GS50 General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• asymptomatic or chronically itchy until acutely infected, then pain/tenderness, purulent discharge,

and increased moisture near the tailbone

Treatment

• acute abscess

• l&D (often performed by primary care physicians)

wound packed open

40% develop chronic pilonidal sinuses

• surgery

indication:failure of healing after l&D, recurrent disease, or complex disease

pilonidal cystotomy: excision ofsinus tract and cyst;wound closed by secondary intention (vac

dressing), primary closure with tissue flap,or marsupialization (cyst edge sewn to surrounding

tissue to leave sinus tract open)

Rectal Prolapse

Definition

• protrusion ofsome or all of rectal mucosa through external analsphincter

Epidemiology

• extremes of ages:<5 yr and >50 yr

• 85% women

Etiology

• lengthened attachment of rectum secondary to constantstraining

• 2 types

1. false/partial/mucosal: protrusion of mucosa only, radial furrows at junction with analskin;

most common type of rectal prolapse in childhood

2. true/complete (most common):full-thickness extrusion of rectal wall, concentric folds in:

- 1st degree: prolapse includes mucocutaneous junction

- 2nd degree: without involvement of mucocutaneous junction

- 3rd degree (internal intussusception): prolapse is internal, concealed, or occult

True rectal prolapse

Risk Factors

• gynaecological surgery

• chronic neurologic/psychiatric disorders affecting motility e.g. chronic constipation

• multiparity

• weak pelvic floor

Clinical Features

• extrusion of mass with increased intra-abdominal pressure

• difficulty in bowel regulation

tenesmus, constipation,fecal incontinence

• permanently extruded rectum with excoriation, ulceration, and constantsoiling

• may be associated with urinary incontinenceor uterine prolapse

• pain is not common

\

Ji Extornal hemorrhoids

Figure 23. Rectal prolapse (true vs.

false)

Treatment

• type I

conservative:gentle manual reduction of prolapsed area, especially in children

mucosectomy with excision of redundant mucosa, mostly in adults

• type 11

conservative: reduce if possible

« surgery:abdominal, perineal, and trans-sacral approaches

Anal Neoplasms

ANAL CANAL

Squamous Cell Carcinoma of Anal Canal (Distal to Dentate Line)

• most common tumour of anal canal (75%)

• anus prone to human papillomavirus (HPV) infection, therefore at risk for anal squamous intraepithelial lesions (ASIL)

high-grade squamous intra-epithelial lesion (HSIL) and low-grade squamous intra-epithelial

lesion (LSIL) terminology used

• clinical features: anal bleeding, pain, mass, ulceration, and pruritus; 25% asymptomatic

• treatment: chemotherapy ± radiation ± surgery

• prognosis:80% 5 yrsurvival

r *i

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GS5I General and Thoracic Surgery Toronto Notes 2023

Malignant Melanoma of Anal Canal

• 3rd most common site for primary malignant melanoma after skin, eyes

• aggressive, distant inetastases common at time of diagnosis

• occasionally an incidental finding in pathological evaluation of an anal specimen

• clinical features: bleeding, mass anorectal pain, change in bowel habits, pigmented in one third cases,

regional lymph node involvement

• treatment:wide excision or APR ± chemoradiation

• prognosis: <5% 5 vr survival

ANAL MARGIN

• clinical features and treatment as for skin tumours elsewhere

• squamous and basal cell carcinoma, Bowen'

s disease (SCC in situ), and Paget'

s disease

Liver

Inferior vena cava Inferior vena cava

Middle hepatic vein

/ Left hepatic vein Right hepatic Middle hepatic vein vein eft hepatic vein Right hepatic vein

Hepatic artery proper

Portal vein Portal vein

k. Bile duct Bile duct hepatic artery

proper

I

CN

O

I. Posterior (caudal)$egment IVa. Medialsegment (medialsuperior area) VI. Rightanterior lateralsegrnentlposterior inferior areal 5

II. LateralsegmentI lateralsuperior area) IVb. Medialsegment (medial inferior area) VII. Posterior lateralsegrnentlposteriorsuperior area) “

III.Left anterior lateralsegment V. Anterior medialsegment VIII. Posterior medialsegmentianteriorsuperior area)

(lateral inferior area) I anterior inferior area)

i

s

iz.

