Download MBBS Surgery Presentations 14 Common Bile Duct Stones Stricture Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 14 Common Bile Duct Stones Stricture PPT-Powerpoint Presentations and lecture notes


CBD Stones, Stricture

Carcinoma Gal Bladder

Cholangiocarcinoma


Common Bile Duct Stones
(Choledocholithiasis)
? May be small or large

? Single or multiple

? Found in 6 to 12% of patients with stones in the gallbladder

? Incidence increases with age

? Secondary stones:

? Formed within the gallbladder and migrate down the cystic

duct to the common bile duct

? Cholesterol stones

? Primary stones : form in the bile ducts

? Brown pigment type

? Associated with biliary stasis and infection

Clinical Manifestations

? Silent and often are discovered incidentally

? May cause obstruction, complete or incomplete

? Cholangitis or gallstone pancreatitis

? Pain

? Mild epigastric or right upper quadrant tenderness
Clinical Manifestations

? Mild icterus

? Symptoms may also be intermittent

? Elevation of serum bilirubin, alkaline phosphatase, and

transaminases are commonly seen in patients with

bile duct stones

? However, in about one third of patients with common

bile duct stones, the liver chemistries are normal

Diagnosis

Investigation

Sensitivity

Specificity

US

25-82%

56-100%

EUS

95 %

95-98 %

MRCP

95 %

97 %

CT

87 %

97 %


Ultrasound shows a normal or mildly dilated common bile

duct with a stone

ERCP shows multiple stones in the common bile duct
? Dilated CBD (>8 mm in diameter) on ultrasonography

in a patient with gallstones, jaundice, and biliary pain is

highly suggestive

? Magnetic resonance cholangiography (MRC) provides

excellent anatomic detail

? Endoscopic cholangiography is the gold standard for

diagnosing common bile duct stones.

Management Options? CBD Stones

? Open cholecystectomy + CBD exploration

? ERCP + Endoscopic Sphincterotomy (followed by

cholecystectomy ? most frequently used).

? Laparoscopic cholecystectomy + Laparoscopic CBD exploration

? in specialized centers.

? Choledochoscopy at laparoscopy or percutaneous

choleydochoscopy or choleydochoscopy through T tube.
? ERCP has become a popular technique to clear CBD stones.

? Currently in the laparoscopic era studies have shown that

laparoscopic treatment of CBD stones is possible and is

potential y as effective as ERCP.

? This is most commonly done by a transcystic approach,

though evidence of success in large volume cohorts with a

more technical y demanding laparoscopic Choledochotomy

is emerging .

Common Bile Duct Stricture
Causes

? operative injury MC by lap. cholecystectomy
? fibrosis due to:

?chronic pancreatitis
?common bile duct stones
?acute cholangitis

biliary obstruction:

? cholecystolithiasis (Mirizzi's syndrome)
? sclerosing cholangitis
? Cholangiohepatitis
? strictures of a biliary-enteric anastomosis

Clinical presentation

? Episodes of cholangitis

? Jaundice

? Liver function tests usually show evidence of

cholestasis


Diagnosis

? Ultrasound / CT scan will show dilated bile ducts

proximal to the stricture

? MRC : anatomic information about the location

and the degree of dilatation

? Endoscopic cholangiogram will outline the distal

bile duct

ERC showing stricture of the common hepatic duct
Management

Depends on the location and the cause of the stricture

? Percutaneous or endoscopic dilatation and/or stent placement

give good results in more than one half of patients

? Surgery with Roux-en-Y choledochojejunostomy or

hepaticojejunostomy is the standard of care with good or

excellent results in 80 to 90% of patients

? Choledochoduodenostomy may be a choice for strictures in the

distal-most part of the common bile duct

Carcinoma Gal bladder
Etiology

? Accounts for 2 to 4% of malignant GI tumors
? 2-3 times more common in females than males
? 90% of patients have gallstones
? Larger stones (3 cm) are associated with tenfold

increased risk of cancer

? Polypoid lesions of the gallbladder (>10 mm)
? Calcified "porcelain" gallbladder >20% incidence

? Choledochal cysts
? Sclerosing cholangitis
? Anomalous pancreaticobiliary duct junction
? Exposure to carcinogens (azotoluene, nitrosamines)
Pathology

? 80 and 90% of the tumors are adenocarcinomas

? papillary, nodular, and tubular

Squamous cell

Adenosquamous

Oat cell

Cancer of the gallbladder spreads through:

? lymphatics

? venous drainage

? direct invasion into the liver parenchyma
Clinical Manifestation

? Abdominal discomfort

? Right upper quadrant pain

? Nausea & vomiting

? Jaundice

? Weight loss

? Anorexia

? Ascites

? Abdominal mass

Diagnosis

? FNAC /Biopsy (guided)

? Ultrasonography

? CT scan

? Percutaneous transhepatic or endoscopic cholangiogram

(in jaundiced pt)

