surg2

WILLIAM L. OLALIA, M.D., FPCS, FPSGSAssociation Professor, Department of Surgery

UST Faculty of Medicine & Surgery

Anatomy & PhysiologyAnatomy & Physiology Gallstone formationGallstone formation

– Types of stonesTypes of stones Diagnostic StudiesDiagnostic Studies Gallstone DiseaseGallstone Disease

– Natural historyNatural history– ComplicationsComplications

Acute/chronic cholecystitisAcute/chronic cholecystitis CholedocholithiasisCholedocholithiasis CholangitisCholangitis Biliary pancreatitisBiliary pancreatitis

Operative interventionsOperative interventions

AnatomyAnatomy

GallbladderGallbladder Bile ductsBile ducts ArteriesArteries

N.B. Anatomical variations N.B. Anatomical variations commoncommon

AnatomyAnatomy

AnatomyAnatomy

Gall BladderGall Bladder – pear-shaped sac in the fossa of pear-shaped sac in the fossa of

the liverthe liver– 7-10 cms long7-10 cms long– 30-50 ml average capacity 30-50 ml average capacity – divides the liver into right and divides the liver into right and

left left lobeslobes

AnatomyAnatomy

Blood supply of the gall bladderBlood supply of the gall bladder

cystic arterycystic artery – a branch of the – a branch of the right right hepatic artery in 90% hepatic artery in 90% of casesof cases

AnatomyAnatomy

The bile ductsThe bile ductsExtrahepatic ductsExtrahepatic ducts

right and left hepatic ductsright and left hepatic ductscommon hepatic ductcommon hepatic ductcystic ductcystic ductcommon bile ductcommon bile duct

* The arterial supply to the bile ducts is * The arterial supply to the bile ducts is from the from the Gastroduodenal and Right Gastroduodenal and Right Hepatic ArteriesHepatic Arteries

AnatomyAnatomy

Common hepatic ductCommon hepatic duct

- 1 to 4 cms length - 1 to 4 cms length

- approx. 4 mm diameter- approx. 4 mm diameter

N.B.: the common hepatic duct is N.B.: the common hepatic duct is joined at an acute angle by the joined at an acute angle by the cystic duct to form the cystic duct to form the common common bile ductbile duct

AnatomyAnatomy

Cystic duct Cystic duct – variable length variable length – contains contains spiral valves of spiral valves of

HeisterHeister

AnatomyAnatomy

Common bile ductCommon bile duct is about 7- 11 cm in is about 7- 11 cm in length and length and 5 to 10 mm5 to 10 mm in diameter in diameter

Ampulla of VaterAmpulla of Vater- opening of the - opening of the common bile duct into the duodenumcommon bile duct into the duodenum

Sphincter of Oddi-Sphincter of Oddi- surrounds the surrounds the common bile at the ampulla of vater common bile at the ampulla of vater

it controls bile flow it controls bile flow

AnatomyAnatomy

AnatomyAnatomy

Gallbladder

DUODENUM

CBD

stomach

pancreas

jejunum

PhysiologyPhysiology

Bile formation and CompositionBile formation and Composition 500- 1000 mL of bile/day500- 1000 mL of bile/day mainly composed of water, electrolytes, mainly composed of water, electrolytes,

bile salts, proteins, lipids, and bile bile salts, proteins, lipids, and bile pigmentspigments

Enterohepatic circulation (95% of bile Enterohepatic circulation (95% of bile acid pool)acid pool)

Digestion and absorption of fats in the Digestion and absorption of fats in the intestinesintestines

PhysiologyPhysiology

Gallbladder functionGallbladder function– Concentrate & store hepatic Concentrate & store hepatic

bilebile– Deliver bile into the duodenum Deliver bile into the duodenum

in response to a mealin response to a meal

Gallstone DiseaseGallstone Disease

One of the most common problems of One of the most common problems of the GIT (11-36%)the GIT (11-36%)