©

Figure 24. Anatomy of liver

Liver Cysts

Table 25. Characteristics of Liver Cysts

Simple Cysts Polycystic Liver Disease Choledochal Cysts Hydatid (Cystic

Echinococcosis)

Cystadenoma

(Premalignant)/

Cystadenocarcinoma

Description form from biliary ducts that

do not communicate with the

inlrahepatic biliary tree and

contain clear fluid

Most common

May have multiple cysts

Always benign

Eiamples include congenital

cysts.Catoli disease, biliary

hamartomas, and polycystic liver

disease IPCtO)

Clinical Features Usually asymptomatic

Mass died can cause: dull RUO

pain. N /V. bloabng, and/or early

satiety

Several (>20) cyststhat replace

much of the liver parenchyma

Autosomal dominant condition

More common in females

Congenital malformations ol the Infection with parasite

Echinococcus granulosus

Associated with exposure to

Cysladenomas ate rare cystic

neoplasms arising trom the

bile ducts

dogs,sheep,horses, pigs, goats. Cystadenoma is the most common

camels, and cattle in Southern premalignant liver lesion

Europe.Middle East, Australasia. Cystadenocarcinoma isan

South America

Ingested parasitic eggs hatch in

the small intestine, where larvae

enter blood and lymph

bile ducts

High-risk of malignancy

Majority present before age10

Todani classification based on

anatomical characteristics within

biliary tree invasive carcinoma

Minority present with acute

complications due to cyst

rupture, hemorrhage,infection,

and compression of adjacent

structures

Progressive

50% associated with polycystic

kidney disease (if ove r age GO)

U/S:cysts are well circumscribed

and nonenhancing

MRI:more sensitive and specific,

used for preoperative planning

Recurrent abdominal pain

Intermittent jaundice

RUO mass

Cholangitis

Symptomatic gallstones

Pancreatitis

Portal HIN

Upper abdominal mass

May have palpable RUO mass or Abdominal pain

Anorexia

Usually asymptomatic

hepatomegaly

Chronic RUO pain when

symptomatic

Nausea, lever, and dyspepsia are

non-specific symptoms

Labs:LfT abnormalities Labs: anti-Echinococcusab Labs:cystadenocarcinoma may

have elevated LFIs.CEA, or

CA 19-9

UIS:anccholc mass with internal

septations that are highly

cchogcnic

Investigations Labs:some have elevated GOT,

CEA.CA 19-9

U/S: Used for diagnosis and

followup

Cl:well demarcated lesion lhal

does notcnhancc with contrast

r t

U /S U/S

lJ

ct CT: calcified cystic walls

Iranshcpalic cholangiography Needle biopsy

ERCP

MRCP

Cl

MRI +

MRCP

ERCP

Need histology (or definite

diagnosis

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GS52 General and Thoracic Surgery Toronto Notes 2023

Table 25. Characteristics of Liver Cysts

Simple Cysts Polycystic Liver Disease Choledochal Cysts Hydatid (Cystic

Echinococcosis)

Cystadenoma

(Premalignant)/

Cystadenocarcinoma

Symptomatic patients: cyst

aspiration with sclerosis,cyst

fenestration, hepatic resection. if cystic dilatation involves

transarterial emboliiation. and

transplantation

Complete excision of cysts Systemic chemothera py:

Liver resection or transplantation Albendazole (anti-helminthic

drug) cure up to 30%

Surgical:radical (total

pcricystectomy, partial

hepatectomy, or lobectomy) vs.

conservative (drainage or open/

closed cystectomy)

Percutaneous: PAIR Ipuncture,

aspiration, injection, reaspiration)

Biliary cirrhosis, portal KIN.cyst IVC compression

rupture, or citolangiocarcinoma Cyst rupture which can cause

Increased risk of biliary fever, pruritis. eosinophilia.

malignancy biliary colic, jaundice.

cholangitis, pancreatitis,or

anaphylaxis

All complex,multiloculated cysls

(exceptechinococcal)should be

excised because of malignancy

Treatment Not required unless very large

and/or symptomatic

Monitor if >4 cm

laparoscopic or open cyst

wall removal (unroofing)is

established treatment and is

usually curative

Percutaneous aspiration and

ethanol sclerotherapy also an

option, butnot curative

inlrahepalic bile ducts(Caroli’s

disease)

lisk

Cystadenocarcinoma can invade

adjacent tissues and metastasize

Complications Hemorrhage, rupture,infection.

and biliary obstruction more

likely in larger cysts

Intracystic hemorrhage is

rare and presents with severe

abdominal pain

Liver Abscesses

Etiology

. types

pyogenic (bacterial):most common etiology; most often polymicrobial- Klebsiella, E. coli,

Proteus, Streptococcus, Staphylococcus,and anaerobes

parasitic (amoebic):Entamoeba histolytica,Hchinococcal cyst

fungal:Candida

sources: direct spread from biliary tract infection, portal spread from G1 infection,systemic

infection (e.g. endocarditis)

Clinical Features

• fever, malaise, chills, anorexia, weight loss, abdominal pain, and nausea

• RUQ tenderness, hepatomegaly, and jaundice

Investigations

• CBC (leukocytosis, anemia), Ll-Ts(elevated ALP and hypoalbuminemia common; elevated

transaminases and bilirubin variable), blood cultures, INR/PTT,stool cultures, and serology ( E.

histolytica and Echinococcus)

• CT or VIS are the imaging modalities used for diagnosis with abscess drainage for C&S to confirm

diagnosis; MRI can also be used.

