Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1232_Библиотеки_им_академика_М_И_Перельмана.pdf
Mirizzi Syndrome
WhitneyN.Jones andLeahC.Tatebe
60
Scenario
A 55-year-old male presents to the emergency room with
worsening right upper quadrant and epigastric pain, nausea, vomiting with oral intolerance for the last 4days. He
has a history of cholelithiasis and has had chronic episodic
epigastric pain radiating to his back and right side for the
last year. His pain normally resolves itself within 24–36h.
He previously presented 9months ago with similar signs and
symptoms and a right upper quadrant ultrasound demonstrated a distended gallbladder with multiple gallstones.
Past medical history includes hypertension and obesity. He
was subsequently discharged and the patient failed to follow
up with surgery for further evaluation.
Physical exam is notable for epigastric and right upper
quadrant tenderness and scleral icterus.
Labs were notable for mildly elevated white blood cells
(13.3×103/L), total bilirubin (7.4mg/dL), and direct bilirubin (4.8mg/dL).
What differential diagnosis should be considered for this
patient? (Khokhar etal. 2022)
• Acute cholecystitis
• Choledocholithiasis
• Mirizzi syndrome
• Gallbladder cancer
• Cholangiocarcinoma
• Pancreatic cancer
• Sclerosing cholangitis
• Metastatic disease
What steps should be taken for denitive diagnosis?
Abdominal Ultrasound (Chen etal. 2018)
• Typically the initial imaging modality to evaluate biliary
disease due to it being noninvasive and widely available
• Evidence of MS includes atrophic gallbladder, ectatic
common hepatic duct with a normal distal CBD
MRCP
• Next imaging modality when signs of obstructive jaundice are seen on US (Grohol etal. 2023)
• Increased sensitivity to detect MS when compared to US
• Useful in dening the biliary anatomy and detect characteristics of MS
• Ineffective inlocalizing stulas (Chen etal. 2018)
ERCP (Chen etal. 2018)
• Gold standard for diagnosing MS, as it is highly sensitive
and provides therapeutic options
• Provides superior visualization of the biliary tree and can
visualize if stulation has occurred
• Allows for decompression of biliary tree
• Pre or post operative stenting can be helpful in dening
the anatomy
CT
• Most useful imaging modality to distinguish MS from
malignancy (Chen etal. 2018)
• Location and cause of biliary obstruction can be seen
(Chen etal. 2018)
Describe the stages of progression of MS?
• Initially, isolated compression of hepatic bile duct or
common bile duct is the rst stage
• Progresses to inammation, ulceration, and the formation
of cholecystoenteric and cholecystobiliary stulas as the
compression becomes prolonged and chronic
What are intraoperative ndings found during operation
may indicate Mirizzi syndrome?
W. N. Jones · L. C. Tatebe (*)
Department of Surgery, Northwestern University,
Chicago, IL, USA
e-mail: whitney.jones@nm.org; ltatebe@nm.org
© 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_60
• Hard brous adhesions between gallbladder and CBD
• Thick-walled gallbladder
• Contracted gallbladder
185
186
W. N. Jones and L. C. Tatebe
MS is treated surgically with a cholecystectomy. What are
the challenges of operating on patients with MS and what are
common complications?
• Challenges include difcult, distorted anatomy with
dense adhesions secondary to inammation
• CBD injury
• Massive hemorrhage
What is the operative approach for MS? (Klekowski etal.
