*Hizbullah Abid*

1. *Hizbullah Abid*

2. Hepatobilliary surgery - billary tract

3. Anatomy of gallbladder • Gallbladder is a pear shaped, hallow structure located just beneath the right lobe of the liver and on the right side of the abdomen • In adult the, the gallbladder is approximately 8 cm in length and 4 cm in diameter. Angel of gallbladder is located between the costal margin and the lateral margin of the rectus abdomens muscle. • The gallbladder is divided into three sections: the funds, body and neck: • Fundus—> is a rounded end that faces the front of the body • Body—> is in contact with the liver, lying in the gallbladder fossa, a depression at the bottom of the liver • Neck—> tapers and is continuous with the cystic duct, part of the biliary tree.

4. physiology of gallbladder • Gallbladder is made up of layers of tissue:mucosa ( the inner layer of epithelial cells and lamina propria loose connective tissue)muscular layer ( a layer of smooth muscle)perimuscular layer ( connective tissue that covers the muscular layer)serosa (the outer covering of the gallbladder) • The cystic duct units with the common hepatic duct to become the common bile duct. Junction of the neck of the gallbladder and the cystic duct, has a an opening patching to the gallbladder wall forming a mucosal fold known as Hartmanns pouch, where gallstones commonly get stuck • The primary function of gallbladder is to store and concentrate bile ( yellow-brown digestive enzyme produced by the liver)

5. physiology of gallbladder • Gallbladder serves as a reservoir for bile while its not used for digestion. The absorbent lining concentrates the stored bile. • When food enters the small intestine a hormone called cholecystokinin is released, signaling the gallbladder to concentrate and secrete bile into the small intestine through the common bile duct • Bile—> helps the digestive process by breaking up fats, and it also drains waste products from the liver into the duodenum.

6. Blood supply • The celiac trunk branches from the abdominal aorta and splits into three major branches, one of which, the common hepatic artery, supplies blood to the liver and gallbladder along with the stomach, small intestine, and pancreas. • common hepatic artery further divides into three more branches, with the proper hepatic artery supplying blood to the liver, gallbladder, and part of the stomach. • common hepatic artery further bifurcates into the left and right hepatic arteries to deliver blood the left and right sides of the liver. As the right hepatic artery approaches the gallbladder, it branches off to form the cystic artery, which supplies the gallbladder and cystic duct with oxygenated blood. • These arteries further branch off into many smaller arteries and arterioles and, finally, capillaries to provide oxygen and nutrients to all of the tissues of the liver and gallbladder.

7. Anatomy and physiology of the biliary tree • The biliary tract refers to the liver, gallbladder and bile duct, and how they work together to make store and secrete bile • Bile consist of water, electrolytes, bile acid, cholesterol, phospholipids and conjugated bilirubin. • Bile is secreted by the liver into small ducts that join to form the common hepatic duct. between meals, secreted bile is stored in the gallbladder, where 80-90 % of the water and electrolyte can be absorbed, leaving the bile acids and cholesterol. • During a meal, the smooth muscles in gallbladder wall contract, leading to the bile begin secreted into the duodenum.

8. Anatomy and physiology of the biliary tree • Biliary tract is often referred as the tree, because it begins with many small branches which end in the common bile duct, and sometimes as the trunk of the biliary tree. the duct, the branches of the hepatic artery and the portal vein form the central axis of the portal triad. • The term hepatobiliary is used to refer just to the liver and bile ducts. • Path of flow: Liver cells (hepatocytes) excrete bile into >> Bile canaliculi>> canals of hering>> intrahepatic bile ductule >> interlobular bile duct ( from gallbladder) >> forming>> common bile duct>> joins with >> pancreatic duct>> forming>> ampulla of vater>> enters duodenum. • Biliary system main function: to drain waste products from the liver into the duodenum. To help in digestion with the controlled release of bile.

9. Cholelithiasis (Gallstones) • There are two main types of gallstones: cholesterol stones, containing crystalline cholesterol monohydrate ( 80 % of stone in west), and pigmented stones, made of bilirubin calcium salts. • Bile formation is the only significant pathway to eliminate excess of cholesterol from the body, as free cholesterol or as bile salts. • Cholesterol is rendered water-soluble by aggregation with bile salt and lecithins. When cholesterol concentrate exceed the solubilizing capacity of bile, cholesterol can no longer remain dispersed and crystalizing out of solution. • Cholesterol gallstone formation is enhanced by hypomobility of the gallbladder, which promotes nucleation and by mucus hypersecretion with trapping of crystals thereby enhancing their aggregation into stones. • Cholesterol stones consist of 50- 100 % cholesterol. Pure cholesterol stones are pale yellow increasing proportions of calcium carbonate, phosphate, and bilirubin. They can occur single, but most often several. • Formation of pigment stones is more likely in the presence of unconjugated bilirubin in the biliary tree. The precipitates are primarily insoluble calcium bilirubinated salts. • They can arise anywhere in the biliary tree and classified into black and brown stones. Black pigmented stones are found in sterile gallbladder bile, whereas brown stones are found in infected intrahepatic or extra hepatic duct.

