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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1232_Библиотеки_им_академика_М_И_Перельмана.pdf
Gallstone Ileus
KeshavKooragayala andYoungK.Hong
50
Way Question May BeAsked?
A 45-year-old female with a history of gallstones presents to
the hospital with abdominal pain, nausea, and vomiting for
1week. She has no prior surgical history. She undergoes an
abdominal X-ray in the emergency room, which identies a
radiolucent stone in the small bowel and pneumonia.
How toAnswer?
Full History
• Onset of symptoms
• Any history of biliary symptoms (RUQ pain, postprandial
abdominal pain)
• Nausea
• Emesis (bilious, non-bilious)
• PO tolerance
• Fevers
• Jaundice
• “Tumbling obstruction”—intermittent symptoms of
obstruction as the stone intermittently blocks the lumen of
the intestine
Surgical Procedure
Preoperative resuscitation, enteric decompression with NGT
• Management is focused on relieving bowel obstruction,
and not the biliary stula
• Exploratory laparotomy
• Longitudinal enterostomy proximal to stone, with transverse closure of enterotomy
• Delayed management of biliary disease
• Cholecystectomy with/without takedown of biliary stula
should be considered based on the patient’s specic
comorbidities
Common Curveballs
• It is essential to examine the remainder of the bowel for
additional stones that can cause recurrent symptoms
• The patient has postoperative bowel obstruction (missed
second stone)
• Patient is unstable
Full Physical Examination
• Abdominal exam
• Evaluation of character of emesis
• Check for hernias as a source of bowel obstruction
Diagnostic Tests
• CT scan with IV and/or PO contrast
• RUQ ultrasound
K. Kooragayala · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: kooragayala-keshav@CooperHealth.edu;
Hong-young@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_50
Clean Kills
• Performing an up-front cholecystectomy and takedown of
biliary stula before addressing gallstone.
• Performing a one-stage surgery in the setting of intense
inammation in the right upper quadrant would place the
patient at risk for signicant morbidity.
• Not milking the stone back from the terminal ileum
(where it typically gets lodged).
165
166
Words ofWisdom
When managing a patient with gallstone ileus, it is crucial to
evaluate the entirety of the bowel so as not to miss secondary
stones. While it may be tempting to take down the
choleduodenal stula, the primary objective of the index
operation is to relieve the intestinal obstruction.
K. Kooragayala and Y. K. Hong
Choledochal Cyst
KeshavKooragayala andYoungK.Hong
51
Concept
In choledochal cysts, the pancreatic duct often joins the common bile duct outside the pancreas, creating a long common
channel allowing for biliary reux, leading to inammatory
changes and cyst formation.
Characterization of Cyst Type
• Type I: Fusiform cysts: 50% of cysts, highest risk of
malignancy
• Type II: Saccular diverticula of common bile duct
• Type III: Intraduodenal cysts
• Type IV: Multiple cysts, which could be intra- or
extra-hepatic
– Type IVa: Intrahepatic disease
– Type IVb: Isolated extrahepatic disease
• Type V: Caroli disease: multiple intrahepatic cysts
Way Question May BeAsked?
A 53-year-old female with a history of pancreatitis presents
with abdominal pain, jaundice, and palpable mass.
Alternatively, this patient may present with cholangitis.
How toAnswer?
Full History
• Onset of symptoms
• Any history of biliary symptoms (right upper quadrant
(RUQ) pain, postprandial abdominal pain)
• Nausea
• Emesis (bilious, nonbilious)
• PO tolerance
• Fevers
• Jaundice
• History of any anomalies seen at birth, genetic syndromes,
etc.
Full Physical Examination
• Abdominal exam
• Lymph node exam
• Functional assessment
Diagnostic Tests
• Laboratory studies, including liver function tests (LFTs),
complete blood count (CBC), and lipase
• CT scan with IV and/or PO contrast
• RUQ ultrasound
• MRCP
Surgical Management
• Surgical management is based on the location and type of
the cyst
• For type I/II, surgical excision of the cyst, cholecystectomy with or without Roux-en-Y hepaticojejunostomy is
performed
• For type III cysts, the intra-duodenal segment may necessitate a pancreaticoduodenectomy for complete removal
of the cyst or resection through a transduodenal approach
• For type IV, excision of all cysts, including segmental
liver resection and reconstruction based on individual
patient history
• For type V, liver transplantation is often the only treatment option for the eradication of all cystic tissue
K. Kooragayala · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: kooragayala-keshav@CooperHealth.edu;
Hong-young@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_51
167
168
K. Kooragayala and Y. K. Hong
Common Curveballs
• For patients presenting with cholangitis, clearance of
infection should be managed before surgical resection
• The goal of resection is to reduce the risk of malignant
potential
• Postoperative complication: stricture
Clean Kills
• After the excision of the choledochal cyst, performing a
biliary–enteric bypass is critical if there is concern about
biliary stricture.