2021)
• Open cholecystectomy is generally accepted as the stan-
dard of care. There should be a high rate of conversion to
open and increased risk of bile duct injury, up to 17%
• However laparoscopic cholecystectomy could be an
option if a stula is not present
• If MS diagnosis is made intraoperatively, recommend
intraoperative cholangiogram to evaluate for a stula and
to further dene the biliary anatomy. If a stula is present
repair or stent bile injury
• Concerning involving a hepatobiliary surgeon
• Can consider endoscopic therapies until denitive surgi-
cal treatment in poor surgical candidates
What characteristic anatomic distortions can you expect
to see in MS? (Klekowski etal. 2021)
Clean Kills
• Failing to dene the biliary anatomy with the proper
imaging modality
• Failing to consider malignancy and other biliary pathology including acute cholecystitis, cholangitis, and pancreatitis that could be occurring concurrently with MS
• Failing to address biliary obstruction
• Surgical plan should consider and address known
difculties
• No leaving a drain if there is concern for a stula or bile
leak
Words ofWisdom
MS is a very rare sequelae of biliary disease with an incidence of roughly 1% in the United States and slightly higher
in low and middle income countries and it is very challenging to diagnose preoperatively. MS should be considered in
differential diagnosis of any patient presenting with obstructive jaundice as preoperative diagnosis allows for proper
operative planning to limit and prevent high mortality and
morbidity associated with MS. While surgery remains the
mainstay of treatment, preoperative diagnosis of MS allows
a collaborative multidisciplinary approach to both diagnosis
and treatment.
1. Atrophic gallbladder with thick or thin walls
2. Obliterated cystic duct
3. Cystic duct—long, parallel to the common bile duct and
with low insertion
4. Cystic duct—short cystic duct with another anatomical
variation
5. Bile duct—partially obstructed due to the external compression or a gallstone eroding from the gallbladder
6. Distal bile duct with normal thin walls and no distended
lumen
7. Proximal bile duct—dilated with inamed walls
8. Abnormal communication between the bile duct and the
gallbladder
9. Fistula between the gallbladder and stomach, duodenum,
colon, or other structures
Bibliography
Chen H, Siwo EA, Khu M, Tian Y. Current trends in the manage-
ment of Mirizzi syndrome. Medicine. 2018;97:e9691. https://doi.
org/10.1097/md.0000000000009691.
Grohol B, Fortin GT, Ingold T, Bennett P. Mirizzi syndrome: a
case report. Cureus. 2023;15:e34783. https://doi.org/10.7759/
cureus.34783.
Jones MW, Troy F. Mirizzi syndrome. StatPearls Publishing; 2023.
https://www.ncbi.nlm.nih.gov/books/NBK482491/. Accessed 21
Aug 2023.
Khokhar I, Adourian M, Delia E, Mohan G, Mathew M. Mirizzi
syndrome: a case report and review of the literature. Cureus.
2022;14:e24375. https://doi.org/10.7759/cureus.24375.
Klekowski J, Piekarska A, Góral M, Kozula M, Chabowski M.The
current approach to the diagnosis and classication of Mirizzi syndrome. Diagnostics. 2021;11:1660.
Part VII
Pancreas
Acute Pancreatitis
RachaelPalumbo andAditiKapil
61
A 52-year-old male presents to the emergency department
with a 1-day history of severe epigastric pain with mild nausea and decreased appetite. He denies previous similar
symptoms, vomiting, changes in bowel habits, weight loss, or
fever. He has no history of alcohol or drug use. There is no
signicant past medical or surgical history. Lab data include
WBC 12, Hb 14, bicarb 19, creatinine 1.2, lactic acid 3, and
lipase 3000. Vitals: HR 110 (regular), BP 100/60, Temp
36°F, RR 18. Physical exam signicant for epigastric pain
and dry mucous membranes but otherwise normal. How
would you manage this?
• Based on the Revised Atlanta Criteria, the patient has
acute pancreatitis.
– This includes presence of at least two of the following:
(1) upper abdominal pain; (2) serum amylase or lipase
level more than three times the upper limit of normal;
(3) characteristic imaging ndings (contrast enhanced
CT, MRI, and etc.).
• Initial management includes uid resuscitation and close
monitoring. Recommend goal directed uid resuscitation
(e.g., 10cc/kg bolus of Ringer’s lactate with continuous
rate at 1.5cc/kg given evidence of hypovolemia on vitals)
that is adjusted based on urine output, vital signs, and lab
data after admission (De-Madaria etal. 2022).