Predisposing factors:Predisposing factors:– age, gender, ethnic backgroundage, gender, ethnic background– obesity, pregnancy, dietobesity, pregnancy, diet– terminal ileal resection, gastric surgery, terminal ileal resection, gastric surgery,

hemolytic disordershemolytic disorders* * FemalesFemales are three times more likely are three times more likely

to to develop gallstonesdevelop gallstones* 4F’s (fat, female, fetus, family history)* 4F’s (fat, female, fetus, family history)

Gallstone formationGallstone formation

Dependent on the concentrations Dependent on the concentrations of :of :– Bile saltsBile salts– CholesterolCholesterol– LecithinLecithin

Gallstones form as a result of Gallstones form as a result of solid settling out of solutionsolid settling out of solution

Gallstone formationGallstone formation

Two major typesTwo major types– Cholesterol stones (80% of Cholesterol stones (80% of

cases) cases) – Pigment stones (15-20%)Pigment stones (15-20%)

Black pigment stones (hemolytic Black pigment stones (hemolytic disorders)disorders)

Brown pigment stones (bacterial Brown pigment stones (bacterial infection, parasites)infection, parasites)

Gallstone FormationGallstone Formation

Cholesterol stonesCholesterol stones– usually multiple, variable size, hard usually multiple, variable size, hard

and faceted or irregular, mulberry- and faceted or irregular, mulberry- shaped and soft. shaped and soft.

– supersaturation of bile with cholesterolsupersaturation of bile with cholesterol common primary event in the formation of common primary event in the formation of

cholesterol stonescholesterol stones caused by cholesterol hypersecretioncaused by cholesterol hypersecretion

Cholesterol Stones

Gallstone FormationGallstone Formation

Pigmented stonesPigmented stones

- small, brittle, black and - small, brittle, black and sometimes sometimes spiculatedspiculated

- formed by supersaturation of - formed by supersaturation of calcium calcium bilirubinate, carbonate bilirubinate, carbonate and and phosphatephosphate

- secondary to hemolytic disorders- secondary to hemolytic disorders

Pigmented StonesPigmented Stones

Gallstone DiseaseGallstone Disease

Most patients with gallstones will Most patients with gallstones will remain asymptomaticremain asymptomatic

About 3% become symptomatic About 3% become symptomatic per yearper year

3 to 5% of symptomatic patients 3 to 5% of symptomatic patients develop complicationsdevelop complications

Few patients develop Few patients develop complications without previous complications without previous biliary symptomsbiliary symptoms

Natural History

Diagnostic StudiesDiagnostic Studies

Ultrasound of Ultrasound of LGBPSLGBPS

Sensitivity and Sensitivity and specificity of over specificity of over 90%90%

Posterior acoustic Posterior acoustic shadowingshadowing Posterior

Acoustic shadow

Diagnostic StudiesDiagnostic Studies

Oral cholecystographyOral cholecystography– stones noted on film as filling stones noted on film as filling

defects defects– seldom utilized nowadaysseldom utilized nowadays

Biliary Radionuclide Scanning Biliary Radionuclide Scanning (HIDA Scan)(HIDA Scan)– acute cholecystitisacute cholecystitis– biliary leak after biliary surgery biliary leak after biliary surgery – non-visualized gall bladder with non-visualized gall bladder with

filling filling of the common duct and of the common duct and duodenumduodenum

– Specificity and Sensitivity is Specificity and Sensitivity is 95%95%

Diagnostic StudiesDiagnostic Studies

Diagnostic StudiesDiagnostic Studies

Endoscopic Endoscopic Retrograde Retrograde CholangiographyCholangiography

- both diagnostic and - both diagnostic and therapeutictherapeutic

- invasive- invasive

- direct visualization of - direct visualization of the ampullary region the ampullary region & distal CBD& distal CBD

- success rate 90%- success rate 90%

Diagnostic StudiesDiagnostic Studies

Endoscopic Retrograde Endoscopic Retrograde CholangiographyCholangiography

Success rate 90%Success rate 90% Complications:Complications:

- occur in 5% of cases- occur in 5% of cases

- pancreatitis - pancreatitis

- cholangitis- cholangitis

Diagnostic StudiesDiagnostic Studies

Computed Computed Tomography ( CT Tomography ( CT Scan)Scan)

