Surgery Marrow Pg 271-280 (GIT)

Bismuth and Strasberg Classification of Bile Duct Injury

• Bismuth and Strasberg classifications describe bile duct injuries.
• Strasberg Classification A: Cystic duct leak or minor leak.
• Strasberg Classification B: Occlusion of an aberrant (right) hepatic duct.
• Strasberg Classification C: Leak from an abnormal right hepatic duct.
• Strasberg Classification D: Lateral injury to the common bile duct.
• Bismuth Type I: Stricture of the common hepatic duct.
• Bismuth Type II: Stricture at the hilum of the liver, with confluence preservation.
• Bismuth Type III: Stricture leading to an aberrant right hepatic duct.
• Bismuth Type IV: Stricture to an aberrant right hepatic duct, with confluence involvement.
• Bismuth Type V: Stricture to an aberrant right hepatic duct.

Gallstones in Pregnancy

• Hormonal changes during pregnancy can increase cholesterol secretion and decrease bile acid secretion, potentially slowing gallbladder emptying.
• Progesterone can decrease bile acid secretion.
• Gallstones diagnosis during pregnancy is possible using Ultrasound (USG).
• First-trimester management for mild cases is conservative.
• Second-trimester management involves Laparoscopic cholecystectomy.
• Third-trimester management is non-operative.

CBD Stones Detection and Management

• CBD stones can be detected during or after laparoscopic cholecystectomy.
• If CBD stones are detected during laparoscopic cholecystectomy, the procedure includes laparoscopic exploration of CBD and stone removal, followed by T-tube insertion (7-10 days).
• A T-tube cholangiogram is conducted to check for residual stones after T-tube insertion.
• If residual stones are present, the T-tube is retained for 2-3 weeks, and a channel is formed via a choledoscope to remove stones using the Burhenne technique.
• If no residual stones are present, the T-tube is removed.
• If CBD stones are detected after laparoscopic cholecystectomy, symptoms may include pain, fever, and jaundice.
• Initial assessment involves imaging using an Imaging of the Common Bile Duct (IOC): MRCP.
• If residual or retained CBD stones are present within 2 years of lap cholecystectomy, further evaluations including ERCP+Sphincterotomy are necessary.
• If recurrent/primary CBD stones are present more than 2 years after Lap Cholecystectomy, evaluations including ERCP+Sphincterotomy are necessary.

Gallstone Ileus

• Gallstone ileus is a misnomer and refers to dynamic bowel obstruction.
• It's caused by the impaction of a gallstone in the neck of the gallbladder, leading to bile absorption and mucus production by the GB wall.
• Symptoms include a distended gallbladder and pain.
• Diagnosis is made using USG.
• Treatment involves laparoscopic cholecystectomy.
• Complications include infected mucocele, leading to empyema of the GB, and gallstone ileus.
• Common site of obstruction is the last 2 feet/60cm of ileum.
• The stone rarely can lead to gastric outlet obstruction, causing Bouveret syndrome.

Gastrointestinal and Abdominal Surgery

• CECT is the IOC for GIST, GB cancer, and renal cell cancer.

Gall Bladder Cancer

• 90% of GB cancer is associated with GB stones.
• Other risk factors include Salmonella typhi carrier, porcelain gallbladder, abnormal pancreatico biliary duct junction (APBDJ), and heavy metal contamination of water.
• GB polyps > 10 mm/1 cm in size, multiple polyps, or adenomatous type increase the risk.
• Cholesterol polyps do not increase the risk.
• GB polyps < 10mm are monitored with regular USG.
• Adenocarcinoma is the most common type, including infiltrating, nodular, and papillary types.
• Clinical presentation may include a GB mass, pain, and jaundice.
• Spread occurs through direct invasion, lymphatic spread, and hematogenous spread.

Gall Bladder & Bile Ducts: Part 1

• Mirizzi syndrome occurs when inflammation causes the GB to adhere to the CBD, leading to fistula formation.
• Clinical features of Mirizzi syndrome include pain and jaundice.
• Investigations for Mirizzi syndrome include MRCP and Intraoperative Cholangiopancreatography (IOC).
• Management involves Lap cholecystectomy.
• Choledocholithiasis is the presence of stones in the common bile duct. 90% are secondary to GB stones, and 10% are primary.
• Brown pigment stones are commonly formed within the CBD.

Laparoscopic Cholecystectomy

• The surgeon positions on the left side, the assistant on the left side, and the patient in reverse Trendelenburg with the right side up.
• The "B Safe" method focuses on visualizing the bile duct, status of Rouviere, hepatic artery, umbilical fissure, and enteric/duodenum before proceeding with surgery.
• Calot's triangle, containing the cystic artery and cystic duct, must be visualized.
• Traditional laparoscopic cholecystectomy uses multiple ports, including a right hypochondrial port for the left hand, and a fourth port for retraction and GB manipulation.
• SILS laparoscopic cholecystectomy is performed through a single incision.
• Bailout strategies, such as aborting the procedure, converting to an open procedure, performing a tube cholecystostomy, or carrying out a subtotal cholecystectomy, are used in cases of frozen Calots.
• Complications include right shoulder tip pain (most common), bleeding, and injury to the bile duct.

Bile Duct Injury

• Types of bile duct injuries include injury to the bowel, residual/recurrent stones, and stricture to the common hepatic or common bile duct.
• Injuries can be classified by whether awareness occurs during surgery or post-operatively.
• Partial tear may be treated with repair using an absorbable suture.
• Complete transection without loss of segment may be treated with anastomosis using a T-tube.
• Complete transection with loss of segment may require anastomosis with a T-tube and closure of the distal end with choledochojejunostomy.
• Post-operative management for minor bile leaks involves observation with close monitoring of symptoms.
• Workup for persistent or worsening symptoms includes CBC, TLC, abdominal ultrasound, and collection below the liver, with confirmation via MRCP.
• One common intervention for biliary leaks is an ERCP with stenting procedure.
• The management strategy depends on the complexity of the injury and patient response.

Chronic Cholecystitis

• Chronic cholecystitis is characterized by multiple episodes of cholecystitis.
• Symptoms include right upper quadrant pain, nausea, and vomiting.
• Diagnosis is made using ultrasound, which may reveal the Wall echo shadow (WES) sign, gallstones, and post-acoustic shadow.
• Histopathology reveals clefts, chronic inflammatory cells, and Rokitansky Aschoff sinuses.
• Potential outcomes include rupture, xanthogranulomatous cholecystitis, or cancer.
• Management involves laparoscopic cholecystectomy.

Emphysematous Cholecystitis

• This condition is caused by Clostridium bacteria.
• Predisposing factors include immunocompromised status.
• Clinical features include pain, fever, and sepsis.
• Diagnosis involves ultrasound and computed tomography, which visualize gas within the gallbladder and wall.
• Management includes nil per oral, intravenous fluids, and broad-spectrum antibiotics.

Mucocele of Gallbladder

• Mucocele is aseptic dilatation of the gallbladder caused by a stone impacted at the Hartmann pouch neck.
• Management involves early laparoscopic cholecystectomy or tube cholecystostomy.

Test your knowledge on the Bismuth and Strasberg classifications of bile duct injuries. This quiz covers details about various types of bile duct injuries, including stricture and leaks. Additionally, explore the impact of pregnancy on gallstone formation.