• Early initiation of nutrition is recommended, including a
trial of regular diet within 24h of admission. Parenteral
nutrition should only be employed when enteral feeds
cannot be tolerated and nutritional support is required
(Crockett etal. 2018).
• Prophylactic antibiotics are not recommended (Crockett
etal. 2018).
After 3days of resuscitation and initiation of regular diet,
the patient has improved. Vital signs and labs have normalized, and the patient’s pain has much improved. What inves-
R. Palumbo · A. Kapil (*)
Department of Surgery, Yale School of Medicine,
New Haven, CT, USA
e-mail: aditi.kapil@yale.edu
tigational studies and potential interventions should be done
prior to discharge?
• The patient should have an evaluation of biliary sources
of pancreatitis. This would include a RUQ ultrasound to
evaluate for cholelithiasis. Gallstone pancreatitis is the
most common cause of acute pancreatitis.
• If cholelithiasis is present, a cholecystectomy is recommended prior to discharge. Normalization of serum
enzymes or resolution of pain is not specically required
prior to undergoing cholecystectomy in mild–moderate
gallstone pancreatitis.
Alternate Scenario
A 52-year-old male presents to the emergency department
with a 1day history of severe epigastric pain with nausea
and vomiting. Denies previous similar symptoms, changes in
bowel habits, weight loss, or fever. No history of alcohol or
drug use. No signicant past medical or surgical history. Lab
data including: WBC 15, Hb 16, bicarb 16, creatinine 2.1,
lactic acid 5, lipase 3000. Vitals: HR 120 (regular), BP
90/50, Temp 36 °F, RR 18. Physical exam signicant for
altered mental status (confusion), epigastric pain. How
would you manage this?
• Similar to the above scenario, the patient has acute pancreatitis. However, he is showing signs of hemodynamic
instability with tachycardia, hypotension, and altered
mental status with lab data showing concern for
hypovolemia.
• Initial management would include close monitoring with
ICU admission and uid resuscitation. Prophylactic antibiotics are not recommended.
Fluid resuscitation and close monitoring initiated.
However, despite this, over the next 48h, the patient is persistently hypotensive (MAP 55) and becomes progressively
lethargic and altered. His temperature is now 39°C with a
© 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_61
189
190
R. Palumbo and A. Kapil
leukocytosis of 24 and hemoglobin of 14. How would you
manage this patient?
• This patient is progressively critically ill from his pancreatitis, requiring intubation and initiation of vasopressors.
• Given development of fever, worsening leukocytosis, and
persistent hemodynamic instability, would recommend
CT imaging to evaluate pancreatitis.
– If a patient with acute pancreatitis fails to show clinical
improvement within 72h of admission or infected necrotizing pancreatitis is suspected, cross sectional imaging is recommended with initiation of antibiotics with
superimposed infection.
Contrast enhanced cross sectional imaging performed,
showing areas of both pancreatic parenchymal enhancement
and nonenhancement with evidence of a small amount of
peripancreatic emphysema. How would you manage this
patient?
• This patient has necrotizing pancreatitis with associated
infection. Would initiate broad spectrum antibiotics and
continue supportive care, including nutritional support
with enteral feeds.
The patient is started on antibiotics and enteral feeds.
Initially, he clinically improves, allowing for extubation and
weaning from vasopressor support. However, on hospital
day 9, he decompensates with Tmax 39°C and hypotension
requiring vasopressor support. Repeat imaging shows a
6cm retroperitoneal peripancreatic uid collection with gas
and necrotic debris. How would you manage this patient?
• The patient is now showing an acute necrotic collection
with associated infection.
