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)

Pancreatic cancer

Indications preop stents.
Acute cholanfitis
Intense puritis
Neoadjuvant chemotherapy
- short length self expanding stent
Management of nonresectable cancers
- ercp and stent
- PTC mettalic stent if no ercp access
- Eus or us guided fna biopsy possible celiac plexus block
- if associated gastric outlet obstruction then double bypass or
duodenal stent
Operative management
- Any metastatic disease in pancreatic cancer - the patient is
unresectable
- staging laparoscopyuswd in some institutions but low yield

If non-resectable
- Trans duodenal trucut pancreatic biopsy
- palliative


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