Surgical Management of Benign and Malignant conditions of Biliary Tree

Houssam G. Osman, M.D.

HPB surgery Associate Director, HPB Fellowship Methodist Dallas Medical Center, Dallas ACOS: In-Depth Review - 2014 Kansas city, MO

CHOLECYSTITIS     Acute cholecystitis Achalculous cholecystitis Gangrenous cholecystitis Emphysematous cholecystitis Imaging: US Treatment options:  Antibiotics  Cholecystectomy  Percutaneous cholecystotomy tube

CHOLEDOCHOLITHIASIS • Secondary 85% • Primary 15% - benign biliary strictures - sclerosing cholangitis - choledochal cysts. - parasitic infections

CHOLEDOCHOLITHIASIS • • • • Conditions Painful jaundice Cholangitis Gallstone pancreatitis Silent CBD stone

CHOLEDOCHOLITHIASIS • Probability of CBD stone American Society of Gastrointestinal Endoscopy Standards of Practice Committee Maple JT, et al.: The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 71 (1):1-9 2010

CHOLEDOCOLITHIASIS Imaging • • • Ultrasound 1 st line Jaundice + CBD > 10 mm -> stone in 90% of cases Maybe able to visualize stone • • MRCP Most sensitive non invasive study (decreased sensitivity for stones < 5 mm) Intermediate probability or when ERCP is not feasible

CHOLEDOCOLITHIASIS • ERCP ? Therapeutic more than diagnostic?

• EUS Comparable efficacy to ERCP but ? less complication • I.O.C

Routine Vs selective

CHOLEDOCOLITHIASIS Treatment approaches  ERCP  PTC  CBDE

BILE DUCT INJURY • Incidence during open cholecystectomy 0.2 – 0.3 % • Incidence during laparoscopic cholecystectomy 0.3 – 0.6%

BILE DUCT INJURY

Causes of laparoscopic biliary injury

• • • • • • • • • Misidentification of the bile ducts as the cystic duct Misidentification of the CBD as the cystic duct Misidentification of the aberrant right sectoral hepatic duct as the cystic duct Improper techniques of ductal exploration Failure to occlude the cystic duct securely Plane of dissection away of gallbladder wall into liver bed Excessive retraction of cystic duct with tenting of CBD Injudicious use of electrocautery Injudicious use of clips Modified from Strasberg SM et al, 1995: An analysis of problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180: 101-125 William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

BILE DUCT INJURY

Classification of laparoscopic biliary injury

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

BILE DUCT INJURY

Injury recognized at time of surgery

• • • Stop!

Consider your expertise and ask for help Leave a drain and transfer to HPB surgeon • • • • What is HPB surgeon going to do?

Quick return to OR - open approach (likely) Identify injury and assess concomitant vascular injury Cholangiogram Repair: -Roux en Y hepatojejunostomy -Direct repair over T tube

BILE DUCT INJURY You are doing a tough laparoscopic cholecystectomy and suspect Mirizzi syndrome, what do you do?

 Proceed with subtotal cholecystectomy Or  Place cholecystotomy tube

BILE DUCT INJURY Hold on a second! How can suspect Mirizzi syndrome??

• • • Long standing gallstone disease Contracted gallbladder Jaundice or cholangitis

BILE DUCT INJURY You are doing a tough laparoscopic cholecystectomy and suspect Mirizzi syndrome and you perform partial cholecystectomy. You encounter a gush of bile! what is going on?

• Mirizzi syndrome type 2: cholecystocholedochal fistula What do you do?

• • Cholecystocholedochoduodenostomy, or Hepatojejunostomy William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

BILE DUCT INJURY

Injury recognized postoperatively

• • • Bile leak Biloma and infection Juandice • • • • Workup ERCP - diagnostic and therapeutic MRCP CT – assess vascular injury and fluid collection PTC if needed

BILE DUCT INJURY

Injury recognized postoperatively

 Control bile leak  Drain fluid collection  Treat infection  Volume resuscitation  Electrolyte replacement  Delayed repair

BILE DUCT CYST

Classification

Chijiiwa K, Koga A: Surgical management and long-term follow-up of patients with choledochal cysts. Am J Surg 165:238-242, 1993

BILE DUCT CYST

Presentation – Adulthood

• • • • • Asymptomatic (majority) Biliary colic like symptoms and mild jaundice Pancreatitis Liver cirrhosis Malignancy ( weight loss) Incidence of malignancy 2.5 – 28 %

BILE DUCT CYST

Treatment

 Type I : Excision + Roux en Y hepatojejunostomy vs. hepatoduodenostomy  Type II: Excision  Type III: Trans-duodenal excision vs. endoscopic sphinterotomy  Type IV A: Bile duct and hepatic resection and hepatojejunostomy  Type IV B: Excision + Roux en Y hepatojejunostomy vs. hepatoduodenostomy +/- sphincteroplasty  Type V: Liver resection vs. transplant

Cyst excision does not eliminate risk of malignancy

PRIMARY SCLEROSING CHOLANGITIS • • Associated with IBD mainly UC Risk of cholangiocarcionoma 1% per year • • • Presentation Asymptomatic Liver cirrhosis Cholangitis – uncommon

PRIMARY SCLEROSING CHOLANGITIS • • Diagnosis Cholangiography / MRCP Multifocal strictures Treatment  Asymptomatic : Observe  Stricture : ERCP vs resection  Liver cirrhosis: Transplant  Cholangiocarcinoma: Resection

EXTRA-HEPATIC CHOLANGIOCARCINOMA

Risk factors

• • • • Primary sclerosing cholangitis Bile duct cysts Biliary parasites; Clonorchis sinensis, Opisthorchis viverrini ?? sphincterotomy

EXTRA-HEPATIC CHOLANGIOCARCINOMA

Classification

• • Perihilar Mid bile duct - hepatic confluence to cystic duct - rare • Distal bile ducy - distal to cystic duct confluence William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

EXTRA-HEPATIC CHOLANGIOCARCINOMA

Presentation

• • • Jaundice and pruritus Abnormal LFT Non specific symptoms and weight loss

EXTRA-HEPATIC CHOLANGIOCARCINOMA 

Distal cholangiocarcinoma

- treat like periampullary tumor - whipple 

Mid duct cholangiocarcinoma

- very rare - ? Gallbladder / cystic duct base cancer - bile duct resection and cholecystectomy - assess need to treat like GB cancer; segment 4,5 liver resection

EXTRA-HEPATIC CHOLANGIOCARCINOMA 

Perihilar cholangiocarcinoma - Classification

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

EXTRA-HEPATIC CHOLANGIOCARCINOMA 

Perihilar cholangiocarcinoma – Work up

- CT - MRCP - ERCP - PTC

Tissue diagnosis is not required in patient with potentially resectable

EXTRA-HEPATIC CHOLANGIOCARCINOMA 

Perihilar cholangiocarcinoma – Treatment

 Resectable - bile duct resection - achieving R0 resection almost always require partial hepatectomy - hepatojejunostomy - adjuvant treatment  Unresectable - palliative transplant in selected cases preceded by neoadjuvanet chemotherapy (Mayo clinic)