– The Revised Atlanta Criteria characterizes acute pan-
creatitis based on morphologic subtypes and timeline
of the disease process, specically peripancreatic uid
collections. The morphologic subtypes include interstitial edematous acute pancreatitis and necrotizing
acute pancreatitis. Peripancreatic uid collections that
develop within 4 weeks of the onset of interstitial
edematous pancreatitis are termed acute peripancreatic
uid collections; after 4 weeks, as pseudocysts. The
collections that develop within 4weeks in the setting
of necrotizing pancreatitis are acute necrotic collections, and after 4weeks, considered walled off necrosis. This can be seen in Table.
• Given the patient’s decompensation despite antibiotics
and development of a peripancreatic uid collection, it
would be reasonable to recommend a step-up approach
for drainage of the collection. Options include both an
endoscopic and operative step-up approach, with specic intervention depending on the institution
resources.
– The step-up approach is a minimally invasive manage-
ment technique to peripancreatic uid collections, rst
developed from the Panther Trial (Dutch Pancreatitis
Group) compared to open necrosectomy. Treatment
includes a series of percutaneous drain placements,
with ultimate video assisted retroperitoneal debridement if clinically indicated. Since its development,
endoscopic step up approaches have been employed
with similar outcomes, with lower rates of pancreaticocutaneous stulas (van Brunschot etal. 2018).
Interventional GI is not available at your institution, so
over the next several days, the patient undergoes a series of
percutaneous drain placements with upsizing ×2. However,
despite upsizing and ushing the drain, he continues to have
fevers, leukocytosis, and poor PO tolerance. How would you
manage this patient?
• Given the lack of clinical improvement, would recom-
mend a video assisted retroperitoneal debridement, gen-
eral steps:
– Positioned supine, left side elevated. Prep and drape
the left ank and abdomen, including drains.
– Subcostal incision made adjacent to the retroperitoneal
drain, allowing digital exploration and following of the
drain into the collection.
– Collection opened and necrosectomy performed with
ringed forceps and suction.
– Long 10 mm trocar and laparoscope then placed
through incision into the retroperitoneum for further
debridement.
– Two large bore drains placed and incision closed.
Clean Kills
• Recommending open necrosectomy as operative inter-
vention prior to considering Step Up approach or trans-
gastric debridement of necrotic pancreatic collections.
• Failing to initiate initial management of pancreatitis,
including uid resuscitation, close monitoring, and early
nutrition. Remember, pancreatitis can be a critical care
scenario.
• Failing to recognize a biliary etiology as the cause of
pancreatitis.
61 Acute Pancreatitis
191
Bonus Points
• Management of peripancreatic uid collections is complex, and it often requires input from an interdisciplinary
team and close attention to institutional resources.
Knowing the surgical Step Up approach can provide a
reasonable treatment algorithm for most cases.
• Be familiar with the Revised Atlanta Criteria for diagnosis and classication of pancreatitis subtypes.
Words ofWisdom
Management of acute pancreatitis for the general surgeon
includes not only the medical and critical care aspects of
treatment but also the interventional algorithms such as the
Step Up approach in necrotizing pancreatitis. Initial care of
pancreatitis regardless of severity includes uid resuscitation, close monitoring, and nutrition. Cholecystectomy is
recommended during index admission for gallstone pancreatitis but may be postponed 8weeks for necrotizing pancreatitis. Initiate antibiotics only when there is evidence of
superimposed infection. Care for peripancreatic uid collections is complex, with the most common indication for drainage being infection.
Bibliography
Colvin SD, Smith EN, Morgan DE, Porter KK.Acute pancreatitis: an
update on the revised Atlanta classication. Abdom Radiol (NY).
2020;45(5):1222–31.
Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun
AN. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology.
2018;154(4):1096–101.
De-Madaria E, Buxbaum JL, Maisonneuve P, García García De Paredes
A, Zapater P, Guilabert L, etal. Aggressive or moderate uid resuscitation in acute pancreatitis. N Engl J Med. 2022;387(11):989–1000.
