Hepato-Biliary Surgery

U/S (biliary tree) 🏆, CT/MRI (good details of small soft tissues), Nuclear Med (PET, T99, metabolic functions of masses), Angiography, Biopsies under CT/US guidance or intraoperatively

Imaging modalities of the Liver

LIVER (SHE’S A BIG GIRLIE)

What is most commonly injured solid organ in blunt trauma?

Non-Op!

What is the prevailing therapeutic strategy for blunt hepatic trauma?

abdominal distention, pain, tenderness on exam, intolerance of enteral feeding, abnormal LFTs (very common initially - good to follow trends)

Presentation of liver blunt force trauma

Biliary fistula (most common), Arterial pseudoaneurysms (potential for rupture - manage with hepatic arteriography and embolization), Pneumobilia (air in the tree - rare 🫢), Bilomas (loculated collections of bile), Abscess (usually penetrating)

Complications of liver trauma

intermittent episodes of RUQ, upper GI hemorrhage, jaundice

Presentation for arterial pseudoaneurysms

Liberal use of U/S, ERCP and sphincterotomy (MAJOR leaks)

Work up for Liver injury complications

Hepatic Cyst (simple, polycystic liver disease), Hemangioma, Hepatic adenoma, Focal nodular hyperplasia (FNH)

Benign liver masses

Hepatocellular carcinoma (HCC), metastatic

Malignant liver masses

Simple Hepatic Cyst

Which type of cyst presents as a smooth, contoured anechoic lesion with a well-defined interface between tissue and fluid (most common) - if concerned, get a biopsy

Echinococcosis (Hydatid)

A liver cysts that occurs as a results of parasite exposure

Cystadenoma

A liver cyst that is complex, has internal septae, irregular lining, and papillary projections - resect these hoes

Autosomal dominant gene mutation - progressive conditions

Etiology for polycystic liver disease

Cyst fenestration (less than 10 cyst 10 cm+), transplant for type III PLD

Treatment plan for Polycystic liver disease

Hepatic Hemangioma

The most common liver tumor that is more common in males and is characterized by congenital vascular malformations, often found incidentally on MRI

Observation unless there is severe pain, compressive symptoms, hemorrhage, or uncertain of diagnosis

Treatment for hepatic hemangioma

OCPs, androgen steroid use

Risk factors for hepatocellular adenoma

Observation (if less than 3), Resect with complete clear margins (5 cm+, rapid growth, tumors suspicious for malignant transformation)

Treatment for hepatic adenoma

Focal nodular hyperplasia (FNH - manage non-op)

A liver tumor most commonly found in females in their 30-50s that is characterized by benign hepatocellular hyperplasia and nodules with fibrous septations (HOT lesions)

HBV, HCV, EOH, nonalcoholic steatohepatitis, aflatoxin B1 exposure, A1-antitrypsin deficiency, hemochromatosis, primary biliary cirrhosis

Risk factors for HCC

U/S with AFP every 6 months, high resolution CT or MRI, Biopsy 🏆

Diagnostics for HCC

Surgical resection, transplant, ablation; Palliative (TACE, TARE, SBRT, Sorafenib)

Treatment for HCC

Colon cancer (known as colorectal liver metastasis CRLM)

What type of cancer likes to metastasize to the liver?

CT, MRI, PET/CT

Diagnosis of CRLM

surgical resection is potentially curative BUT there are multiple prognostic factors

Treatment of CRLM

infectious, substance induced (tylenol is 🥇), post-op, miscellaneous (metabolic, vascular, autoimmune)

4 major causes of acute liver failure

Fulminant hepatic failure (FHF)

Acute liver failure that is complicated by encephalopathy within 2 weeks of the onset of jaundice

CBC, CMP, Coags, tox screen, sepsis workup, blood and urine cultures, ascitic fluid collection if necessary, Serologic testing for hepatitis, CXR, MRI (encephalopathy), Liver biopsy

Acute liver failure workup

Serial physical exams (monitor for worsening), Resection (if normal function 80% can be removed)

Game plan for acute liver failure

Child Pugh, MELD score

Acute Liver failure scores

chronic liver disease

A long standing ongoing liver injury

Portal Hypertension (PHT)

Increased resistance to portal venous blood flow within the liver - associated with ascites, esophageal varices, hemorrhoids, caput medusa, jaundice, encephalopathy

PT/INR

Important labs to order for chronic liver disease

admit + resuscitation + nutritional support; TIPSS (Shunt between liver inflow and outflow), beta blocker prophylaxis, lactulose to prevent encephalopathy, stop dranking

Treatment for chronic liver disease

Budd Chiari Syndrome

An unusual cause of acute liver failure that is characterized by acute hepatic vein thrombosis - most common in women in a hypercoagulable state

Acute RUQ pain, hepatomegaly, ascites

Budd-Chiari Syndrome triad

U/S, CT

Workup for Budd-Chiari Syndrome

Anticoags, TIPS or other portosystemic shunt, portal decompression of done before massive hepatic necrosis

Treatment for Budd-Chiari Syndrome

Gallbladder wall thickening (3 mm+), pericholecystic fluid, Sonographic murphy sign, it is important to measure the common bile duct!!