Treatment

• treat underlying cause

• pyogenic abscesses generally treated with antibiotic therapy (e.g. ceftriaxone and metronidazole or

piperacillin-tazobactam) and VIS- or CT-guided percutaneous drainage orsurgical drainage

• consider potential source ofsepsis (e.g. biliary source, infected tumour)

Differential Diagnosis of Metastatic

Liver Mass

Some GU Cancers Produce Bumpy

Lumps

Stomach

Genitourinary cancers (kidney,ovary,

uterus)

Colon

Pancreas

Breast

Prognosis Lung

• overall mortality 15% - higher rate if delay in diagnosis, multiple abscesses, malnutrition, elderly, KiU

admissions, shock, cancer, cirrhosis, GKD, acute respiratory failure, and biliary origin of abscess

Neoplasms

BENIGN LIVER NEOPLASMS

Hemangioma (cavernous)

• pathogenesis: most common benign hepatic tumour; resultsfrom malformation and proliferation of

vascular endothelial cells

• risk factors: M:l

'

=3:1

• clinical features

• usually small and asymptomatic, those greater than 10 cm are considered giant and may cause

abdominal pain or discomfort

• consumptive coagulopathy if giant (in children)

• investigations

contrast CT (well-demarcated hypodense mass with peripheral enhancement on arterial phase

with centripetal filling on delayed phases),VIS (homogeneous hyperechoic mass),MR1

avoid biopsy: may result in hemorrhage

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GS53General and Thoracic Surgery Toronto Notes 2023

•treatment

none if asymptomatic

• in symptomatic patients or those with hemangiomas large enough causing mass effect,surgical

resection should be considered after other causes of pain are excluded

• surgical resection options: liver resection, hepatic artery ligation, enucleation, and in severe cases

liver transplantation.

non-surgical treatment: hepatic artery embolization and radiotherapy

Focal Nodular Hyperplasia

•pathogenesis: unclear, hyperplastic response to vascular anomaly leading to disorganized growth of

hepatocytes and bile ducts

•risk factors: female, reproductive age

•clinical features: usually asymptomatic, rarely grows or bleeds, and no malignant potential

•investigations: central stellate scar surrounded by homogenous lesion on CT scan; MRI,biopsy may be

required

•treatment: may be difficult to distinguish from adenoma/ffbrolamellar HCC (malignant potential)

• if confirmed to be l-

'

NH -> no treatment required

Liver Transplantation Criteria for

Hepatocellular Carcinoma

Milan Criteria* 1tumour <5an

Up to 3 tumours each

<3cm

UCSF Criteria* 1lumour <6.5 cm

Up 10 3 Innours each

s4.5cm,total diameter

s8cm

Toronto Criteria’ No tumoursireor number

restrictions

No systemk symptoms

Not poorly differentiated

Adenoma

•pathogenesis: benign abnormal growth of glandular epithelium

•risk factors: female, ages 20-50, estrogen (OCP, pregnancy), obesity, anabolic androgen use, and type 1

glycogen storage disease

•clinical features: asymptomatic, 25% present with RUQ pain or mass, may present with bleeding

•investigations: CT (well-demarcated masses, often heterogeneous enhancement on arterial phase,

isodense on venous phase without washout of contrast), U/S,MRI, biopsy can be considered, with

bleeding risk taken into account

•treatment

stop anabolic steroids or OCP

excise, especially if large (>5 cm), due to risk oftransformation to HCC and spontaneous rupture/

hemorrhage

'Euihctilerla auunanouMityjtkmino

nucravaMuldrlmeiofl

Child- Turcotte-Pugh Score (Prognosis

of Chronic Liver Disease/Cirrhosis,

including Postoperatively)

MALIGNANT LIVER NEOPLASMS

Primary

•most commonly HCC and cholangiocarcinoma

•others include angiosarcoma, hepatoblastoma, and hemangioendothelioma

•risk factors

chronic liver inflammation: cirrhosis from any cause, chronic hepatitis B (inherently oncogenic)

and hepatitis C, hemochromatosis, al -antitrypsin deficiency, and non-alcoholic steatohepatitis

medications: OCPs (3x increased risk),steroids

• smoking, alcohol, betel nuts chewing

chemical carcinogens: aflatoxin, microcvstin, and vinyl chloride (associated with angiosarcoma)