Hallensleben ND, Timmerhuis HC, Hollemans RA, Pocornie S, van
Grinsven J, van Brunschot S, etal. Optimal timing of cholecystectomy after necrotising biliary pancreatitis. Gut. 2022;71(5):974–82.
Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet.
2015;386(9988):85–96.
Maatman TK, Zyromski NJ.Open pancreatic debridement in necrotiz-
ing pancreatitis. J Gastrointest Surg. 2021;25(1):331–2.
Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: a review.
JAMA. 2021;325(4):382–90.
Rayman S, Jacoby H, Guenoun K, Oliphant U, Nelson D, Kaiser A,
etal. Diagnosis and contemporary management of necrotizing pancreatitis. Am Surg. 2023;89:4817.
van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ,
Besselink MG, Boermeester MA, etal. Endoscopic or surgical step up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018;391(10115):51–8.
van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester
MA, Dejong CH, etal. A step-up approach or open necrosectomy
for necrotizing pancreatitis. N Engl J Med. 2010;362(16):1491–502.
Chronic Pancreatitis
ClaraZhu andYoungK.Hong
62
Way Question May BeAsked?
A 60-year-old male with a history of smoking comes to your
ofce with a known history of chronic pancreatitis. He has
constant and signicant abdominal pain, which he states is
impairing his quality of life. He has undergone a CT scan,
which demonstrates diffuse pancreatic calcications without
a visible mass.
How toAnswer?
Full History
• Frequency of abdominal pain
• Length of pain episodes
• Tolerance of food
• Quality of stool
• Recent weight loss
• Family history of cancer
• History of smoking
• History of alcohol use
Full Physical Examination
• Vital signs
– Cachexia
• Temporal wasting (signs of malnutrition)
• Abdominal exam
• Scleral icterus
• Jaundice
• CT scan in work-up of differential diagnosis. CT can
demonstrate characteristic ndings of chronic pancreatitis, e.g., calcications, pancreatic duct dilation, heterogeneity of parenchyma
• MRCP to evaluate for ductal characteristics, including
diameter and pancreas divisum. Diameter determines the
feasibility of a drainage operation
Surgical Procedure
• IR evaluation—celiac plexus block for pain, although this
procedure must be repeated every several weeks
• Consider rst-line endoscopic drainage—ERCP with
sphincterotomy—if pancreatic divisum is the underlying
cause of chronic pancreatitis
• Surgical approach to be considered after failure of symptom relief after nonoperative management, obstruction, or
variceal bleeding
• Puestow operation—lateral pancreaticojejunostomy for
ductal dilation (ductal decompression)
• Beger operation—subtotal pancreatic head resection with
duodenal preservation (resection of diseased tissue)
• Frey procedure—coring out of the pancreatic head with
lateral pancreaticojejunostomy (ductal decompression
with resection of diseased tissue)
Common Curveballs
Diagnostic Tests
• Labs including CBC, BMP, lipase, amylase, albumin,
prealbumin
C. Zhu · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: Zhu-clara@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_62
• Lack of interventional GI availability
• Recurrent symptoms after standard operations. Patients
should be considered for total pancreatectomy, though
this will cause signicant morbidity, including brittle
diabetes
193
194
C. Zhu and Y. K. Hong
Clean Kills
• Forgetting to order imaging
• Failing to consider endoscopic interventions before
surgery
• Not ordering testing to elucidate the underlying etiology
of chronic pancreatitis
• Choosing drainage operations for a nondilated pancreatic
duct
Words ofWisdom
Chronic pancreatitis is an irreversible disease of the pancreatic parenchyma that can progress to diabetes, weight loss
from malabsorption, and pancreatic malignancy.
Radiographic tests can indicate whether there is tissue in
need of resection, drainage, or both. Patients who have recurrent symptoms after standard operations for chronic pancreatitis should be considered for a total pancreatectomy.