10. Risk factor to develop gallstones are • - Age and gender: the prevalence of gallstones increases throughout life. In USA less then 5-6 % of population younger then 40 has stones. and 25-30 % of those older then 80 years. Prevalence in women of all age is about twice as high as in men. • Ethnic and geographic: cholesterol gallstones approaches 50- 70% in certain Native American population. Whereas pigment stones are rare. • Heredity: positive family history increases the risk, as do a variety of inborn error of metabolism like impair bile salt synthesis and secretion. • Environment: oral contraceptives and pregnancy increases hepatic cholesterol uptake and synthesis, leading to excess biliary. • High blood cholesterol level, rapid weight loss, diabetes and pregnancy, old age, gender= risk to develop cholesterol gallstones. • Disorders that lead to destruction of red blood cells such as sickle cell anemia are associated with the development of pigmented or bilirubin stones

11. symptoms • 70-80 % of individual with gallstones remain asymptomatic throughout life. • . Some of the symptoms are pain, typically localized to the right upper quadrant or epigastric region and can be constant or less commonly spasmodic. • Pain like this is usually caused by biliary tree or gallbladder obstruction or inflammation of the gallbladder. • Severe complicationempysema, perforation, fistula, inflammation of biliary tree, or obstructive cholestasis or pancreatitis.

12. Diagnosis of Cholelithiasis • is suspected when symptoms of right upper quadrant abdominal pain, nausea or vomiting occur. Location, duration and character (stabbing,cramping) of the pain help to determine the likelihood of gallstone disease. Patient with uncomplicated cholelithiasis typically have normal laboratory test result. Blood test when its indicated includes, complete blood count, liver function panel, amylase, lipase. • Abdominal ultrasound examination is a quick, sensitive and relatively inexpensive method to detect gallstones in the gallbladder or common bile duct. • Abdominal radiography upright and supine(used to exclude other cause of abdominal pain), ultrasonography, CT ( more expensive and less sensitive than ultrasound for detecting gallbladder stones) • Scintigraphy ( highly accurate for the diagnosis of cystic duct obstruction)

13. Treatment of Cholelithiasis • treatment of gallstones depend on the stage of the disease. However obstruct gallstones to the common bile duct is ERCP or surgery . ERCP involves a thin flexible scope through the mouth and into duodenum where it is used to evaluate the common bile duct or pancreatic duct. • Gallbladder surgery is performed if there is stones found in the gallbladder itself, as these cannot be removed by ERCP so the surgery performed is cholecystectomy which is frequently done by laparoscopy. • Lithogenic state- interventions are currently limited to a few special circumstances. • Asymptomatic gallstones- expectant management • Symptomatic gallstones- usually definitive surgical intervention like cholecystectomy. • The medical treatments used individually or in combination are: oral bile salt therapy, contact dissolution, extracorporeal shockwave lithotripsy

15. Gallbladder polyps • Gallbladder polyps are growths or lesions in the wall of the gallbladder. • Affects around 5 % of the adult population. causes are uncertain, but there is a correlation with increasing age and the presence of gallstones. Higher prevalence among women • The main types of polypoid growths of the gallbladder are: cholesterol polyp/cholesterosis, cholesterosis with fibrous dysplasia of gallbladder, adenomyomastosis, hyperplastic cholecystosis and adenocarcinoma. • Most of small polyps (less than 1 cm) are not cancerous and may remain unchanged for years. About 95 % of gallbladder polyps are benign. However, when small polyps occur with other conditions, like primary sclerosing cholangitis, they are less likely to be benign. • larger polyps are more likely to develop into adenocarcinoma.

16. Cholesterolosis • is characterized by an outgrowth of the mucosal lining of the gallbladder into fingerlike projections due to excessive accumulation of cholesterol and triglycerides within macrophages in the epithelial lining. • This type of cholesterol polyps accounts for most benign gallbladder polyps

17. Adenomyomatosis • describes a disease state of gallbladder in which the gallbladder wall is excessively thick, due to proliferation of subsurface cellular layer. • it is characterized by deep folds into muscular propria. • ultrasonography can reveal the thickened gallbladder wall with intramural diverticula, called Rokitansky- Aschoff sinuses.