•clinical features

RUQ discomfort and rightshoulder pain

jaundice, weakness, weight loss, and ± fever (if central tumour necrosis)

hepatomegaly,bruit, and hepatic friction rub

• ascites with blood (sudden intra-abdominal hemorrhage)

paraneoplastic syndromes: hypoglycemia, hypercalcemia, erythrocytosis, and watery diarrhea

metastasis: lung, intra-abdominal lymph nodes, bone, adrenal gland, brain, and peritoneal

seeding

•investigations

• INR and LFTs: AST, ALT, ALP, bilirubin, and albumin

1Point 2Points 3PolnU

Albumin (g'L) »35 28-35 *2!

Absent Easily Poorty

cootrdM (or

*

olid

Biluutn <34 34-51 >51

(limolil)

Ascites

<2.0 20-3.0 >10

Coagulation <1.7 1J-23 >23

(mgfdll

in -1

Hepatic Hone Unriial

Encephalopathy

(Grade Ml) Mranced

(Grade III

Points Class OneYr IwoYr

Survival Survival

54 m isv

on 57%

45% 35%

A

7-9 1

elevated ALP, bilirubin, and a-fetoprotein (80% of patients)

U/S (poorly-defined margins with internal echoes), triphasic CT (enhancement on arterial phase

and washout on portal venous phase), and MRI

1015 C

•treatment

cirrhosis is a relative contraindication to tumour resection due to decreased hepatic reserve

surgical: resection (10% of patients have resectable tumours)

liver transplant; may use bridging therapy while awaiting transplant

absolute contraindications: extrahepatic disease and vascular invasion

relative contraindications: dependent on liver transplant protocol based on staging criteria

followed by transplant centre

non-surgical: radiofrequency ablation, percutaneous ethanol injection, transcatheter arterial

chemoembolization (TACE), chemotherapy (consider sorafenib for HCC; preoperative

chemotherapy for hepatoblastoma is standard of care),and radiotherapy

r t

L J

•prognosis

• 5 yr survival: 18% of all patients; 40-70% of patients undergoing complete resection

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GS5I General and Thoracic Surgery Toronto Notes 2023

Secondary

• metastases to the liver are the most common malignant tumoursfound in the liver

• etiology

G1 (colorectal most common),lung, breast, pancreas,GI NET,stomach, melanoma,ovary, uterus,

kidney,gallbladder, and prostate

Secondary liver metastases are common

inmany cancers,with some studies

showing a prevalence of 40-50%

amongst patients with oitrahepatic

cancers. They commonly arise from

colorectal,lung, and breast cancers.

For metastases secondary to colorectal

cancer,surgical resection offers the

greatest likelihood of cure

• treatment

depends on the primary cancer site and prognosis

often liver metastases are a manifestation of Stage IV disease and chemotherapy is indicated

metastasectomy may be appropriate for cancers either through surgical resection or local

treatment (i.e. embolization)

hepatic resection of metastatic colorectal liver metastases isstandard of care as part of multimodality treatment that includes chemotherapy if complete resection of the primary cancer

and metastases is possible

transplant also a new and emerging alternative for metastatic disease in the liver.

• prognosis

• following liver resection for colorectal metastases is an overall survival of 30-60% at 5 yr

Liver Transplantation

Table 26. Conditions Leading to Transplantation Living Liver Donors vs. Deceased Liver

Donors

The right lobe of a living donor liver is

transplanted into the recipient whereas

whole livers from deceased donors are

transplanted orthotopically into the

recipient

Parenchymal Disease Cholestatic Disease Inborn Errors Tumours

Chronic hepatitis B or C *

Alcoholic cirrhosis

Acute liver failure

Budd-Chiari syndrome

Congcnilal hepatic fibrosis

Biliary atresia"

Primary biliary cirrhosis

Sclerosing cholangitis

atantilrypsin deficiency

Wilson's disease

Hemochromatosis

Hepatocellular carcinoma

Hepatoblastoma

Metastatic NETs

Coloredal cancer

Li

Autoimmune hepatitis

Cryptogenic cirrhosis

Drug induced hepabtoxicity

Non-alcoholic sleatohepatitis

'leading cause in adults:"leading cause in children

Clinical Indications

• early referral for transplant should be considered for all patients with progressive liver disease not

responsive to medical therapy, especially:

decompensated cirrhosis (ascites, esophageal variceal hemorrhage,spontaneous hepatic

encephalopathy, coagulopathy, progressive jaundice,severe fatigue)

unresectable primary liver cancers

unresectable but localized liver metastasis of colorectal cancer - new emerging indication

