Q1. Endoscopic stone extraction from Common Bile Duct (CBD) is possible only in
a) Multiple bile duct stones
b) Intrahepatic bile duct stones
c) Multiple Gallstones
d) Prior Gastrectomy
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 is difficult in multiple gallstones, intrahepatic stones, large gallstones, impacted stones, duodenal diverticula, prior gastrectomy, bile duct stricture.
Sabiston 17 th page 1618
Q2. Which of the following is not the functions of bile?
a) Excretion of toxins and normal cellular metabolites
b) Absorbtion of lipids
c) Cholesterol excretion
d) Absorbtion of water soluble vitamins
Bile functions in two important ways in the human body
1st--- Liver is the major site of detoxification.Bile transport allows excretion of toxins and normal cellular metabolites
2nd important function of the bile is to form micelles which helps in absorbtion of lipids. in the deficiency of bile there is malabsorbtion of fat soluble vitamins
Bile also functions to remove excessive cholesterol
Bile has no role in absorbtion of water soluble vitamins like vitamin B
Q3. What is the management of choledochal cyst (bile duct 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.
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.
Q4. In the classification of cholangiocarcinoma of hepatic duct hilum (Klatskin tumor) by site, Type II is
a) Confined to the common hepatic duct
b) Involve the bifurcation without involvement of secondary intra hepatic ducts
c) Tumors extend into either the right or left secondary intra hepatic ducts, respectively.
d) Involve the secondary intrahepatic ducts on both sides.
Bismuth classification of perihilar cholangiocarcinoma by anatomical extent.
Type I tumors confined to 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.
Q5. What is not true regarding laparoscopic bile duct injuries?
a) As surgeon experience goes beyond twenty cases rate of bile duct 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
All are true but most of the injuries are due to visual perceptual illusion and not error of skill.
Q 6. Brown pigment stones, true is
a)They are earthy
b) stones Seen in Asian population
c) Easily breakable
d) All the above
Brown pigment stones are earthy in texture and are typically found in the bile ducts
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