• Incomplete cyst excision can lead to malignant conversion of remnant cystic tissue.
Words ofWisdom
When managing a patient with choledochal cysts, it is important to advise patients that the purpose of surgery is due to
the malignant potential of the cystic tissue. Excision and
reconstruction of the biliary tree can require complex reconstructive procedures and is best done at quaternary care centers by biliary/pancreatic surgeons.
Choledocholithiasis
KeshavKooragayala andYoungK.Hong
52
Way Question May BeAsked?
A 53-year-old female with a history of weight loss presents
with abdominal pain, jaundice, and intermittent pain. She
has elevated serum bilirubin, alkaline phosphatase, and a
dilated CBD on ultrasound. She has been afebrile but noted
that these symptoms have progressed over the last week.
How toAnswer?
Full History
• Onset of symptoms
• Any history of biliary symptoms (RUQ pain, postprandial
abdominal pain)
• Nausea
• Emesis (bilious, nonbilious)
• PO tolerance
• Fevers
• Jaundice
Charcot Triad: fevers, jaundice, RUQ pain
Reynold’s Pentad: triad+hypotension and altered mental
status
Full Physical Examination
• Vital signs
• Abdominal exam
Diagnostic Tests
• Laboratory studies, including LFTs, CBC, and lipase
– Serum bilirubin, alkaline phosphatase, liver enzymes
• RUQ ultrasound—best initial test
• MRCP
• ERCP: diagnostic and therapeutic
Surgical Management
• NPO, IVF, and IV antibiotics before surgery
• ERCP with sphincterotomy to decompress the CBD followed by laparoscopic cholecystectomy
• If ERCP is unavailable, perform laparoscopic cholecystectomy with intraoperative cholangiogram through a
transcystic approach
• If stones are too large or unable to cannulate, can perform
CBD exploration
– Stay sutures on the duct, longitudinal choledochotomy
with clearance of duct
– Duct should be closed over T-tube
Common Curveballs
• If lling defects are identied during IOC during routine
laparoscopic cholecystectomy, they can proceed with
ERCP after surgery.
• Percutaneous transhepatic cholecystostomy tube or
laparoscopy- assisted ERCP access is helpful in patients
with RNY bypass anatomy.
• If stones are impacted at the ampulla, perform transduodenal sphincterotomy.
• If stones are unable to be removed, perform choledochoduodenostomy or RNY hepaticojejunostomy.
• The CBD will be small.
• The patient will have had a previous gastric bypass or previous duodenal switch.
K. Kooragayala · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: kooragayala-keshav@CooperHealth.edu;
Hong-young@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_52
169
170
K. Kooragayala and Y. K. Hong
Clean Kills
• It is critical to evaluate for signs of cholangitis, which
could progress to systemic sepsis without prompt treatment
• Not leaving a T-tube if performing CBD exploration
Words ofWisdom
Choledocholithiasis with secondary stones from the gallbladder is a typical disease process. While some are incidentally identied, biliary decompression and cholecystectomy
are considered the standard of care to prevent recurrent
symptoms and complications. Do not perform CBD explorations on small CBDs. They will stricture or leak or both, and
your patient will not do very well.
Bile Leak
ClaraZhu andYoungK.Hong
53
Concept
A bile leak may occur after cholecystectomy, with similar
preoperative symptoms. Reported incidence is approximately 0.5–1%. Early detection of bile leaks allows for
prompt treatment and avoidance of postoperative morbidity.
Very important to rule out a major bile duct injury promptly.
Way Question May BeAsked?
A 45-year-old female with a history of obesity undergoes
laparoscopic cholecystectomy for symptomatic cholelithiasis. She presents to your ofce 5 days after the operation
with right upper quadrant abdominal pain and fevers.
How toAnswer?
Full History
• Onset of symptoms
• Abdominal pain
• Nausea
• Emesis
• PO tolerance
• Fevers
• Jaundice
• Operative details of cholecystectomy
• Indication for cholecystectomy
• If a drain was left in the index operation. If so, what is the
quality of and the amount of uid?
Full Physical Examination
• Vital signs
C. Zhu · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: Zhu-clara@cooperhealth.edu;
Hong-young@cooperhealth.edu
– Abdominal tenderness on palpation
– Peritonitis
– Jaundiced skin
– Scleral icterus
Diagnostic Tests
• Labs including CBC, BMP, LFTs, INR
– Right upper quadrant ultrasound—least sensitive test
but inexpensive but a fast and safe initial test
– CT abdomen—more sensitive than ultrasound but can-
not differentiate biloma from abscess, hematoma, or
simple uid
– HIDA—the most specic test for biliary leak and can
aid inlocalizing the source of the leak
Surgical Procedure
• IR drainage—the initial procedure to drain the biloma and
send uid for culture. Drain volume also aids in further
decision-making.