• acute liver failure

liver-based metabolic conditions including a-l-antitrypsin deficiency

• end-stage liver disease with life expectancy <1 yr and if no other therapy is appropriate

• suitable HCC not amenable to liver resection

Criteria for Transplantation

• Model for End-Stage Liver Disease (MELD): prognostic model to estimate 3 mo survival following

transjugular intrahepatic portosystemic shunt (TIPS) procedure and to prioritize patients awaiting

liver transplant;based on creatinine, bilirubin, IN R,sodium (MELD-Na), female sex, and serum

albumin;MELD scores used to prioritize liver allocation

• Child-Turcotte-Pugh Score:classification system to assess the prognosis and the abdominalsurgery

perioperative mortality of chronic liver disease and cirrhosis; patient must have 7 points (Class B) for

transplant evaluation

Contraindications

• active alcohol/substance use

• extrahepatic malignancy within 5 yr

• advanced cardiopulmonary dis

• active uncontrolled infection

ease

Postoperative Complications

• primary non-function (graft failure): urgent re-transplantation is indicated

• acute and chronic rejection, ischemia-reperfusion injury

• vascular: hepatic artery or portal vein thrombosis, IVC obstruction

• biliary complications: fever, increasing bilirubin

• complications related to immunosuppression: HTN, renal disease, DM, obesity, hyperlipidemia,

osteoporosis,malignancy, neurologic complications, infection (leading cause of mortality following

transplant)

Prognosis

• patientsurvival at 1 yr:85%

• graft survival at 1 yr: >80%, at 5 yr:60-70%

rt

and ALF

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GS55 General and Thoracic Surgery Toronto Notes 2023

Biliary Tract

Cholelithiasis

<§

>

Definition

• the presence ofstones in the gallbladder

Risk Factorsfor Cholesterol Stones

Pathogenesis

• imbalance of cholesterol and itssolubilizing agents ( bile salts and lecithin)

• excess hepatic cholesterol secretion relative to bile salts and lecithin > supersaturated cholesterol

which precipitates as gallstones

• North America:cholesterol stones (80%), pigment stones(20%)

Risk Factors

• cholesterol stones

• obesity

• increasing age

prevalence higher in females (especially females <50 y r)

• estrogens:female, multiparity,OCPs

• impaired gallbladder emptying:starvation, T'

PN, DM

rapid weight loss:rapid cholesterol mobilization and biliary stasis

• pigmentstones(contain calcium bilirubinate)

cirrhosis

chronic hemolysis

biliary stasis (strictures, dilation, biliary infection)

terminal ileal resection or disease (e.g. Crohn'

s disease)

• protective factors

• statins, physical activity, vitamin C, poly- and monounsaturated fats and nuts, coffee

4Fs

Fat

Female

Fertile

Forties

Summary of Biliary Tract Conditions

Gallbladder Asympto- Pain Infection -

matk Only Pain

Cholelithiasis •

Nionlr)

Biliary Celle

Cholecystitis V

Common Bile Asympto- Pah Infection*

Duct matk Only Pain

Uioledoclmlilhiaiis (napAyl

Cholangitis

J

J

(majority)

Cholelilliiasis/Cholecvslitis

Common hepatic duct

Cystic duct

Gallbladder

LigamentolTreitz

Pancreas

Pancreatic duct Choledocholllhiasis/Cholangitis

Sphincter of Oddi

Ampulla of Veter Duodenum

Cliolecystoenleric fistula may

lead to gallstone ileus © Morry Shiyu Wang 2012

Figure 25. Gallstone disease

Clinical Features

• asymptomatic (80%):found incidentally

18% risk of progression to symptomatic gallstone disease within 20 yr

most do NOT require treatment

• consider cholecystectomy if: increased risk of malignancy (choledochal cysts,Caroli’s disease,

porcelain or calcified gallbladder),sickle cell disease, paediatric patient, bariatric surgery, and

immunosuppression

. biliary colic (10-25%)

Investigations

• normal Woodwork:CBC, electrolytes, Gr, LITs, bilirubin, lipase

• U/S:diagnostic procedure of choice

image for signs of inflammation, obstruction, and localization ofstones

• 95% specific for detecting stones

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Biliary Colic

Pathogenesis

• gallstone transiently impacted in cystic duct, no infection

Clinical Features

• an episode of steady,severe dull pain in the epigastrium or RUQ lasting minutes to hours(<6 h),

crescendo-decrescendo pattern

• can present with chest pain, right shoulder tip pain,scapular pain

. N/V

• frequently occurs at night or after fatty meal, not after fasting

• no peritoneal findings, no systemic signs

Biliary colic is a pain that comes and

goes, but cholecystitis is a pain which is

constant and usually increasing

2 Most Important Lab Tests lor Biliary

1' II I!

