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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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2 Biliary System
Gallbladder cancer
Case Management
57
Patient with T1a gallbladder cancer (cancer
extends into lamina propria only)
Patient with T1b gallbladder cancer (cancer
extends into the muscular layer)
Management
Survival Depth of invasion of gallbladder cancer correlates with overall survival
Patient with T2 gallbladder cancer (cancer
invades the perimuscular connective tissue
without involvement of the serosa)
Patient with T3/T4 gallbladder cancer Resection in some patients but most will be
Patient with metastatic gallbladder cancer Gemcitabine+Cisplatin
Portal lymphadenectomy➔minimum of three lymph nodes (including the common hepatic
artery and portacaval lymph nodes)
Overall, 5-year survival is 19%
According to SEER classication, for localized disease, 5-year survival is 66% this decreases
to 28% for regional spread and 2% with distal spread
Similarly, ve-year survival in patients with Tis, T1a, T1b, T2a, T2b, and T3 is 100%, 92.4%,
84.8%, 52.4%, 47.3%, and 17.1%, respectively
For stages I, II, IIIA, IIIB, and IVB, the ve-year recurrence free survival is 75.4%, 64.1%,
32.7%, 17.9%, and 12.5%, respectively
Cholecystectomy alone if cystic duct margin
is negative
If cystic duct positive➔re-resection of
cystic and/or CBD
If in muscle but not
beyond➔cholecystectomy+wedge
resection of IVb and V+portal
lymphadenectomy
Formal resection of segments IVb and
V+locoregional lymph node dissection
unresectable
Radical resection versus chemotherapy
Research
Reference Findings
Shindoh J, de Aretxabala X, Aloia TA, etal.
Tumor location is a strong predictor of tumor
progression and survival in T2 gallbladder
cancer: An international multicenter study.
Ann Surg. 2015;261(4):733–9
Kasumova GG, Tabatabaie O, Najarian RM,
etal. Surgical management of gallbladder
cancer: Simple versus extended
cholecystectomy and the role of adjuvant
therapy. Ann Surg. 2017;266(4):625–31
After curative resection of T2 gallbladder cancer, tumor
location predicts the pattern of recurrence and survival
Adjuvant therapy prolongs survival after resection of T2/T3
tumors
58
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Benign Biliary Obstruction
Cholangitis
Choledocholithiasis Most common cause
A. H. Sohail et al.
Benign biliary
strictures
Causes
Presentation Charcot’s triad: Fever, RUQ pain, and jaundice
Acute/chronic
pancreatitis
Malignant biliary
strictures
Choledochal cysts See table of choledochal cysts
Mirizzi syndrome Results when the bile duct is obstructed from external compression by a
Lemmel syndrome Periampullary duodenal diverticulum that causes compression of the
Iatrogenic causes Indwelling biliary stents and catheter obstructions
Reynold’s pentad: Charcot triad+hypotension and altered mental status➔indicates progression to
septic shock
Charcot’s triad and the Reynold’s pentad are present in less than 50% of patients with acute
cholangitis
Results from ischemia, inammation from recurrent choledocholithiasis or
cholangitis, and primary sclerosing cholangitis
Inammation of the pancreas➔cause distal biliary strictures or external
compression due to pseudocyst formation
Results from any type of cancer that obstructs bile ow
(cholangiocarcinoma, gallbladder cancer, liver cancers, pancreatic cancers,
and ampullary cancers)
stone within the cystic duct or gallbladder infundibulum
intrapancreatic portion of the CBD
2 Biliary System
Cholangitis
Diagnosis CBC, BMP, LFT, amylase and lipase, prothrombin time+blood cultures
Diagnostic modalities Characteristics Radiology
Ultrasound • Initial modality for
diagnosing biliary obstruction
• Sensitive for CBD dilation
and cholelithiasis but not for
choledocholithiasis
Gray-scale abdominal ultrasound image
demonstrates an 8mm echogenic
common bile duct calculus (arrow) with
posterior shadowing and resultant
proximal dilation of the common bile
duct
CT • Provides improved anatomic
details compared with
ultrasound
59
• Identify the cause and site of
a biliary obstruction
• Poor sensitivity for gallstones
because they are isodense to
bile
Axial abdomen CT image with IV
contrast demonstrates a partially
obstructing common bile duct calculus
(arrow) with hyperenhancement of the
duct wall, consistent with cholangitis
MRCP • Provides anatomic denition
of the entire biliary tree and
pancreas
• High sensitivity for common
duct stones
• Used to evaluate biliary
strictures, complex biliary
pathology, and malignancy
Axial HASTE abdomen MR image
without IV contrast demonstrates a
1.1cm common bile duct calculus
(arrow) with dilation of the proximal
common bile duct (arrowhead)
Direct hyperbilirubinemia+ultrasound ndings of a dilated CBD (>8mm) suggest
choledocholithiasis as the diagnosis
Management ERCP with sphincterotomy and stone extraction and/or stenting
Percutaneous transhepatic cholangiography and laparoscopic common bile duct exploration
60
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Tokyo classication of cholangitis and its management