• ERCP—if the output from a percutaneous drain is high or
increasing, ERCP has a high success rate of improving
the leak volume. Sphincterotomy and CBD stent placement divert the ow of bile through the ampulla. However,
patients will require stent removal or exchange at 6weeks.
• It is infrequent to require a washout operation. However,
this would be indicated when a large-volume leak causes
diffuse peritonitis.
Common Curveballs
• Interventional radiology is not available
– The patient has no window for interventional radiol-
ogy drainage
– The patient has Roux-en-Y anatomy, which precludes
normal ERCP
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_53
171
172
C. Zhu and Y. K. Hong
Clean Kills
• Failure to check liver function tests
• Failure to resuscitate and start antibiotics in patients with
sepsis
• Failing to obtain imaging to establish diagnosis
• Failing to drain the biloma
• Failing to perform ERCP after high drainage volume
• Performing surgery before noninvasive interventions
Words ofWisdom
When evaluating a patient with a postoperative bile leak, the
rst step is to establish a diagnosis, as a differential diagnosis
may include postoperative hematoma or abscess. The majority of bile leaks can be managed nonoperatively with percutaneous drainage by interventional radiology and ERCP with
sphincterotomy and stent placement.
Bile Duct Injury
ClaraZhu andYoungK.Hong
54
Concept
Early workup and transfer to a center with hepatobiliary
experience are components of safe management. If a bile
leak is detected intraoperatively and hepatobiliary capabilities are unavailable, it is best to widely drain the area and
transfer the patient to a higher level of care.
Way Question May BeAsked?
There is a 60-year-old male on whom you perform a laparoscopic cholecystectomy. The gallbladder is densely inamed.
After transection of what you believe to be the cystic duct,
you notice bile leaking from an unclear source. You decide to
perform an intraoperative cholangiogram and do not see any
contrast ow into the duodenum.
How toAnswer?
Full History
• Indications for cholecystectomy
• When the cholecystectomy was performed relative to the
discovery of the injury
• Operative report of the cholecystectomy
• Previous surgical anatomy
• Abdominal pain
• Nausea or emesis
• Fevers or chills (indications of sepsis)
Full Physical Examination
• Vital signs
– Scleral icterus
C. Zhu · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: Zhu-clara@cooperhealth.edu; Hong-young@cooperhealth.edu
– Jaundice of the skin
– Abdominal pain
– Peritonitis
– Presence of a drain from cholecystectomy
Diagnostic Tests
• Labs including CBC, BMP, LFTs, INR.
• Cholangiography should be performed if a ductal injury is
suspected intraoperatively and equipment is available.
• Right upper quadrant ultrasound—again, this test is nonspecic but a safe and inexpensive test to order for complications after cholecystectomy.
• CT scan is also a high-yield test and allows for visualization of uid collections and associated hepatic vascular
injury.
• MRCP is critical to delineate the level of injury.
Surgical Procedure
• If a bile leak is detected intraoperatively and hepatobiliary
capabilities are unavailable, it is prudent to widely drain
the area and transfer the patient to a higher level of care.
• If the patient has a delayed presentation (greater than
4 days), the leak should be temporized with a plan for
operative repair in approximately 8 weeks. Short-term
intervention includes percutaneous drainage of a biloma
and an external biliary drain for complete ductal
transection.
• Partial duct injuries <50% circumference can be repaired
with absorbable suture over a T-tube. If the two ends can
be brought together without tension, the duct can be primarily anastomosed over a T-tube. However, the bile duct
will often retract, causing tension.
• Often, the safest surgical option is a Roux-en-Y hepaticojejunostomy (HJ):
– Division of the jejunum 30 cm from the ligament of
Treitz.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_54
173
174
C. Zhu and Y. K. Hong
– Bring up the limb to the debrided proximal edge of the
bile duct.
– Creation of the hepaticojejunostomy anastomosis with
absorbable suture.
– Creation of small bowel anastomosis 50 cm from the
HJ to prevent bile reux.
Common Curveballs
• The timing is 2 weeks or greater from the index
operation
• The level of the injury is above the conuence
Clean Kills
• Performing a choledochoduodenostomy when there is
tension
• Attempting to perform an HJ without experience
• Doing a primary repair for an injury that is greater than
50% circumference
• The examiner asks you how you explain the injury to the
patient/family and you are not honest and upfront in your
explanation
Words ofWisdom
The most important factors after diagnosis of a bile duct
injury are timing from the index operation, level of the injury,
and extent of the injury. The safest initial option is to transfer
to a center with hepatobiliary experience. Early diagnosis is
amenable to either primary repair or hepaticojejunostomy.
Late diagnoses should have drainage and interval
hepaticojejunostomy.