• Lipase:to determine if element of

pancreatitis

• Bilirubin:to determine if bile duct

Investigations obstruction

• normal blood work:CBC, electrolytes,Cr,LFTs, bilirubin,lipase

* U/S shows cholelithiasis,may show stone in cystic duct

Treatment

o

• analgesia, rehydration during colic episode

• elective cholecystectomy (95% success)

complications:CBD injury (0.3-0.5%), hollow viscus injury, bile peritonitis, and vessel injury

leading to liver damage

laparoscopic cholecystectomy isthe standard of care, no benefit to delayingsurgery

Biliary colic istreated with analgesia and

elective cholecystectomy

Acute cholecystitis is treated with

antibiotics and early cholecystectomy if

surgical risk appropriate

Acute Cholecystitis Toronto Video Atlas of Surgery:

Standard Laparoscopic

Cholecystectomy

TV Asurg is an open accesslibrary of

animation enhanced surgical videos

created by surgeons in Toronto. For

a videosimulation of a standard

laparoscopic cholecystectomy,see

pie.med.utoronto.ca/TVASurqfproiect/

Pathogenesis

• inflammation of gallbladder resulting from sustained gallstone impaction in cystic duct or

Hartmanns pouch

• no cholelithiasisin 5-10% (see AcalculousCholecystitis,GS57)

Clinical Features

• often have history of biliary colic

• severe constant (>6 h ) epigastric or RUQ pain, anorexia, N/V, and low grade fever (<38.5"C)

• focal peritoneal findings: Murphy'

ssign, palpable, and tender gallbladder (in 33%)

• Boas'

sign:rightsubscapular pain

Investigations

• blood work: elevated WBC and left shift,mildly elevated bilirubin concerning for bile duct obstruction

(eitherstones or Mirizzisyndrome)

• U/S:98% sensitive, consider HI DA scan if U/S negative

• signs:gallbladder wall thickening >4 mm, edema (double-wall sign), gallbladder sludge,

cholelithiasis, pericholecystic fluid, and sonographic Murphy'

s sign

Mirizzi Syndrome

Extrinsic compression of the CHD

by a gallstone in the cystic duct

or Hartmann 's pouch. Impacted

gallstone may erode into the CHD or

CBD, creating a cholccystohepatic or

cholecystocholedochal fistula: Mirizzi

syndrome has an association with

gallbladder cancer

Complications

• gangrenous gallbladder (20%) most common complication

• perforation (10%):result in abscessformation or rarely local peritonitis

• Mirizzi syndrome:extra-luminal compression of CBD/CHD due to large stone in cystic duct

• empyema of gallbladder:suppurative cholecystitis (pus in gallbladder) and sick patient

• emphysematous cholecystitis: bacterial gas present in gallbladder lumen, wall, or pericholecystic space

(risk in diabetic patient); organisms involved in secondary infection:C. welchii, E.coll, Klebsiella,

anaerobic streptococci, Enterococcus

• cholecystoenteric fistula (from repeated attacks of cholecystitis) can lead to gallstone ileus

Rouviere's Sulcus

Fissure between right lobe and caudate

process (segment I) of liver; keeping

dissection anterior to this landmark can

minimize bile duct injury

Treatment

• admit, hydrate, NPO, NG tube (if persistent vomiting from associated ileus), analgesics

• antibiotics

• cefazolin if uncomplicated cholecystitis

• ERCP prior to surgery if CBD stones are present on US

MRCP ± ERCP if CBD is markedly dilated or CBD stonessuspected

• cholecystectomy

early (within 72 h) vs.delayed (after 6 wk)

equal morbidity and mortality

early cholecystectomy preferred:shorter hospitalization and recovery time, no benefit to

delaying surgery

emergent OR indicated if high-risk, e.g. emphysematous

• laparoscopic isstandard of care (convert to open for complications or difficult case)

reduced risk of wound infections,shorter hospital stay,reduced postoperative pain, and

increased risk of bile duct injury

• intraoperative cholangiography (IOC)

indications:clarify bile duct anatomy, history of biliary pancreatitis,small stonesin gallbladder

with a wide cystic duct (>15 mm), and jaundice

Critical View of Safety (CVS)

Decreases risk of injury to CBD during

laparoscopic cholecystectomy . 3criteria

are required to achieve the CVS:

1. The hepatocystic triangle (formed

by the cystic duct,CHD, and inferior

edge of the liver) is cleared of fat and

fibroustissue

2.The lower one third of the gallbladder

isseparated from the liver to expose

the cystic plate

3.Two and only two structuresshould be

seen entering the gallbladder (cystic

duct and artery)

