Biliary Tract

  1. Sphincter Of Oddi relaxed by
  2. Couvoisier's Law
    In patient with jaundice, if GB is palpable, it is not due to stones. In stone disease, GB is contracted and fibrosed, so not distended. 

    • Exceptions of the law - 
    • - Double impaction of stone, one in CBD and one is cystic duct 
    • - Large stone in Hartman Pouch
  3. Mirizzi Syndrome Types
    Type I - Compression of CBD without lumen narrowing 

    Type II - Compressing causing CBD lumen narrowing 

    Type III - Comprssion causing CBD wall necrosis 

    Type IV - Cholecysto-choledochal fistula
  4. Contranindications of Transcystic approach
    • Small, Friable cystic duct
    • Numerous stones (>8)
    • Large stones (>1cm)
  5. Contraindications of Choledochotomy
    Small caliber of bile duct (<6mm) – which can be strictured by closure
  6. Sump syndrome
    In choledochoduodenostomy, distal bile duct does not drain, debris collected that leads to occlusion of ampulla, pancreatitis, anastomotic stricture and cholangitis
  7. Transduodenal sphincteroplasty
    Incision at 11 o’clock, avoid 5’clock (to avoid injury to pancreatic duct), duodenal mucosa sewn with bile duct mucosa with absorbable 4.0 suture
  8. Importance of Traction in Lap cholecystectomy
    • Traction of fundus – Cystic duct overlies CHD, cystic duct is parallel with CHD
    • Inferolateral traction of Infundibulum – dissociate these structures, opens calots triangle
  9. Bisthmuth and Strasberg classification
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    • Image Upload 2

    Bismuth form E1-5 for Enjury 
  10. Stewart-Way Classification
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  11. Management of Enterocutaneous fistula
    • - Sepsis, skin care
    • - Nutrition
    • - Anatomy - define intestinal anatomy
    • - Plan
  12. Insertion of T-tube
    At least 14F, 2.5cm of each limb, The back wall of vertical stem should be excised, V-shaped wedge fashioned at the junction of limbs, to facilitate subsequent removal
  13. Recurrent Pyogenic Cholangitis
    Biliary pathogens Clonarchis sinensis, Ascaris lumbroides populate biliary tree – secrete enzyme that hydrolyze water soluble bilirubin glucuronides to form bilirubin, that precipitates to brown pigment stone – obstruct biliary tree to cause recurrent cholangitis and eventually abscess or even cirrhosis
  14. PSC associated with
    • Ulcerative Colitis
    • Riedel Thyroiditis
  15. PSC cholangiography finding
    Chain of lakes, Diverticular like outpouch, multiple short segment strictures
  16. Radiological finding of Benign biliary strictures
    Long, Smooth, gradually tapered narrowing
  17. Todani Classification
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  18. Triad of Choledochal cyst
    Jaundice, Mass, Pain
  19. Moynihans Hump
    Bailey 1098
  20. Classification of Biliary Atresia
    • Type I – Atresia restricted to CBD
    • Type II – Atresia of CHD
    • Type III – Atresia of left and right Hepatic duct
  21. Treatment of Biliary Atresia
    For type II and III – Kasai Operation – Excision of biliary tract with Roux-en-Y loop of jejunum anastomosis with exposed area of liver capsule, above the bifurcation of portal vein
  22. Burhenne Technique
    Extraction of Stone from T-tube
  23. Indication of Cholecystectomy in GB polyp
    • Size >10mm 
    • Age > 60 years 
    • Symptomatic GB polyp disease
  24. TNM  Carcinoma Gall Bladder
    T1 - Tumor invades lamina propria (T1a) or Muscle layer (T1b) 

    T2 - Perimuscular connective tissue 

    T3 - Invade liver or any one of stomach, duodenum, colon or pancreas 

    T4 - Invades two structures or Invasion to main portal vein or Hepatic artery
  25. Treatment of Ca GB
    • T1a - Cholecystectomy 
    • T1b, T2 - Extended Cholecystectomy 
    • T3 - Radical Cholecystectomy 
    • T4 - Paliative care 

    Radical Cholecystectomy - GB + Segment IV, V and VIII (Trisegmentectomy)
  26. TNM Intraheptaic Bile duct Tumor
    T1 - Soliary Tumor without vascular invasion 

    T2a - Solitary tumor with vascular invasion 

    T2b - Multiple tumor with/without vascular invasion 

    T3 - Tumor perforating the visceral peritoneum or involving extrahepatic structure by direct extension 

    T4 - Tumor with periductal invasion
  27. TNM Perihilar Bile duct Tumor
    T1 - Tumor Confined to bile duct, with extension upto muscular layer or fibrous tissue 

    T2a - Tumor invading beyond the wall of bile duct to surrounding adipose tissue 

    T2b - Tumor invades adjacant Hepatic parenchyma 

    T3 - Tumor invades unilateral branches of portal vein or hepatic artery 

    T4 - Tumor invades main portal vein or its branches bilaterally or CHA or the secondaries, biliary radicals b/l or, Unilateral second order biliary radical with contralateral portal vein or hepatic artery involved
  28. Nodal classification in TNM for all Biliary Ca
    N1 - Node along cystic duct, CBD, Hepatic artery, or portal vein 

    N2 - Periaortic, pericaval, SVC, Celiac artery nodes
Card Set
Biliary Tract
Gall Bladder