Q1. Endoscopic stone extraction from CBD is not possible in all except?
a) Multiple CBD stones
b) Intrahepatic stones
c) Multiple Gallstones
d) Prior Gastrectomy
Q2. What is the management of choledochal cyst adherent to portal vein?
a) Excision and Roux en y hepaticojejunostomy
b)Internal drainage into roux en y jejunal limb
c) Hepatic lobectomy
d) The internal lining of the cyst can be excised, leaving the external portion of the cyst wall intact.
Q3. In the classification of cholangiocarcinoma by site, Type II is
a) Confined to the common hepatic duct
b) Involve the bifurcation without involvement of secondary intrahepatic ducts
c) Tumors extend into either the right or left secondary intrahepatic ducts, respectively.
d) Involve the secondary intrahepatic ducts on both sides.
Q4. What is not true regarding laparoscopic biliary injuries?
a) As surgeon experience goes beyond twenty cases rate of biliary injusry decreases.
b) The rate of laparoscopic bile duct injury is approximately 0.8%
c) Most of the injuries are due to errors of judgement and skill
Q 5. Brown pigment stones, false is
a) Earthy
b) Seen in Asians
c) Easily breakable
d) All the above
Answers
1.a
Approximately 7% to 15% of patients undergoing cholecystectomy have common bile duct stones
1% to 2% of patients managed with laparoscopic cholecystectomy without a cholangiogram for gallstones present after the cholecystectomy with a retained stone.
Endoscopic sphincterotomy and stone extraction was introduced more than 20 years ago and permits common bile duct stones to be removed without the need for conventional surgery
Endoscopic stone extraction iis difficult in multiple gallstones, intrahepatic stones, large gallstones, impacted stones, duodenal diverticula, prior gastrectomy, bile duct stricture.
Sabiston 17 th page 1618
2. d
Total cyst excision with Roux-en-Y hepaticojejunostomy is the definitive procedure for management of types I and II choledochal cysts.
In cases whereby there is significant inflammation, it may be impossible to safely dissect the entire cyst way from the anterior surface of the portal vein. In these circumstances, the internal lining of the cyst can be excised, leaving the external portion of the cyst wall intact.
Type III cysts are typically approached by opening the duodenum, resecting the cyst wall with care to reconstruct and marsupialize the remnant pancreaticobiliary ducts to the duodenal mucosa.
In type IV cysts, the bile duct excision is coupled with a lateral hilar dissection to perform a jejunal anastomosis to the lowermost intrahepatic cysts. If the intrahepatic cysts are confined to a single lobe or segment, hepatic resection may be indicated.
The treatment of type V cysts involving both lobes is usually palliative with transhepatic or U tubes until liver transplantation can be performed.
Type I cysts represent 80% to 90% of cases and are simply cystic dilations of the common bile duct. Type II cysts are represented as a diverticulum arising from the common bile duct. Type III cysts are also referred to as choledochoceles and are isolated to the intrapancreatic portion of the common bile duct and frequently involve the ampulla. Type IV cysts are second in frequency and represent dilation of both intrahepatic and extrahepatic bile ducts. In type V cysts, only the intrahepatic ducts are dilated.
Type I cysts represent 80% to 90% of cases and are simply cystic dilations of the common bile duct. Type II cysts are represented as a diverticulum arising from the common bile duct.
Type III cysts are also referred to as choledochoceles
Type IV cysts are second in frequency and represent dilation of both intrahepatic and extrahepatic bile ducts.
In type V cysts, only the intrahepatic ducts are dilated.
3. b
Bismuth classification of perihilar cholangiocarcinoma by anatomical extent.
Type I tumors common hepatic duct
Type II tumors involve the bifurcation without involvement of secondary intrahepatic ducts.
Type IIIa and IIIb tumors extend into either the right or left secondary intrahepatic ducts, respectively. Type IV tumors involve the secondary intrahepatic ducts on both sides.
4. c
All are true but most of the injuries are due to visual perceptual illusion and not error of skill.
5. d
Brown pigment stones are earthy in texture and are typically found in the bile ducts, especially in Asian populations.
Brown stones often contain more cholesterol and calcium palmitate and occur as primary common duct stones in Western patients with disorders of biliary motility and associated bacterial infection.
