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General Surgery
Cancer of the Gallbladder and Bile Ducts
Built from Maingot's Abdominal Operations
What’s inside
6 sections · 161 slides
Overview
- Scope of this topic
- Two separate diseases in one region
- Roadmap of the topic
Gallbladder Cancer: The Disease
Who develops it, what it looks like under the microscope, and how it is staged
- Incidence of gallbladder cancer
- Geographic distribution
- Gallstones as the principal risk factor
- Recognised risk factors for gallbladder cancer
- Porcelain gallbladder and gallbladder polyps
- Chronic infection and carcinogen exposure
- Abnormal pancreaticobiliary duct junction
- Features of cancers arising with APBDJ
- Sequence of malignant transformation
- Pathogenesis of gallbladder cancer
- Molecular changes in gallbladder cancer
- Histological types of gallbladder cancer
- Morphological growth patterns
- Prognostic value of growth pattern
- Staging systems for gallbladder cancer
- Node categories in the seventh edition
- Stage group revisions in the seventh edition
- TNM stage groups for gallbladder cancer
- Depth of invasion in the T categories
- Symptoms of early gallbladder cancer
- Features of advanced gallbladder cancer
- Laboratory tests and tumour markers
- Transabdominal ultrasonography
- Ultrasound appearance of gallbladder cancer
- What to notice on the ultrasound images
- Endoscopic ultrasonography
- Computed tomography in gallbladder cancer
- CT appearance of gallbladder cancer invading the liver
- Magnetic resonance imaging and cholangiography
Gallbladder Cancer: Treatment
Stage-directed resection, operative technique, palliation and outcomes
- Role of surgical resection
- Indications and contraindications for preoperative biopsy
- Stages 0 and I: Tis and T1a disease
- Management of incidentally discovered early cancer
- Management of a positive cystic duct margin
- Management of T1b gallbladder cancer
- Rationale for re-exploration in T2 disease
- Extent of re-exploration for T2 disease
- Re-excision of previous wound and port sites
- Planned resection for suspected T2 disease
- Choice of liver resection for T2 disease
- Stage III gallbladder cancer
- Extent of resection in T3 disease
- Stage IV gallbladder cancer
- Operation matched to T stage
- Staging laparoscopy before laparotomy
- Avoidance of laparoscopic cholecystectomy in suspected cancer
- Incision and exploration
- Intraoperative frozen-section decisions
- Kocher manoeuvre and nodal assessment
- Regional lymphadenectomy
- Common duct resection
- En bloc liver resection
- Avoiding injury to the right hepatic artery
- Operative field after radical cholecystectomy
- What the resection illustration shows
- Biliary reconstruction after common duct resection
- Adjuvant therapy after resection
- Goals of palliation in gallbladder cancer
- CT of advanced gallbladder cancer with a biliary stent
- Wallstent placed for obstructive jaundice
- What the stent images demonstrate
- Non-surgical treatment of advanced disease
- Population-based survival in gallbladder cancer
- Survival in contemporary surgical series
- Morbidity and mortality of resection
- 11.7 mo
Bile Duct Cancer: The Disease
Cholangiocarcinoma - risk factors, anatomical classification, staging and diagnosis
- Definition of cholangiocarcinoma
- Incidence and demographics
- Primary sclerosing cholangitis
- Recognised risk factors for bile duct cancer
- Liver flukes and hepatolithiasis
- Congenital, chemical and occupational risks
- Genetic conditions predisposing to bile duct cancer
- Molecular pathogenesis in bile duct epithelium
- Histological types of bile duct cancer
- Growth patterns of cholangiocarcinoma
- Resectability by growth pattern
- Anatomical classification of cholangiocarcinoma
- Sites of origin and their frequencies
- Bismuth classification of perihilar bile duct cancers
- Bismuth types by level of duct involvement
- Purpose of the Bismuth classification
- Separate staging systems in the seventh edition
- TNM stage groups for intrahepatic bile duct cancer
- TNM stage groups for perihilar bile duct cancer
- TNM stage groups for distal bile duct cancer
- Reading the three staging tables together
- Presentation of intrahepatic cholangiocarcinoma
- Presentation of extrahepatic cholangiocarcinoma
- Differential diagnosis
- Laboratory findings and tumour markers
- Ultrasonography and computed tomography
- CT appearance of intrahepatic cholangiocarcinoma
- Indirect CT signs of perihilar tumours
- CT findings in distal bile duct cancer
- Staging information from the CT scan
- Atrophy-hypertrophy complex
- Determining proximal and distal tumour extent
- ERCP appearance of a hilar cholangiocarcinoma
- What the cholangiogram shows
- Magnetic resonance cholangiopancreatography
- Positron emission tomography and biopsy
- Dominant biliary stricture in primary sclerosing cholangitis
- Endoscopic ultrasound-guided fine-needle aspiration
Bile Duct Cancer: Treatment
Resectability, the perihilar operation step by step, palliation and outcomes
- Role of resection in cholangiocarcinoma
- Patient and disease contraindications to resection
- Anatomical contraindications to resection
- Preoperative biliary stenting for distal tumours
- Preoperative drainage for perihilar tumours
- Operation matched to tumour location
- Staging laparoscopy in cholangiocarcinoma
- Laparotomy and nodal assessment
- Lowering the hilar plate
- Sagittal section through the hilar plate
- Orientation to the hilar plate illustration
- Mobilisation of the extrahepatic biliary tree
- Dissection of the biliary tree off the portal vein
- Use of traction during the dissection
- Dissection at the hepatic duct bifurcation
- Transection of the right and left hepatic ducts
- Skeletonized hepatoduodenal ligament after resection
- Margin assessment after resection
- Reconstruction after resection of a Klatskin tumour
- Technique of biliary catheter exchange
- Exchange of Ring catheters for Silastic catheters
- Construction of the biliary-enteric anastomoses
- Posterior row of the bilateral hepaticojejunostomies
- Operative field after completed reconstruction
- Fixation of the Roux limb and catheter marking
- Steps of the perihilar resection
- Addition of hepatic resection
- Resection specimen from an extended hilar resection
- Preoperative portal vein embolization
- Liver transplantation for cholangiocarcinoma
- Adjuvant and neoadjuvant therapy
- Principles of palliation in bile duct cancer
- Choice of stenting route
- Number of stents in hilar obstruction
- Metal and plastic biliary stents
- Prophylactic cholecystectomy at laparoscopy
- Surgical bypass for unresectable disease found at laparotomy
- Palliative options for unresectable perihilar tumours
- Technique of segmental duct bypass
- Surgical approach to the segment 3 duct
- Radiotherapy in advanced bile duct cancer
- Systemic chemotherapy for advanced bile duct cancer
- Photodynamic therapy
- Outcomes in perihilar cholangiocarcinoma
- Outcomes in intrahepatic and distal cholangiocarcinoma
- 11.7 mo
Summary
What to carry away from gallbladder and bile duct cancer
- Key points: gallbladder cancer
- Key points: bile duct cancer
- Shared principles across biliary tract cancer
- References
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition