeks) and cholangiography through it
shows a patent cystic duct. Elective laparoscopic cholecystectomy can be scheduled within approximately 6 to 8 weeks,
assuming their medical fitness recovers. Failure to improve
after cholecystostomy may be due to gangrene of the gallbladder or perforation, in which case, damage control surgery
may be unavoidable. (See Schwartz 11th ed., p. 1406.)
21. Charcot triad is defined as which of the following?
A. Fever, pain, jaundice
B. Fever, pain, shock
C. Fever, altered mental status, jaundice
D. Pain, altered mental stasis, jaundice
22. What is the treatment for a gallstone ileus?
A. Endoscopic retrieval at the ileocecal valve
B. Surgical enterolithotomy to retrieve the stone and
primary closure or bowel resection
C. Surgical enterolithotomy to retrieve the stone if
beyond the ileocecal valve
D. Supportive management
Answer: A
The most common presentation is fever, epigastric or right
upper quadrant pain, and jaundice. These classic symptoms,
known as Charcot triad, are present in about two-thirds of
patients. The illness can progress rapidly with the development of shock and altered mental status, known as Reynolds
pentad (eg, fever, jaundice, right upper quadrant pain, septic
shock, and mental status changes). However, the presentation
may be atypical, with little if any fever, jaundice, or pain. (See
Schwartz 11th ed., p. 1408.)
Answer: B
Management of gallstone ileus focuses on relieving the intestinal obstruction and removing the stone. In cases of very proximal obstructions in the stomach or duodenum, endoscopic
retrieval can be effective. For more distal stones, surgical
enterolithotomy can be accomplished either laparoscopically
or open. This procedure entails the removal of the stone
through an enterotomy that is then either repaired or resected
depending on its size (Fig. 32-2). Stones that have successfully
traversed the ileocecal valve are likely to pass without further
intervention. The role of pursuing cholecystectomy and/or
choledochoenteric fistula closure at the time of enterolithotomy or addressing it at a later time remains a topic of debate,
but it should be considered to reduce the risk of recurrence.
(See Schwartz 11th ed., p. 1409.)
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CHAPTER 32
The Gallbladder and Extrahepatic Biliary System
23. Which of the following choledochal cysts require
transplantation?
A. I
B. II
C. III
D. IV
E. V
FIG. 32-2. Gallstone Ileus. Intraoperative photo showing a
longitudinal enterotomy and extraction of an impacted stone from
the distal small bowel.
Answer: E
Choledochal cysts are classified into five types depending
on the location and structure of the cysts. The subcategories
of choledochal cysts are defined in Fig. 32-3. Type I cysts
(fusiform common bile duct [CBD] dilations) are the most
common form, accounting for approximately 50% of cases,
and have the highest risk of malignancy (>60%). For types I
and II (saccular diverticula of the common bile duct), excision of the cystic dilations in the extrahepatic biliary tree,
including cholecystectomy, with either simple cyst excision or
duct resection with Roux-en-Y hepaticojejunostomy is ideal.
Type III cysts (intraduodenal) create a treatment challenge
as full resection would require pancreaticoduodenectomy.
Given that type III cysts are associated with the lowest malignancy risk of any choledochal cyst (~2%), sphincterotomy
and surveillance are generally recommended over formal
excision. In Type IV (multiple cysts), excision of all cystic tissues and reconstruction is again recommended. For type IVa,
which is characterized by multiple cysts with intrahepatic
involvement, additional segmental resection of the liver may
be required if intrahepatic stones, strictures, or abscesses are
present. Type V choledochal cysts (Caroli disease) are very
rare and account for <1% of patients with choledochal cysts.
These cysts are multiple and can affect the entire liver. In
advanced stages, this may result in cirrhosis and liver failure
necessitating liver transplantation. (See Schwartz 11th ed.,
p. 1417.)
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Type III
Type II
Type I
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CHAPTER 32
The Gallbladder and Extrahepatic Biliary System
FIG. 32-3. Classification of choledochal cysts. Type I, fusiform or cystic dilations of the extrahepatic biliary
tree, is the most common type, making up >50% of the choledochal cysts. Type II, saccular diverticulum of
an extrahepatic bile duct. Rare, <5% of choledochal cysts. Type III, bile duct dilatation within the duodenal
wall (choledochoceles), makes up about 5% of choledochal cysts. Types IVa and IVb, multiple cysts, make
up 5% to 10% of choledochal cysts. Type IVa affects both extrahepatic and intrahepatic bile ducts, whereas
type IVb cysts affect the extrahepatic bile ducts only. Type V (Caroli disease), intrahepatic biliary cysts, is very
rare and makes up 1% of choledochal cysts.