- defines the course and - defines the course and status of the extra-status of the extra-hepatic biliary tree hepatic biliary tree and adjacent and adjacent structuresstructures

- - test of choice in test of choice in evaluating patients evaluating patients with suspected with suspected malignancy of biliary malignancy of biliary tree and pancreas tree and pancreas

cholecystitis

Diagnostic StudiesDiagnostic Studies

Percutaneous Percutaneous Transhepatic Transhepatic CholangiographyCholangiography– Intrahepatic bile Intrahepatic bile

duct is accessed duct is accessed percutaneously with percutaneously with a needle under a needle under fluoroscopyfluoroscopy

– It defines the biliary It defines the biliary tree proximal to the tree proximal to the affected segment affected segment

Diagnostic StudiesDiagnostic Studies

Magnetic Resonance Magnetic Resonance Cholangiopancrea-Cholangiopancrea-tographytography– Offers a single non Offers a single non

invasive test for the invasive test for the diagnosis of biliary diagnosis of biliary tract and pancreatic tract and pancreatic diseasedisease

– Sensitivity is 95%Sensitivity is 95%– Specificity is 89%Specificity is 89%

CBDPancreaticduct

Gallstone DiseaseGallstone Disease

Acute /chronic cholecystitisAcute /chronic cholecystitis CholedocholithiasisCholedocholithiasis CholangitisCholangitis Gallstone pancreatitisGallstone pancreatitis Biliary-enteric fistulae (gallstone Biliary-enteric fistulae (gallstone

ileus)ileus) Gallbladder carcinomaGallbladder carcinoma

Complications

Symptomatic Symptomatic GallstonesGallstones

Acute CholecystitisAcute Cholecystitis– secondary to gallstones in 90-secondary to gallstones in 90-

95%95%– initiated by obstruction of the initiated by obstruction of the

cystic duct by a stonecystic duct by a stone– Distention Distention inflammation/edema inflammation/edema

secondary bacterial infection secondary bacterial infection– Thickened gall bladder wall, Thickened gall bladder wall,

pericholecystic fluid on ultrasoundpericholecystic fluid on ultrasound

Symptomatic Symptomatic GallstonesGallstones Acute CholecystitisAcute Cholecystitis

– may progress to acute may progress to acute gangrenous cholecystitis, gangrenous cholecystitis, empyema, or emphysematous empyema, or emphysematous cholecystitischolecystitis

– Positive Murphy’s signPositive Murphy’s sign– Mild to moderate leukocytosis Mild to moderate leukocytosis

(12-15,000 wbc) (12-15,000 wbc)

Symptomatic Symptomatic GallstonesGallstones Acute CholecystitisAcute Cholecystitis

Diagnosis:Diagnosis:- Clinical profileClinical profile- UltrasonographyUltrasonography- Biliary radio nuclide scanning Biliary radio nuclide scanning (HIDA)(HIDA)

Symptomatic Symptomatic GallstonesGallstones

Acute CholecystitisAcute Cholecystitis

Treatment:Treatment:- Fluid resuscitationFluid resuscitation- Antibiotics VS gram (-) aerobes and Antibiotics VS gram (-) aerobes and

anaerobesanaerobes- AnalgesicsAnalgesics- Cholecystectomy is the definitive Cholecystectomy is the definitive

treatmenttreatment- Early cholecystectomy preferred over Early cholecystectomy preferred over

interval/delayed cholecystectomyinterval/delayed cholecystectomy

Symptomatic Symptomatic gallstonesgallstones

- gallbladder - gallbladder wall becomes wall becomes grossly grossly thickened and thickened and reddish with reddish with subserosal subserosal hemorrhages hemorrhages