Things to look for on U/S for gallbladder stuff 🏆

ERCP

Which type of imaging allows for diagnosis AND treatment

Cholescintigraphy (HIDA, radionuclide scan - use when U/S is limited or inconclusive, shows the functionality of the gallbladder)

What is the most sensitive and specific study to diagnose acute cholecystitis?

Age, female, obesity, parity, Mexican and Native american groups (LTH gene)

Major Risk factors for Gallstones 4Fs

cholesterol (80%), Pigment (hemolysis - calcium billirubinate)

What is the make up of gall stones?

U/S 🏆, MRCP (if intermediate risk for choledochlithiasis), LFTs (if previous episodes with hyperbilirubinemia)

44 y/o women presents to the ED for RUQ pain that comes and goes. She states that it worsens after greasy meals and that this has happened multiple times. Vitals are stable. What do you want to order

Cholecystectomy (any symptomatic), Non-op (RARE - UCDA, ESWL)

Treatment for chronic Cholecystitis

CBC (leukocytosis) ALP, LFTs, bilirubin, U/S 🏆, HIDA (most sensitive and specific)

42 y/o female presents to the ED for sharp, RUQ that started about 1 hour ago and has NOT stop. She also reports N/V. Vitals are stable with the exception of a 102.3 temp. On physical exam you note a positive Murphy’s sign. What do you want to order?

NPO, IV hydration, broad spectrum Abx (cover gram - and anaerobes), NG tube (if severe N/V), Laparoscopic Cholecystectomy (Within 72 hours of symptoms - definitive), PCT (for homies non op, elective cholecystectomy at a later date)

Treatment for acute cholecystitis

Critically Ill patients (trauma, large surface burns, long term parenteral nutrition, major ops)

Acalculous cholecystitis is more common in…

biliary stasis, ischemia, TPN, E.coli, CMV, EBV, Salmonellosis brucellosis

Etiology for Acalculous cholecystitis

gangrene (most common), perforation, gallbladder empyema

Complications of Acalculous cholecystitis

Early laparoscopic cholecystectomy, cholecystomy tube (poor surgical homies)

Treatment plan for Acalculous cholecystitis

gallstones that originate from the biliary tree (brown stones - primary), Gallstones migrate into the CBD from the gallbladder (secondary)

Etiology of Choledocholithiasis

Abdominal pain that radiates to the back, jaundice, Nausea, acholic stools, dark urine

Symptoms for Choledocholithiasis

RUQ pain, fever, jaundice

What is Charcot’s triad (Cholangitis)?

pancreatitis

Complications of Choledocholithiasis

Leukocytosis, Serum bilirubin rise (🥇), ALP, LFTs

Lab findings in Choledocholithiasis

U/S (dilation of the duct 10mm+), ERCP (diagnostic AND therapeutic) MRCP

Imaging for Choledocholithiasis

ERCP and Systemic Abx→ Lap cholecystectomy (if mild cholangitis and stones)

Treatment for Choledocholithiasis

55+, bilirubin 1.7+, common duct dilation 6mm+, visible stone on US

High risk patients of Choledocholithiasis

Cholangitis

A bacterial infection of the biliary ducts that ALWAYS signifies an obstruction

Choledocholithiasis, biliary stricture, neoplasm, chronic pancreatitis, ampullary stenosis, pancreatic pseudocyst, duodenal diverticulum, congenital cyst, parasitic invasion

Primary causes of Cholangitis

Fever, hypotension, jaundice, RUQ pain, AMS

Reynold’s Pentad for Cholangitis

Leukocytosis, Elevated serum bilirubin, ALP, blood cultures (look for E.coli, Kleb, Pseudo, enterococci, proteus), Abd U/S 🏆,

Diagnostics for Cholangitis

IV abx (cipro + metro) → ERCP; IF severe transhepatic drainage (decompress the bile duct) or ERCP (if severe or unremitting)

Treatment plan for Cholangitis

Symptomatic cholelithiasis, cholecystitis, cholangitis, cholangiocarcinoma

Indications for cholecystectomy

Laparoscopic (10 mm umbilical port, insufflate abdomen with CO2, 2-3 more 5 mm ports for instrument), Robotic, Open (Kocher’s incision in RUQ)

Technique for Cholecystectomy

Bleeding, Injury to surrounding structures, retained common bile duct stones (seen on IOC), infection, bile leak, incisional hernia, stricture (may progress to multiple intrahepatic abscess and death)

Complications of Cholecystectomy

Percutaneous gallbladder drainage (Call IR - if no improvement in 24-48hrs, check placement with contrast)

If a patient is a poor surgical candidate for cholecystectomy, what’s the back up plan?

enough tissue has been dissected that you can see the cystic duct and artery, and lower 1/3 of the liver

Critical view of safety

NPO initially then advance diet as tolerate, serial CBCs (check for leukocytosis), serial BMPs (monitor electrolytes), IV abx (until afebrile and leukocytosis), LMWH (DVT prophylaxis), early ambulation, Control pain, IS/deep

Follow up plan for cholecystectomy

Follow up in 1 week, eval incisions/healing and review the path report; normal activirt in 6-8 weeks

Discharge Criteria POST cholecystectomy