24. Which of the following features is an indication for
cholecystectomy?
A. Gallbladder polyp >5 mm
B. Gallbladder polyp >10 mm
C. Three gallbladder polyps of various sizes
D. An 8 mm polyp stable in size over 1 year
25. A 55-year-old man presents with painless jaundice and is
found to have a Bismuth-Corlette type II cholangiocarcinoma, which of the following is the next best step?
A. Whipple
B. Primary resection followed by an hepaticojejunostomy
C. Local tumor excision with lymphadenectomy, chole-
cystectomy, common bile duct (CBD) excision, and
bilateral Roux-en-Y hepaticojejunostomies
D. Diagnostic laparoscopy
Type VType IVbType IVa
Answer: B
Polypoid lesions of the gallbladder, which are present in
as many as 5% of adults, are also associated with increased
risk of cancer. This is particularly true for polyps measuring
>10 mm, which carry a 25% risk of malignancy. Solitary or
sessile polyps, or those showing rapid growth on serial imaging, particularly if in the presence of gallstones or age > 50,
are also concerning for malignancy. When such findings are
identified, the patient should have their gallbladder removed,
even if they are asymptomatic. Polyps that are not removed
should be monitored on serial imaging. (See Schwartz 11th ed.,
p. 1421.)
Answer: B
Patients suspected of having resectable disease should first
undergo diagnostic laparoscopy. Those who are found to have
previously unidentified metastatic disease should undergo
cholecystectomy and surgical bypass for biliary decompression. For curative resection, the location and local extension of the tumor dictates the extent of the surgery required.
Distal bile duct tumors are often resectable but may require
pancreaticoduodenectomy (Whipple procedure). For patients
with distal bile duct cancer found to be unresectable on sur-
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gical exploration, Roux-en-Y hepaticojejunostomy, cholecystectomy, and gastrojejunostomy to prevent gastric outlet
obstruction should be performed. Perihilar tumors involving
the bifurcation or proximal common hepatic duct (BismuthCorlette types I or II) with no signs of vascular involvement
are candidates for local tumor excision with portal lymphadenectomy, cholecystectomy, common bile duct excision, and
bilateral Roux-en-Y hepaticojejunostomies. If the tumor
involves the right or left hepatic duct (Bismuth-Corlette types
IIIa or IIIb), right or left hepatic lobectomy, respectively, should
also be performed. Frequently, resection of the adjacent caudate lobe is required because of direct extension into caudate
biliary radicals or parenchyma. Type IV K latskin tumors, those
with more extensive involvement of both hepatic ducts and
intrahepatic spread, are often considered unresectable or only
treatable with liver transplantation. (See Schwartz 11th ed.,
p. 1423.)
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CHAPTER 32
The Gallbladder and Extrahepatic Biliary System
26. Which of the following scenarios can result in a 5-year
disease survival rate as high as 68%?
A. Resectable perihilar cholangiocarcinoma
B. Resectable distal cholangiocarcinoma
C. Cholangiocarcinoma treated with liver
transplantation
D. None of the above
Answer: C
Most patients with perihilar cholangiocarcinoma present
with advanced, unresectable disease. Median survival in
this population is between 5 and 8 months. The most common causes of death are hepatic failure and cholangitis. The
overall 5-year survival rate for patients with resectable perihilar cholangiocarcinoma is between 10% and 30%, but for
patients with negative margins, it may be as high as 40%. The
operative mortality for perihilar cholangiocarcinoma is 6% to
8%. Patients with distal cholangiocarcinoma are more likely
to have resectable disease and improved prognosis compared to perihilar cholangiocarcinoma. The overall 5-year
survival rate for resectable distal disease is 30% to 50%, and
the median survival is 32 to 38 months. Patients who receive
liver transplantation for cholangiocarcinoma can experience 5-year disease-free survival rates as high as 68%. (See
Schwartz 11th ed., p. 1423.)
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