Symptomatic Symptomatic GallstonesGallstones

Chronic CholecystitisChronic Cholecystitis– recurrent episodes of painrecurrent episodes of pain– pain due to pain due to stone obstructing the cystic stone obstructing the cystic

ductduct– pain in the epigastrium or RUQ area pain in the epigastrium or RUQ area

radiating to the backradiating to the back– pain associated with fatty/ heavy mealpain associated with fatty/ heavy meal– pathologic changes do not correlate well pathologic changes do not correlate well

with symptomswith symptoms– hydrops of the gallbladderhydrops of the gallbladder

Symptomatic Symptomatic GallstonesGallstones

Chronic CholecystitisChronic Cholecystitis

DiagnosisDiagnosis:: same as acute same as acute cholecystitischolecystitis

Symptomatic Symptomatic GallstonesGallstones Chronic CholecystitisChronic Cholecystitis

Treatment:Treatment:- elective open or laparoscopic - elective open or laparoscopic

cholecystectomy (relief in about cholecystectomy (relief in about 90%)90%)

- dietary advice while waiting for surgery- dietary advice while waiting for surgery

- diabetic patients should have - diabetic patients should have prompt prompt cholcystectomycholcystectomy

Symptomatic Symptomatic GallstonesGallstones CholedocholithiasisCholedocholithiasis

– Found in 6 to 12% with gallbladder stonesFound in 6 to 12% with gallbladder stones– 20-25% of patients > 60 years old with 20-25% of patients > 60 years old with

symptomatic gallstonessymptomatic gallstones– Majority are Majority are secondarysecondary stones stones– Primary CBD stones more common Primary CBD stones more common

among among asiansasians

Symptomatic Symptomatic GallstonesGallstones CholedocholithiasisCholedocholithiasis

Clinical Profile:Clinical Profile:– Maybe silent or asymptomaticMaybe silent or asymptomatic– Biliary colic just like in gallbladder stonesBiliary colic just like in gallbladder stones– Symptoms maybe intermittent (ball valve Symptoms maybe intermittent (ball valve

mechanisms) mechanisms) bilirubin, alkaline phosphatase & transaminasesbilirubin, alkaline phosphatase & transaminases– Impacted stone Impacted stone progressive jaundice progressive jaundice– Small stone may pass thru the ampulla Small stone may pass thru the ampulla

spontaneously spontaneously

Symptomatic Symptomatic GallstonesGallstones CholedocholithiasisCholedocholithiasis

Diagnosis:Diagnosis:– Ultrasonography: stones in the gallbladder, Ultrasonography: stones in the gallbladder,

dilated CBD (> 8mm)dilated CBD (> 8mm)– Biliary colic, jaundice, gallbladder stones on Biliary colic, jaundice, gallbladder stones on

ultrasoundultrasound– Magnetic Resonance Cholangiography (MRC) Magnetic Resonance Cholangiography (MRC)

95% & 89% sensitivity and specificity 95% & 89% sensitivity and specificity – ERCP – gold standard in diagnosing CBD ERCP – gold standard in diagnosing CBD

stones with therapeutic options stones with therapeutic options

Symptomatic Symptomatic GallstonesGallstones CholedocholithiasisCholedocholithiasis

Treatment:Treatment:Plan APlan A

pre-op endoscopic cholangiographypre-op endoscopic cholangiography

sphincterotomy + stone removalsphincterotomy + stone removal

laparoscopic cholecystectomylaparoscopic cholecystectomy

Symptomatic Symptomatic GallstonesGallstones

CholedocholithiasisCholedocholithiasis

Treatment:Treatment:Plan BPlan B

open cholecystectomy open cholecystectomy intraoperative cholangiogramintraoperative cholangiogram

open common bile duct explorationopen common bile duct exploration

t-tube placementt-tube placement

Symptomatic Symptomatic GallstonesGallstones

Acute CholangitisAcute Cholangitis– Ascending bacterial infection from bile Ascending bacterial infection from bile

duct obstructionduct obstruction– Stones, strictures, parasites, Stones, strictures, parasites,

instrumentationinstrumentation– Fever, abdominal pain & jaundice Fever, abdominal pain & jaundice

(Charcot’s triad)(Charcot’s triad)– May lead to septicemia and disorientation May lead to septicemia and disorientation

