Surgical Management of Benign and Malignant conditions of Biliary Tree

1. 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

2. CHOLECYSTITIS • Acute cholecystitis • Achalculouscholecystitis • Gangrenous cholecystitis • Emphysematous cholecystitis Imaging: US Treatment options: • Antibiotics • Cholecystectomy • Percutaneous cholecystotomy tube

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

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

5. 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. GastrointestEndosc. 71 (1):1-9 2010

6. CHOLEDOCOLITHIASIS Imaging Ultrasound • 1st 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

7. CHOLEDOCOLITHIASIS ERCP • ? Therapeutic more than diagnostic? EUS • Comparable efficacy to ERCP but ? less complication I.O.C • Routine Vs selective

8. CHOLEDOCOLITHIASIS Treatment approaches • ERCP • PTC • CBDE

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

10. 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 CollSurg 180: 101-125 William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

11. 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

12. 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

13. 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

14. BILE DUCT INJURY Hold on a second! How can suspect Mirizzi syndrome?? • Long standing gallstone disease • Contracted gallbladder • Jaundice or cholangitis

15. 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

16. 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

17. BILE DUCT INJURY Injury recognized postoperatively • Control bile leak • Drain fluid collection • Treat infection • Volume resuscitation • Electrolyte replacement • Delayed repair

18. 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

19. 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 %

20. 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

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

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

23. EXTRA-HEPATIC CHOLANGIOCARCINOMA Risk factors • Primary sclerosing cholangitis • Bile duct cysts • Biliary parasites; Clonorchissinensis, Opisthorchisviverrini • ?? sphincterotomy

24. 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

25. EXTRA-HEPATIC CHOLANGIOCARCINOMA Presentation • Jaundice and pruritus • Abnormal LFT • Non specific symptoms and weight loss

26. 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

27. EXTRA-HEPATIC CHOLANGIOCARCINOMA • Perihilarcholangiocarcinoma - Classification William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

28. EXTRA-HEPATIC CHOLANGIOCARCINOMA • Perihilarcholangiocarcinoma – Work up - CT - MRCP - ERCP - PTC Tissue diagnosis is not required in patient with potentially resectable

29. EXTRA-HEPATIC CHOLANGIOCARCINOMA • Perihilarcholangiocarcinoma – 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)