Pancreatic Cancer
ClaraZhu andYoungK.Hong
63
Way Question May BeAsked?
A 60-year-old male presents to the emergency room with
painless jaundice and weight loss over the last month. A CT
scan performed identied a pancreatic mass. You are consulted to evaluate the patient.
How toAnswer?
Full History
• Constitutional symptoms (fatigue, weight loss)
• Abdominal pain
• Nausea/vomiting
• Pruritus
• Medical history
• Assessment of functional status
• Cancer history
• Substance use history (ETOH, smoking)
• Family history
Full Physical Examination
• Abdominal exam
• Lymph node exam
• Assessment of patient’s functional status
Diagnostic Tests
• Laboratory studies, including LFTs, CBC, and lipase
– Serum bilirubin, alkaline phosphatase, liver enzymes
• Staging evaluation
– Tumor markers (CEA, CA 19-9 [most sensitive, but
falsely elevated with hyperbilirubinemia])
– CT with triple-phase contrast pancreatic protocol
– CT chest for evaluation of metastatic disease
C. Zhu · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: Zhu-clara@cooperhealth.edu;
Hong-young@cooperhealth.edu
– ERCP/EUS for endoscopic assessment and biopsy
Stent placement can be performed if there is concern for obstructive jaundice
– Staging laparoscopy (Controversial)
Surgical Management
Resectable Disease → No vascular abutment or less than
180° of PV/SMV
Borderline Resectable → Pancreatic head disease: less
than 180° abutment of SMV or Celiac artery→Neoadjuvant
chemotherapy
Unresectable disease or metastatic disease → Locally
advanced with greater than 180° encasement of SMA,
encasement of the celiac axis and/or aorta→Denitive systemic therapy
Key Steps for Whipple’s Procedure
1. Full abdominal exploration to evaluate for resectability
2. Clockwise rotation:
(a) Cattell–Braasch maneuver
(b) Identication of intrapancreatic superior mesenteric
vein (SMV)
(c) Extended Kocher maneuver
(d) Portal dissection
(e) Ligation of gastroduodenal artery (GDA)
(f) Cholecystectomy
(g) Transaction of common hepatic duct proximal to cys-
tic duct
(h) Transect distal stomach
(i) Transect jejunum distal to LOT
(j) Transect pancreas at the level of the portal vein with
frozen margin
3. Counterclockwise reconstruction:
(a) End-to-side pancreaticojejunostomy (PJ) in two lay-
ers over pediatric feeding tube as a stent
(b) End-to-side choledochojejunostomy
(c) End-to-side gastrojejunostomy
© 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_63
195
196
C. Zhu and Y. K. Hong
Braun jejunojejunostomy to reduce risk of bile
reux
(d) Drain placement at PJ anastomosis
Common Curveballs
The patient’s functional status should be taken into consideration before offering surgery.
• Those with limited ECOG status should be considered for
denitive chemoradiation therapy
• Intraoperative discovery of metastatic disease in
obstructed biliary tree
Borderline resectable disease → Neoadjuvant therapy
FOLLOWED by restaging.
Distal pancreatectomy/splenectomy is an option for a dis-
ease of the pancreatic body/tail.
Explain the course of replaced hepatic arteries.
Surgical complications
• Anastomotic leak
• Pancreatic leak at PJ→Management options if a leak is
high output
• Delayed gastric emptying
• Marginal ulcer management
• Chyle leak
What to do in the setting of metastatic disease (be able to
describe palliative bypass procedures).
Clean Kills
• Inadequate staging workup
• Lack of understanding of anatomic resectability
• Never operate with very elevated serum bilirubin→Biliary stent before surgery to reduce the risk of
cholestatic liver failure
Words ofWisdom
Pancreatic cancer is a deadly disease, but surgical resection
with perioperative chemotherapy offers a meaningful survival benet for patients with resectable disease. It is essential to understand the criteria for resectability, as well as
complications that can occur in the postoperative setting.