18. Gallbladder polyps • Most affected individuals do not have symptoms. They are usually detected during abdominal ultrasonography performed for other reasons. • Small gallbladder polyps are common and does not require any treatment, however recommended follow up of small polyps varies from author to author. • a commonly accepted strategy includes: <5 mm (no further follow up necessary.) 6-9mm ( follow-up to ensure no interval growth; follow-up interval varies from 3 to 6 months. > 10 mm (surgical consultation) usually warrant cholecystectomy, if no cholecystectomy, annual follow up is warranted.

19. Gallbladder cancer • Gallbladder cancer is relatively uncommon. Carcinoma of gallbladder is the most frequent malignant tumor of the biliary tract. • Carcinoma of gallbladder is more frequent in the populations of Mexico and Chile, due to higher incidence of gallbladder stones disease in these region. The mean 5- years survival rate is dismal 5 %, and gallstones are present in 50- 60 % of cases. • Gallbladder containing stones or infectious agents develops cancer as a result of recurrent trauma and chronic inflammation. • Cancer may exhibit exophytic or infiltrating growth patterns. infiltrating—> is more common and usually appears as a poorly defined area of diffuse thickening and induration of the gallbladder wall that may cover several square cm or involve the entire gallbladder, these tumor are scirrhous and very firm. Exophytic—> grows into the lumen as an irregular, cauliflower like mass but at the same time also invades the underlying wall.

20. Gallbladder cancer • By the time gallbladder cancers are discovered, most have invaded the liver or have spread to the bile ducts or to the portal hepatic lymph nodes. • If its detected early enough it can be cured by removing the gallbladder, part of the liver and associated lymph nodes. • Gallbladder cancer is most often found after symptoms such as • abdominal pain, jaundice, lump in the abdomen, fever, bloating and vomiting. • The risk factors are: Gender 2:1 women 7-8 decades, obesity, chronic cholecystitis and cholelithiasis, chronic typhoid infection of gallbladder ( chronic salmonella).

21. Diagnosis Gallbladder cancer • for gallbladder cancer is difficult to detect and diagnose. signs and symptoms are not usually seen in the early stage of the disease and often overlap with the symptoms of gallstones and biliary colic. • Some tests that might be helpful in the diagnosing gallbladder cancer include: Liver function test, CA 19-9 assay, carcinoembryonic antigen assay (CEA) • Image studies: Ultrasound is the standard initial study in patient with right upper quadrant pain. A mass can be identified in 50-70 % of patient with gallbladder cancer. • CT- might be useful in patients with upper abdominal pain and can demonstrate tumor invasion outside of the gallbladder and identify metastatic disease elsewhere in the abdomen or pelvis. • staging for gallbladder cancer:

22. Treatment Gallbladder cancer • surgery, • radiation therapy, • chemotherapy • palliative therapy.

23. Cholangiocarcinoma • Is adenocarcinoma that arise from cholangiocytes lining the intrahepatic and extrahepatic biliary ducts. • Extrahepatic cholangiocarcinomas constitute approximately two third of these tumors and may develop at the hilum (known as Klatskin tumor) or more distally in the biliary tree. • It occur mostly in person at 50-70 year of age. the prognosis is poor and most patients has unresectable tumor. • Both intra and extrahepatic cholangiocarcinoma are generally asymptomatic until they reach an advanced stage. Intraheptatic tumor might show symptom only when much of the liver is replaced by tumor, whereas extraheaptic might spread to sites as regional lymph nodes, lungs, bones, and adrenal gland.

24. Risk factors • primary sclerosing cholangitis, fibropolycystic disease of the biliary tree, and infestation by clonorchis sinensis(chinese liver fluke). • All the risk factors of cholangiocarcinoma cause chronic cholestasis and inflammation, which promote the occurence of somatic mutations in cholangiocytes. • There are several genetic changes that have been noted in these tumors, including activating mutation in the KRAS and BRAF oncogenes and loss of function mutation in the TP53 tumor suppressor gene.

25. Clinical features • Intrahepatic cholangiocarcinoma may be manifested by the presence of a liver mass and nonspecific signs and symptoms such as wight loss, pain, anorexia, and ascites. • Symptom and sign from extrahepatic: jaundice,wight loss, nausea, and vomiting, result from biliary obstruction. • Common finding includes elevated alkaline phosphatase, and aminotransferases

26. Treatment • Surgical resection, which is not curative in large majority of cases. Transplantation is contraindication. The mean survival time ranges from 6-18 months regardless of aggressive resection or palliative surgery is performed. • Chemotherapy or radiation may be given after surgery to decrease the risk of the cancer returning. • Endoscopic therapy with stent placement can temporarily relive blockages in the biliary duct and relieve jaundice in the patient when the tumor can not be removed. • Laser therapy combined with high activated chemotherapy medications is another treatment option for those with blockage of the bile duct.

27. Thanks  • Google • Current diaagnosis and treatment in surgery • Current diaagnosis and treatment in surgery