Management of Asymptomatic Gallstones

Few predictive factors for symptomatic progression of gallstone disease:
- Bariatric surgery - 30% develop gallstones
- post-colectomy - 20% will develop symptoms within 5 years
- prolonged TPN use

Despite these risk factors, there are few indications for prophylactic cholecystectomy:
- Expectant Management of Cholelithiasis is the accepted treatment despite low morbidity of lap chole
- Diabetes is not an indication for prophylactic chole.  Diabetics do not have any significant difference in prevalence, presentation or complications compared to nondiabetics

Post-Transplantation:
- Cyclosporine leads to gallstone formation.
- Need for prophylactic chole has been shown to be of benefit in cardiac transplant patients if screening u/s shows stones (Milas et al, Mayo clinic)
- in renal transplant patients, majority (~90%) remain asymptomatic

Hemoglobinopathies:
- at risk of developing pigmented stones.
- sickle cell: 70% of pts
- hereditary spherocytosis: 85%
- thalassemia: 24%
- Gallstones in sickle cell patients can pose a problem. ~50% will become symptomatic within 3-5 years. Presence of gallstones can be diagnostically challenging due to possibility of abdominal sickling crisis.
- Hemoglobinopathies are an indication to perform prophylactic lap chole, lap chole should also be performed if doing a lap splenectomy

Bariatric Surgery:
- incidence of gallstone formation after rapid weight loss:
- general population: 10-20%
- bariatric surgery population: 30-40%
- if gallstones documented at time of bariatric surgery - lap chole recommended
- Ursodiol - can decrease incidence if patient compliant (prevents cholesterol absorption, expensive (~$1.50/d), BID). Suggested for patients undergoing bariatric surgery without prior evidence of stones.

Incidental Cholecystectomy - Controversial:
- During AAA: controversial due to the presence of graft material.  Review of incidental chole - shown to be safe as long as performed after retroperitoneum is closed
- Other abdominal surgeries: One study (Watemberg et al) showed that in pts >70 yo with cholelithiasis, M&M was higher if you DO NOT do incidental chole during laparotomy for other reasons.... yet we do not routinely do this in practice - why?
- most were small studies - only Watemberg was larger study

CBD injuries

Strasberg classification CBD injuries

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Gallbladder Polyps

Prevalence GB Polyps: 3-10%

Differential:
- Cholesterol polyps (50-70%)
- inflammatory
- hyperplastic
- adenoma
- malignant (8%)

Predictive factors for malignancy:
- size >1cm
- broad based sessile polyps
- age >50

Treatment:
- suspicion for GB cancer low: lap chole
- suspicious for GB cancer: open chole with intraop frozen section
- small polypoid lesion: U/S q6 mo for 2 yrs to ensure stable lesion

Gallbladder Cancer

T1a GB Ca: usually early stage

- usually found incidentally after routine lap chole

- incidence after routine lap chole for cholelithiasis - 1-2%

- 5 year survival for T1a GB ca confined to the mucosa - 85-100%

Symptomatic patients: usually advanced stage

- U/S only 50% sensitive for GB ca

- if suspicion of GB cancer pt should have a CT scan or MRI to look for invasion into adjacent structures, LN or encasement of portal vein or hepatic artery.

- Other investigations to consider: PET, MRCP, ERCP

Treatment is based T-stage of the tumor

- contraindications to surgical resection: liver mets, malignant ascites, peritoneal mets, distant disease, extensive involvement of hepatoduodenal ligament, encasement or occlusion of major vessels, poor performance status.

Lap Chole:

Tis or T1a

Radical Cholecystectomy:

-T1b (15% subserosal LN involvement) or T2 (40-80% subserosal LN involvement)

- radical cholecystectomy involves resection of GB with a 2cm hepatic parenchymal margin and LN dissection within the porta hepatis, gastroduodenal ligament, gastrohepatic ligament and Kocher for LN dissection behind duodenum
- can be done at time of initial lap chole or can be delayed - survival the same

Radical Cholecystectomy +/- en bloc resection of locally invaded organs:

- advised for T3/T4 tumors only if there is no evidence of metastatic spread

- 25-44% 5 year survival rate

Palliation:
- survival in locally unresectable or metastative disease often <1 yr
- no effective adjuvant treatment - all part of clinical trials

Hepatocellular Carcinoma

Hep C is highest risk factor worldwide of HCC (>50% in NA)

- any type of cirrhosis carries risk of HCC

- what about Hep A (or is it only chronic Hepatides)

Screening in cirrhotic pts important:

- clinical presentation will be late in disease process 

- AFP, U/S q6 months

- any solid liver nodule not clearly a hemangioma should be considered an HCC in a cirrhotic pt until proven otherwise

REsection 

Child PUgh A - normal bili, INR, albumin, no encephalopathy, no ascites

unilobar

no major co-morbidites

Malignant liver tumors

American Associatiion of Liver Disease HCC diagnostic criteria

- ?

- main point is that FNA not necessarily required for diagnosis and may track tumor in needle site converting treatable lesion to untreatable

Treatments for HCC

Curative:

- TRansplant

- resection

- Radiofrequency ablation

Palliative

- TASTE (embolization)

- chemotherapy

Best treatment modality HCC:

- Transplant (treats both tumor underlying liver dysfunction)

- resection has 50% 5 year survival (largely from liver disease and risk of 2nd primary)

Factors for HCC resection

- liver function

- tumor characteristics (number, size, multifocality)

Primary liver tumors:

HCC

cholangiocarcinoma

malignant vascular tumors (epitheliod hemangioendothelioma, angiosarcoma)

sarcomas (embryonal sarcoma, ...)

Most common sources of liver mets (hypoattenuating):

Colorectal, Breast, Lung

Hyperattenuating:

- melanoma, renal cell

Treatment goals:

- R0 resection 

- preserve ~25% hepatic parenchyma

- adjuvant or neoadjuvant chemoRT to reduce risk recurrence 

Benign liver lesions - AHD

3 most common benign liver lesions:

1) Adenoma

2) FNH

3) hemangioma

Factors for resection:

- symptoms (chronic, aching pain under the right costal margin, constant)

- type (adenomas carry malignancy risk, FNH do not)

- location (peripheral hemangioma at risk of rupture)

- growth (compression of biliary/vascular strucutres)