Grade Criteria Treatment
A. H. Sohail et al.
Grade I
(mild):
Grade II
(moderate):
Grade III
(severe):
Acute cholangitis does not meet
criteria for Grade II or Grade III
Acute cholangitis +2 of the
following:
• Abnormal WBC count (<4k
or>12k)
• High fever (>39C)
• Age>75years old
• Hyperbilirubinemia
• Hypoalbuminemia
Acute cholangitis+organ
dysfunction
• Cardiovascular dysfunction
• Neurological dysfunction
• Respiratory dysfunction
• Renal dysfunction
• Hepatic dysfunction
• Hematological dysfunction
Initial medical management
Resuscitation+antibiotic therapy with coverage of gramnegative (Escherichia coli, Klebsiella), gram-positive
(Enterococcus), and anaerobic bacteria
+ERCP with sphincterotomy and stone extraction
Initial medical management
Resuscitation+antibiotic therapy with coverage of gramnegative (Escherichia coli, Klebsiella), gram-positive
(Enterococcus), and anaerobic bacteria
Early endoscopic and/or percutaneous transhepatic drainage
Medical stabilization with antibiotics
Appropriate organ support
+urgent biliary drainage
Common Bile Duct Exploration andCholedochoscopy
Trancystic CBD
exploration
Indications Small stones (<6–8mm)
<8 total stones
Large cystic duct (>5mm)
Transductal CBD
exploration
Large stones
Multiple stones
Small or friable cystic
duct
Stones proximal to cystic
duct–CBD junction
Open CBD
exploration
When open approach
is necessary
Large or impacted
CBD stones
Patients who need
biliary enteric
drainage
Transduodenal
sphincteroplasty
When the pathology
involves the ampulla
(impacted stones or
papillary stenosis)
2 Biliary System
61
Key steps
Trancystic CBD
exploration
• Cholangiogram
• Dilate the cystic duct
• Replace cholangiogram
catheter with basket
extraction or
choledochoscope
• Ductal irrigation with the
use of glucagon to relax
the sphincter of Oddi
• In cases of stone
impaction, use Fogarty
balloon catheters to help
free the stones
Transductal CBD
exploration
• Cholangiogram
• Distal, vertical,
supraduodenal
choledochotomy
• cholangiogram catheter
to ush the stones
• choledochoscopy with a
exible scope
• Retrieve the stones using
a basket retrieval device
• stone impaction, use
Fogarty balloon
catheters
• Close primarily
(monolament
absorbable suture) or
over a T tube (14F)
Open CBD
exploration
• Kocher maneuver
• Distal, vertical,
supraduodenal
choledochotomy
(1.5cm)
• Pass Fogarty
catheters through
common hepatic
duct
• Choledochoscopy
or cholangiogram
• Close primarily
(monolament
suture) or over a T
tube (14F)
Transduodenal
sphincteroplasty
• Kocher maneuver
• Transverse or
longitudinal
duodenotomy on
the lateral
duodenal wall at
the junction of the
lower 1/3 and
upper 2/3 of
duodenum
• Identify papilla
• Cut ampullary
sphincter at 11
o’clock position
• Extract all stones
• Suture the wall of
the CBD to the
duodenal mucosa
• Close the lateral
duodenotomy
Biliary Neoplasms
Benign neoplasms of gallbladder
Gallbladder
neoplasm Characteristics Radiology
Cholesterol polyps Most common type of gallbladder
polyp
<1cm and multiple
No malignant potential
Associated with vesicular
cholesterolosis
Hyperechoic when compared to the
liver parenchyma
62
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Benign neoplasms of gallbladder