(Reynolds pentad)(Reynolds pentad)– Leukocytosis, increased bilirubin and Leukocytosis, increased bilirubin and

alkaline phosphatasealkaline phosphatase

Symptomatic Symptomatic GallstonesGallstones

Acute CholangitisAcute Cholangitis

Treatment:Treatment:– Fluid resuscitation, IV antibioticsFluid resuscitation, IV antibiotics– ERCP/PTC diagnostic/therapeuticERCP/PTC diagnostic/therapeutic– About 15% will require emergency biliary About 15% will require emergency biliary

decompression decompression ERCPERCP PTCPTC T-tube choledochostomy/cholecystostomyT-tube choledochostomy/cholecystostomy

– Definitive treatment done laterDefinitive treatment done later

Symptomatic Symptomatic GallstonesGallstones

Biliary PancreatitisBiliary Pancreatitis– Another complication of CBD stoneAnother complication of CBD stone– Obstruction of the pancreatic duct by Obstruction of the pancreatic duct by

an impacted stonean impacted stone– Temporary obstruction by a stone Temporary obstruction by a stone

passing thru the ampulla passing thru the ampulla – Ultrasound of biliary tree essential in Ultrasound of biliary tree essential in

patients with pancreatitispatients with pancreatitis

Symptomatic Symptomatic GallstonesGallstones Biliary PancreatitisBiliary Pancreatitis

Treatment:Treatment:– Severe pancreatitis: ERCP with Severe pancreatitis: ERCP with

sphincterotomy & stone extractionsphincterotomy & stone extraction– Cholecystectomy (open or laparoscopic later Cholecystectomy (open or laparoscopic later

/same admission)/same admission)– Mild pancreatitis: elective cholecystectomyMild pancreatitis: elective cholecystectomy

N.B. possibility of spontaneous passage N.B. possibility of spontaneous passage of of stone thru ampulla stone thru ampulla

Operative Operative Interventions Interventions

CholecystostomyCholecystostomy– decompresses and drains the decompresses and drains the

distended, inflamed, hydropic, or distended, inflamed, hydropic, or purulent gall bladderpurulent gall bladder

– applicable to patients not fit to applicable to patients not fit to undergo abdominal operationundergo abdominal operation

– done either by open or done either by open or percutaneous ultrasound or CT percutaneous ultrasound or CT guidedguided

Operative Operative InterventionsInterventions

CholecystectomyCholecystectomy

ISSUEISSUE: OPEN vs. LAPAROSCOPIC : OPEN vs. LAPAROSCOPIC CHOLECYSTECTOMY CHOLECYSTECTOMY

Parameters:Parameters:

Operative Operative InterventionsInterventions

CholecystectomyCholecystectomyOPEN OPEN

vs.vs. LAPAROSCOPICCHOLECYSTECTOMYLAPAROSCOPICCHOLECYSTECTOMY

Parameters:Parameters:– Patient’s choice Patient’s choice – Technical expertise Technical expertise – Patient’s conditionPatient’s condition– Cost Cost – Length of hospital stayLength of hospital stay– Complications Complications

Open cholecystectomyOpen cholecystectomy

Safe and effective Safe and effective treatment of acute treatment of acute and chronic and chronic cholecystitischolecystitis

Carl Langenbuch Carl Langenbuch performed the first performed the first cholecystectomy in cholecystectomy in 18821882

Laparoscopic Laparoscopic cholecystectomycholecystectomy

Introduced by Philippe Mouret in Introduced by Philippe Mouret in 19871987

Pneumoperitoneum is introduced Pneumoperitoneum is introduced to the abdominal cavity using to the abdominal cavity using carbon dioxidecarbon dioxide

Surgery is video assisted using Surgery is video assisted using trocars and special instruments trocars and special instruments

Laparoscopic Laparoscopic cholecystectomycholecystectomy

The mortality rate of for The mortality rate of for laparoscopic cholecystectomy is laparoscopic cholecystectomy is 0.1% 0.1%

Conversion to open Conversion to open cholecystectomy is 5%cholecystectomy is 5%