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GS57 General and Thoracic Surgery Toronto Notes 2023

has been mostly replaced by preoperative MRCP

• percutaneous cholecystostonty tube:critically ill or if general anesthetic contraindicated

• some centres can perform percutaneous stone extraction to avoid cholecystectomy

Acalculous Cholecystitis

Definition

• acute or chronic cholecystitis in the absence of stones

Pathogenesis

• typically due to gallbladder ischemia and stasis

Risk Factors

• ICU admission (most common), DM, immunosuppression, trauma patient,TPN, and sepsis

Clinical Features

• see AcuteCholecystitis,GS56

• occurs in 10% of cases of acute cholecystitis

Investigations

• Woodwork:CBC, electrolytes,Cr, LFl'

s,liver enzymes, bilirubin, and lipase

• U/S:showssludge in gallbladder, other U/S features of cholecystitis (see Acute Cholecystitis,GS56)

. CT or HIDA scan

Treatment

• NPO, IV fluids, and pain management

• IV broad-spectrum antibiotics, cholecystectomy

• if patient unstable -> percutaneous cholecystostomy

Choledocholithiasis

Definition

. stones in CBD

Clinical Features

• often have history of biliary colic

• tenderness in RUQ or epigastrium

• acholic stool, dark urine, and fluctuating jaundice

• primary vs.secondary stones

primary:formed in bile duct, indicates bile duct pathology (e.g. benign biliary stricture,

sclerosing cholangitis, choledochal cyst, and CP)

• secondary: formed in gallbladder (85% of cases in the U.S.)

Investigations

• CBC: usually normal; leukocytosissuggests cholangitis

• LI- Ts: increased AST, ALT early in disease, increased bilirubin (more sensitive), ALP, GGT later

• lipase: to rule out gallstone pancreatitis

• U/S:intra-/extra-hepatic duct dilatation;differential diagnosis is choledochal cyst

. MRCP (90% sensitive)

visualization of ampullar)'region, biliar)’,and pancreatic anatomy

non-invasive diagnostic test of choice

. ERCP

CBD stones in periampullary region

diagnostic and therapeutic; removal of stones and sphincterotomy possible

complications: retained stones, ERCP pancreatitis (1-2%),pancreatic or biliary sepsis

• Percutaneous Transhepatic Cholangiography

percutaneous approach to the proximal biliary tree (i.e. intrahepatic biliary system) via the

hepatic parenchyma

useful for proximal bile duct obstruction or when ERCP fails or not available

• contraindications:ascites, peri/intrahepatic sepsis, and disease of right lower lung or pleura

complications:bile peritonitis, chylothorax, pneumothorax,biliary sepsis, and hemobilia

• Intraoperative Cholangiography (IOC)

« intraoperative injection of radiographic contrast into the cystic duct to evaluate CBD during

laparoscopic cholecystectomy

useful for identifying CBD stones, clarifying biliary anatomy, and preventing CBD injury during

cholecystectomy

American Society of Gastrointestinal

Endoscopy 2019 Guideline on

Ible of Endoscopy in Evaluating

Choledocolithiasis

Proceed directly to ERCP

• CBD stone on U/S

• Clinical ascending cholangitis

. Bilirubin >4mg/dL (>347umol/L) &

dilated CBD on U/S

Perform U/S, MRCP, Laparoscopic IOC

or Intraoperative US

. Abnormal liver tests

• Age >55 yr

. Dilated CBD on U/S

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Complications

• cholangitis, pancreatitis, biliary stricture, and biliary cirrhosis

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Treatment

• treat with ERCP for CBD stone extraction possibly followed by elective cholecystectomy in 25% of

patients

• biliary tree flushing with laparoscopic cholecystectomy:

during a laparoscopic cholecystectomy ± cholangiogram, the cystic duct can be flushed to the

CBD with the use of glucagon to relax the sphincter between the CBD and duodenum.Can also

use cholangiogram to confirm stones flushed into duodenum

Acute Cholangitis

Pathogenesis

• obstruction of CBD leading to biliary stasis, bacterial overgrowth,suppuration, and biliary sepsismay be life-threatening, especially in elderly

Etiology

• choledocholithiasis (60%),stricture, neoplasm ( pancreatic or biliary), extrinsic compression

(pancreatic pseudocyst or pancreatitis), instrumentation of bile ducts (PTC, ERCP), and biliary stent

• organisms: E. coli,Klebsiella, Enterobacter, Pseudomonas, Enterococcus, B.fragilis,and Proteus