? MRCP


CT scan of a patient with gal bladder cancer


Staging:

(AJCC 7th Edition)

Treatment

? Surgery :

? Radical Cholecystectomy, Liver resection with

regional lymphadenectomy

? Radiotherapy

? Adjuvant (pT1b onwards)

? Chemotherapy

? Concurrent
? Adjuvant
? Palliative
Prognosis

? 5-year survival rate of al patients <less than 5%

? Median survival: 6 months

? T1 disease treated with cholecystectomy have an excel ent prognosis

(85 - 100% 5-year survival rate)

? 5-year survival rate for T2 lesions treated with an extended

cholecystectomy and lymphadenectomy compared with simple

cholecystectomy is over 70% versus 25 to 40%, respectively

? Patients with advanced but resectable gal bladder cancer are

reported to have 5-year survival rates of 20 to 50%

? Median survival for patients with distant metastasis at the time of

presentation is only 1 to 3 months

Cholangiocarci

noma
? Rare tumor arising from the biliary epithelium

? May occur anywhere along the biliary tree

? About 2/3rd are located at the hepatic duct bifurcation

? Male to female ratio is 1.3:1

? Average age of presentation is between 50 to 70 years

Etiology

Ulcerative Colitis

Thorotrast Exposure

Sclerosing Cholangitis

Typhoid Carrier

Choledochal Cysts

Adult Polycystic Kidney

Disease

Hepatolithiasis

Liver Flukes

Papil omatosis of Bile Ducts
Distribution

? Right or left hepatic duct = 10%

? Bifurcation = 20%

? Proximal CBD = 30%

? Distal CBD = 30%

Pathology

? Over 95% of bile duct cancers are adenocarcinomas.

? Anatomical y they are divided into distal, proximal, or

perihilar tumors.

? Intrahepatic cholangiocarcinomas are treated like

hepatocel ular carcinoma, with hepatectomy when

possible.

? About two-thirds of cholangiocarcinomas are located

in the perihilar location

? Perihilar cholangiocarcinomas, also referred to as

Klatskin tumors, are further classified based on

anatomic location by the Bismuth-Corlette

classification


Bismuth-Corlette classification

? Type I: confined to the common hepatic duct

? Type II: involve the bifurcation without involvement

of the secondary intrahepatic ducts

? Type II A &I IB: extend into the right and left

secondary intrahepatic ducts, respectively

? Type IV: involve both the right and left secondary

intrahepatic ducts


Clinical Presentation

? Painless jaundice
? Pruritus
? Mild right upper quadrant pain
? Anorexia
? Fatigue
? Weight loss
? Cholangitis
? Elevated ALK PO4 and GGT levels

Intra and Extra-hepatic Cholangiocarcinoma


Diagnosis

? Ultrasound abdomen
? CT scan
? Cholangiography : biliary anatomy is defined
? PTC
Defines the proximal extent of the tumor, which is the most

important factor in determining resectability.
? ERC: evaluation of distal bile duct tumors
? Celiac angiography: evaluation of vascular involvement
? MRI: has the potential of evaluating the biliary anatomy,

lymph nodes, vascular involvement, tumor growth

ERCP: Distal CBD Cancer


MRCP of Extra-hepatic Cholangiocarcinoma at the Bifurcation

Klatskin tumor

Treatment

? Surgical excision is the only potentially

curative treatment

? Location and local extension of the tumor

dictates the extent of the resection
Bismuth-Corlette type I or II with no signs of

vascular involvement:
? local tumor excision with portal lymphadenectomy,

cholecystectomy, common bile duct excision, and

bilateral Roux-en-Y hepaticojejunostomies

Bismuth-Corlette type II a or II b:
? right or left hepatic lobectomy respectively should

also be performed

Distal bile duct tumors:
? pylorus-preserving pancreatoduodenectomy

(Whipple procedure)

Unresectable distal bile duct cancer:
? Roux-en-Y hepaticojejunostomy, cholecystectomy

and gastrojejunostomy


Roux-en-Y Hepaticojejunostomy

Cholangiocarcinoma

Extra-hepatic Disease: Positive Margins or

Unresectable

? Stent and Chemo/Radiation Therapy

? 5-FU based or Gemcitabine or Clinical Trial

? Survival with surgery and chemo/radiation is 24 to

36 m

? With chemo/radiation alone survival is 12 to 18 m.
Cholangiocarcinoma

Extra-hepatic Disease: Unstentable

? Bypass if possible
? If not use proximal decompression and

feeding jejunostomy

? Chemotherapy/Radiation

Therapy/Brachy therapy as tolerated or

clinical trial.

Prognosis

? Best Result are with distal CBD tumors completely excised.

Cure = 40%

? Incomplete resection plus radiation gives a median

survival of 30 m.

? Stenting plus chemo/radiation gives a median survival of

17 to 27m

? Those stented alone live only a few months

This post was last modified on 08 April 2022