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Biliary system Prof. Weilin Wang [email protected] Department of Hepatobiliary Pancreatic Surgery The First Affiliated Hospital

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Text of Biliary system Prof. Weilin Wang [email protected] Department of Hepatobiliary Pancreatic Surgery The...

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  • Biliary system Prof. Weilin Wang [email protected] Department of Hepatobiliary Pancreatic Surgery The First Affiliated Hospital
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  • Anatomy of Biliary System 1 Methods of Investigation 2 Disorders of Gallbladder 3 Disorders of Bile Duct 4 Case discussion 5
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  • Anatomy of Biliary System 1
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  • Extrahepatic Biliary Tract Bifurcation Common hepatic duct Common bile duct Cystic duct Gallbladder
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  • The liver secrete bile, bile flow from liver to right and left hepatic ducts. These ducts drain into the common hepatic duct. The common hepatic duct then joins with the cystic duct to form the common bile duct. Transportation of Bile
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  • About 50 percent of the bile produced by liver is first stored and concentrated in gallbladder. When food is taken, the gallbladder contracts and release stored bile into the duodeum to help digest the fats. Transportation of Bile
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  • Calot triangle The triangle is bounded by the cystic duct, the common hepatic duct, and the inferior border of the liver. Important structures including: the cystic artery, the right hepatic artery, and the cystic duct lymph node.
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  • Papilla of Vater Tthe opening of the bile duct and panceatic duct in the descending part of the duodenum. Through the papilla, bile and pancreatic juice pass to to bowel. obstructive jaundice or pancreatitis will happen when papilla of Vater was blocked by stones and tumors,
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  • Normal gallbladder
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  • Agenesis of the gallbladder is extremely rare, with a prevalence of 0.03-0.07 percent. Double gallbladder occurs in about 0.03 per cent, usually with a shared cyctic duct, and the accessory gallbladder is often diseased. Gallbladder Anatomical Variants
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  • Variations of biliary branching A Typical anatomy of the confluence. B Trifurcation of left, right anterior, and right posterior hepatic ducts. C Aberrant drainage of a right anterior (C1) or posterior (C2) sectoral hepatic duct into the common hepatic duct.
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  • Methods of Investigation 2
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  • Ultrasonography (B-US) CT, Computed Tomographic Magnetic Resonance Cholangiopancreatography Endoscopic Retrograde Cholangopancreatography Percutaneous Transhepatic Cholangiography T-tube cholangiography Radiographs Intraoperative cholangiography Endoscopic ultrasound Methods of investigation
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  • Fast, real-time, non-invasive, and no ionizing radiation, cheap and could be available even in countryside. 95% sensitivity for detection of cholelithiasis. --Found a mobile, hyperechoic with acoustic shadowing >90% sensitivity for detection of acute cholecystitis. --Gallbladder wall thickening, pericholecystic fluid B-US
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  • Normal Gallbladder Gallbladder, with sludge and stone present
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  • Gallstones can be seen on CT, but it is not used primarily for this purpose. CT can be used in situations where ultrasound is difficult -- such as in obese patients. It can also be used if the ultrasound is not definitive. CT scan
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  • Plain CT shows multiple gallstones.
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  • Multiple stones were found in the left intrahepatic bile duct.
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  • Becoming a more viable imaging technique New tool for non-invasive evaluation of the pancreatic and biliary ductal systems. Gradually replacing PTC and ERCP for diagnostic purposes. MRCP
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  • MRCP showed slight dilation of CBD Pancreatic duct Common bile duct
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  • Stones was detected in the bile duct by MRCP. Stones in CBD
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  • ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct. ERCP Left: The endoscope was introduced to the papilla of Vater and contrast medium was injected into common bile duct. Right: Radiographic result after the contrast medium was injected into the CBD.
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  • ERCP: Instruments can also be inserted through the scope to remove stones, insert stent, tissue biopsy, and other treatments.
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  • ERCP: showing slightly dilated common bile duct with calculus and normal pancreatic duct. Stones in CBD Endoscope Pancreatic duct
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  • Large stone was drawing out from CBD during ERCP was performing.
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  • Show the procedure of removal the stones using endoscope.
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  • ERCP.wmv
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  • PTC The catheter was placed into the intrahepatic bile duct through patients skin guiding by B-US and fixed on the skin. The radiographic image was taken. Obstructive lesion can be seen in this picture.
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  • Obstructive lesion
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  • Left : After injection of dye, showing a large gallstone trapped in the duct. Right: After removal of the stone through the drainage catheter. BeforeAfter
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  • Postoperatively Injection of contrast medium through a T-tube catheter placed in the CBD Easy way to show whether there are remaining stones or any stricture T-tube cholangiography
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  • T-tube graphy T-tube graphy
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  • Old technique used in the past, widely replaced by the ultrasound and MRCP. Can be used to visualize calcified stones by abdominal x-ray film. Radiographs
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  • Abdominal x-ray demonstrating stones in the gallbladder Stones
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  • Disorders of Gallbladder 3
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  • Acute cholecystitis Gallbladder stones and sludge Adenomyomatous hyperplasia Gallbladder polyps Gallbladder carcinoma Disorders of Gallbladder
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  • Calculous cholecystitis: over 90% Clinical manifestation: --Pain in right upper quadrant --Radiates to right shoulder & back --Nausea & vomiting --Chill and/or fever --Abdominal tenderness --Murphy's sign (+) Acute Cholecystitis
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  • Acute Cholecystitis: B-US The gallbladder contains small stones in the neck and its wall shows oedematous thickening (>5 mm thickness).
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  • Other B-US signs are: -- Gallbladder over distension --Pericholecystic fluid --GB wall thickening --
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  • Less accurate than B-US The CT findings : --Gallbladder wall thickening --Subserosal oedema --Gallbladder distension --Pericholecystic fluid --Gallstones Acute Cholecystitis: CT
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  • Fine, nonshadowing dependent echoes. Composed of calcium bilirubinate granules, cholesterol crystals. Gallstones will develop in 5-15 percent. Sludge
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  • Gallbladder, with sludge and stone present Stone Sludge
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  • Gallbladder polyps The majority of polyps are cholesterol Cholesterol polyps are usually 2- 10mm in size They appear as small echogenic nonshadowing foci adherent to the gallbladder wall Lack of mobility indicates polyp
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  • The affected segment often contains bright echoes Often associated with comet-tail Gallbladder-Adenomyomatosis
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  • Common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct. May result in biliary obstruction and jaundice If not recognized preoperatively, it can result in significant morbidity and mortality Mirrizzi syndrome
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  • Symptomatic cholelithiasis Non-functioning gallbladders (Full of stones) Malignant considered: GB polyps (>1.2cm) or others Indication for Cholecystectomy
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  • The first case was performed in 1882 One safe and effective method Direct visualization and palpation Open Cholecystectomy
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  • A less invasive way to remove the gallbladder Smaller incisions and less pain Shorter hospital stay and a shorter recovery time Laparoscopic Cholecystectomy
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  • Gallbladder Carcinoma Gallbladder carcinoma is associated with stones in over 90% of patients There is a female to male ratio of 3:1 Few patient was diagnosed prior to surgery
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  • Gallbladder Carcinoma
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  • TNM classification
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  • Direct invasion of the liver by gallbladder cancer in a 66-year-old woman Should differentiate gallbladder cancer from acute cholecystitis T?N?M? Quiz
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  • Treatment Radical surgery including segment liver resection, bile duct resection and extensive lymphadenectomy Poor prognosis in patients with unresectable tumor External radiation therapy may provide p

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