When to Excise CBD (Common Bile Duct) in cancer of gallbladder

Indications for the resection of the EHBD in all stages of disease include —
1.Tumors involving the EHBD  Preoperatively indicated by the presence of obstructive jaundice, in the absence of distant metastasis

2. Tumors/gross lymph nodal enlargement close to or involving the common hepatic duct or hilum

3.  Inflamed or a fatty hepatoduodenal ligament rendering nodal dissection difficult

4. Patients ndergoing re-resection (since postoperative inflammation makes differentiation of tumor and scar difficult).

5.Positive cystic duct margin on intraoperative frozen section

6.Patients with associated APBDJ or choledochal cyst— these patients are at an increased risk of further metachronous malignancies of the biliary tree and should hence undergo EHBD resection at the time of treatment of the gallbladder cancer

In case of need for associated vascular resection/ reconstruction

Asymptomatic Gastric Varices

Gastric varices occur due to Left sided Portal hypertension also known as Sinistrial hypertension. In patients who have not bled, conservative management is advocated because the chance of developing significant bleeding is 4-18%
Surgery for the same is carried out in patients who are
Uncompliant
Any other surgery
REd wale sign is positive (These cases are under high risk for bleeding)

Controversies in Heller Myotomy

 In Achalasia Cardia surgical relief in the form of Heller's myotomy give the most long lasting relief from symptoms. There are a lot of controversies associated with  the procedure. We will be discussing these.

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Short Myotomy (1-1.5cm) on gastric wall Vs Long myotomy on gastric wall (3cm)

   Long myotomy has a significant less dysphagia but there is no difference in  postoperative chest pain, regurgitation or heartburn.

 

 

•Addition of Anti reflux procedure 

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•Partial fundoplication is recommended in most cases

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In the only randomized trial the addition of antireflux procedure decreased the incidence of reflux ninefold without having any impact on dysphagia

 

More 

Length of Myotomy-- 

Klatskin Tumor

Q Which of the following is the least common alternative diagnosis in a case of hilar Cholangiocarcinoma?
i) Carcinoma gallbladder
ii) Mirizzi Syndrome
iii) Idiopathic benign focal stricture
iv) Choledocholithiasis


Answer iv)
All of the above mentioned conditions can mimic as tumor of the confluence of bile ducts. Klatskin tumor is a diagnostic and therapeutic dilemma.
Carcinoma neck of the gall bladder can mimic this. The findings in favor of Carcinoma Gall bladder are irregular wall thickening, involvement of segment IV and V of liver.
Mirizzi syndrome is caused by impaction of stone in the CBD and can lead to periductal fibrosis
Idiopathic benign focal stricture or malignant masquerade are group of benign diseases of biliary tract and are very diificult to distinguish from carcinoma. In a suspected case of Klatskin tumor, resectional surgery without preop diagnosis is the accepted modality.

Lymph node stations removed in three field esophagectomy in neck

Esophageal carcinoma is known to have a good network of submucosal lymphatics and hence difuse metastatsis.
Three field esophagectomy removes lymphnodes from neck, medaistinum and abdomen

Among patients with upper thoracic cancer, the rates of nodal metastasis were 42.3% in the cervical nodes, 63.1% in the mediastinal nodes, and 19% in the abdominal nodes. The respective rates were 27.5%, 55.8%, and 41% among patients with middle thoracic cancer, and 10.9%, 43.5%, and 67.4% among patients with lower thoracic cancer.

Neck
Incision --- Low collar
The strap muscles and the medial heads of the sternocleidomastoid are divided.
The nodes posterior and lateral to the carotid sheath are removed along with the supraclavicular nodes.
The dissection is limited superiorly by the inferior belly of the omohyoid.

Positron emission tomography

Positron emission tomography, also called PET imaging or a PET scan, is a diagnostic examination that involves the acquisition of physiologic images based on the detection of radiation from the emission of positrons. Positrons are tiny particles emitted from a radioactive substance administered to the patient. The subsequent images of the human body developed with this technique are used to evaluate a variety of diseases.
PET scans are used most often to detect cancer and to examine the effects of cancer therapy by characterizing biochemical changes in the cancer. These scans can be performed on the whole body.
PET can give false results if a patient's chemical balances are not normal. Specifically, test results of diabetic patients or patients who have eaten within a few hours prior to the examination can be adversely affected because of blood sugar or blood insulin levels.

Also, because the radioactive substance decays quickly and is effective for a short period of time, it must be produced in a laboratory near the PET scanner. It is important to be on time for the appointment and to receive the radioactive substance at the scheduled time. PET must be done by a radiologist who has specialized in nuclear medicine and has substantial experience with PET. Most large medical centers now have PET services available to their patients. Medicare and insurance companies cover many of the applications of PET, and coverage continues to increase.

Finally, the value of a PET scan is enhanced when it is part of a larger diagnostic work-up. This often entails comparison of the PET scan with other imaging studies, such as CT or MRI.

Surgery Multiple choice questions: Colon Question

Surgery Multiple choice questions: Colon Question