Gallbladder
neoplasm Characteristics Radiology
Adenomyomatosis Solitary
Hyperplastic mucosal lesions
Most commonly found in fundus
No malignant potential
Focal gallbladder wall thickening
with diffuse or segmental round
anechoic foci
A. H. Sohail et al.
Adenomas Pedunculated
Associated with gallstones
Have the potential for malignant
transformation to adenocarcinoma
Isoechoic, solitary, and homogeneous
(A) Gray- scale and (B) color Doppler images of the
gallbladder demonstrate gallbladder wall echogenic
foci (arrow) with comet-tail artifacts on color Doppler,
consistent with gallbladder adenomyomatosis
Gray-scale ultrasound images of the gallbladder
demonstrate a 6mm×9mm non-mobile,
pedunculated mass (arrow), arising from the
gallbladder wall with internal color Doppler ow (not
shown), a gallbladder adenoma or enlarged polyp
2 Biliary System
Benign neoplasms of gallbladder
Gallbladder
neoplasm Characteristics Radiology
63
Inammatory
polyps
<1cm
Occurs secondary to inammation
from cholecystitis
No malignant potential
Gallbladder polyps versus gallbladder stones
Gallbladder polyp Gallbladder stones
Fixed to gallbladder
No shadowing
Mobile and can be multiple
Posterior acoustic shadow
Gray-scale ultrasound image of the gallbladder
demonstrates a non-mobile, rounded echogenic polyp
(arrow) along the gallbladder wall without posterior
shadowing
Gray-scale ultrasound image of the gallbladder
demonstrates multiple layering echogenic stones
(arrow) with posterior acoustic enhancement. These
were demonstrated to be mobile during real-time
imaging
Gray-scale ultrasound image of the gallbladder
demonstrates an echogenic gallstone with posterior
shadowing.
64
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Gallbladder polyps
More commonly in males
A. H. Sohail et al.
Characteristics
Types
Presentation Most are asymptomatic and are found incidentally on imaging
Diagnosis Right upper quadrant ultrasound
Management
Most gallbladder polyps are benign
Benign polyps: Cholesterol polyps≫inammatory polyps>adenomyomatous
Malignant polyps: Adenocarcinoma, squamous cell carcinoma, and mucinous
cystadenocarcinoma
Can present as biliary colic or acute cholecystitis if they obstruct the duct
Concern with gallbladder polyps is the risk of malignancy
Risk factors for malignancy: Size>1cm, age>50, sessile morphology, single polyp
Case scenario Management
Patient low risk, asymptomatic, gallbladder polyp <10mm Monitor with serial
Patient with gallbladder polyp >10mm Laparoscopic
Patient with symptomatic gallbladder polyp (any size) Laparoscopic
Patient with gallbladder polyp >6mm with risk factors for
malignancy
ultrasound
cholecystectomy
cholecystectomy
Laparoscopic
cholecystectomy
Research
Reference Findings
Wiles R, Thoeni RF, Barbu ST, etal. management
and follow-up of gallbladder polyps: Joint
guidelines between the European Society of
Gastrointestinal and Abdominal Radiology
(ESGAR), European Association for Endoscopic
Surgery and other interventional techniques
(EAES), International Society of Digestive
Surgery–European Federation (EFISDS) and
European Society of Gastrointestinal Endoscopy
(ESGE). Eur Radiol. 2017;27(9):3856–3866.
If the patient has risk factors for gallbladder malignancy
and a polyp size between 6 and 9mm, cholecystectomy is
recommended if the patient is t for and accepts the
surgery
Cholangiocarcinoma
Denition Bile duct cancer arising in the intrahepatic, perihilar, or distal extrahepatic biliary tree, excluding the
gallbladder and ampulla of Vater
Risk factors Primary sclerosing cholangitis, choledochal cysts, parasitic infections (Clonorchis sinensis),
hepatolithiasis, and hepatitis C
Type IType II Type IIIA Type IIIB Type IV
2 Biliary System
Cholangiocarcinoma
65
Presentation
Types
Intrahepatic cholangiocarcinomas➔asymptomatic but may present with right upper quadrant pain or
weight loss
Extrahepatic cholangiocarcinomas➔jaundice, hepatomegaly, right upper quadrant mass or
fever➔due to biliary obstruction
5–10% of cholangiocarcinomas are intrahepatic
The remaining are classied as distal cholangiocarcinomas
Cancers arising in the perihilar region are classied according to the bismuth-Corlette classication
Bismuth-Corlette classication
Type I Tumor limited to the common hepatic duct (below
the conuence)
Type II Tumor involves the conuence of the right and left
hepatic duct
Type IIIa Tumor occludes the common hepatic and right
hepatic duct
Type IIIb Tumor occludes the common hepatic and left
hepatic duct
Type IV Tumor extends to the bifurcation of both right and
left hepatic ducts
Tumors involving the hepatic duct bifurcation are collectively referred to as Klatskin tumors
Diagnosis Diagnostic modality Characteristics
CT of liver with triple-phase or MRCP • Evaluates the local extent of the tumor
EUS/ERCP • Used if tissue diagnosis is needed (if anticipating
CT scan of the chest➔for staging purpose
• Evaluates the arterial, portal venous, and lymph
node involvement locally
non-operative management)
• To relieve biliary obstruction
66
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Cholangiocarcinoma
To determine resectability evaluate if:
1. Adequate functional liver reserve (FLR)
2. Adequate biliary drainage
3. Preservation of inow and outow
A. H. Sohail et al.
Management
Contraindications to resection: Portal vein or common hepatic artery invasion, metastatic disease,
lymph node involvement beyond the portal lymph nodes, and inadequate function liver reserve, major
vascular invasion not amenable to resection/reconstruction
For resectable locally advanced disease➔diagnostic laparoscopy is advised before resection
Type Management
Distal cholangiocarcinoma Pancreaticoduodenectomy with routine
reconstruction
Hilar cholangiocarcinoma Hemihepatectomy with or without caudate
resection for hilar tumors
Usually abuts caudate lobe➔requires resection
of caudate lobe (otherwise biliary drainage of
caudate will be compromised)
For unresectable hilar
cholangiocarcinoma➔transplantation if node
negative, without intrahepatic disease, size <3cm
(Mayo protocol)
Intrahepatic cholangiocarcinoma Management similar to hepatocellular carcinoma
Partial hepatectomy+portal lymphadenectomy
Case Management
Patient with resectable intrahepatic
cholangiocarcinoma planned for hepatic
resection found to have future liver remnant
<20%
Preoperative portal vein embolization on the side
ipsilateral to the tumor for hypertrophy of the
remnant and then hepatic resection
Patient with obstructive jaundice found to have
hilar cholangiocarcinoma
During exploration for a patient with resectable
hilar cholangiocarcinoma, suspicious superior
mesenteric lymph node was found
Symptomatic patient with unresectable
cholangiocarcinoma
Symptomatic patient with cholangiocarcinoma
with distant metastasis
Adjuvant therapy should be considered even after R0 resection and N0 status because of the risk of
locoregional recurrence
Endoscopic drainage➔then assess for resection
Biopsy and frozen section to rule metastasis
before resection
Biliary drainage by either stenting, drainage
(endoscopic or percutaneous)
Endoscopic drainage (ERCP+stent) or
percutaneous transhepatic biliary drainage
(PTBD)
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