Clinical Features

• Charcot’

s triad:fever, RUQ pain, and jaundice

• Reynold’s pentad:Charcot’striad,hypotension, and altered mentalstatus

• may have N/V,abdominal distention, ileus, acholic stools, and tea-coloured urine (elevated direct

bilirubin)

Charcot’sTriad

Fever.RUO pain, jaundice

Investigations

• GBC:elevated WBC i left shift

• may have positive blood cultures

• LITs:obstructive picture (elevated ALP, GGT, and conjugated bilirubin, possible mild increase in AST,

ALT )

• lipase: rule out pancreatitis

• U/S: intra-/extra-hepatic duct dilatation

• CT:bile duct dilatation and can identify biliary stenosis

• MRCP when diagnosisis unclear

Reynolds' Pentad

Fever.RUO pain, jaundice,shock, and

altered mentalstatus

Common Bacteria in Biliary Tract

KEEPS

Klebsiella

Enterococcus

F.coli, Enterobacter

Proteus. Pseudomonas

Serrotia

Treatment

• initial:NPO,fluid and electrolyte resuscitation,± NG tube, IV antibiotics (treats 80%)

. biliary decompression

ERCP t sphincterotomy:diagnostic and therapeutic

PTC with catheter drainage: if ERCP not available or unsuccessful

open or laparoscopic CBD exploration and I -tube placement if above fails

• in addition to biliary decompression, the underlying cause should be addressed. In the case of

patients with choledocholithiasis, elective cholecystectomy is recommended after resolution of acute

cholangitis to prevent re-occurrence

Prognosis

• suppurative cholangitis mortality rate:20-30%

Gallstone Ileus

Pathogenesis

• repeated inflammation causes a cholecystoenteric fistula (usually duodenal) -> large gallstone enters

the G1 tract (impacting near the ileocecal valve) causing a mechanical bowel obstruction (note:ileus is

a misnomer in this context)

Rigler's Triad of Gallstone Ileus

Pneumobllia

Small bowd obstruction

Gallstone

Clinical Features

• crantpy abdominal pain, N/V, constipation/obstipation (see Large Bowel Obstruction, ( IS37)

Investigations

• AXR: dilated small intestine, air fluid levels, may reveal radiopaque gallstone, and air in biliary tree

(pneumobilia) (40%)

• CT:biliary tract air,obstruction, and gallstone in intestine

• Rigler’s triad: pneumobilia,SBO (partial or complete),and gallstone (usually in right iliac fossa)

ft)

Bouveret'sSyndrome

Gastric outlet/duodenal obstruction

caused by a large gallstone passing

through a cholecystogastric or

cholecystoduodenal fistula

n

LJ

Treatment

• fluid resuscitation, NG tube decompression

• surgery: enterolithotomy and removal of stone, inspect small and large bowel for additional proximal

stones

• may close fistula surgically or manage expectantly (can resolve spontaneously)

• cholecystectomy is generally not performed

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GS59 General and Thoracic Surgery Toronto Xotes 2023

Carcinoma of the Gallbladder

Risk Factors

• chronic symptomatic gallstones (70% of eases), old age, female, gallbladder polvps, porcelain

gallbladder, chronic infection (Salmonella, Helicobacter), primary sclerosing cholangitis, and

abnormal pancreaticobiliary duct junction

Clinical Features

• majority are adenocarcinoma

• may be incidental finding on elective cholecystectomy (~1% of open cholecystectomies OR 0.1% in

laparoscopic cholecystectomies)

• many patients are asymptomatic until late

• local: non-specific RUQ pain ± palpable RUQ mass

• Courvoisier’s gallbladdersign:enlarged gallbladder and painless jaundice due to obstruction of CBD,

suggestive of gallbladder or pancreatic malignancy'

• systemic: jaundice (50%) due to invasion of CBD or compression of CBD by pericholedochal nodes,

anorexia, N/V,weight loss, and malaise

• early local extension to liver, peritoneum, may extend to stomach, duodenum

• early metastasis common to lung, pleura,liver bone

Investigations

• U/S:mural thickening, calcification, loss of interface between gallbladder and liver, and fixed mass

• endoscopic U/S (BUS): good for distinguishing carcinomas from other diagnosessuch as, polyps,

staging, allowssampling of bile for cytology

• abdominal CT: polypoid mass, mural thickening,liver invasion, nodal involvement,and distant

metastases

• MRI/MRCP: good for distinguishing benign and malignant polyps

Treatment

• if carcinoma of the gallbladder is suspected preoperativcly, an open cholecystectomy should be

considered to avoid tumourseeding of the peritoneal cavity

• confined to mucosa (rare): cholecystectomy

• beyond mucosa: cholecystectomy, en bloc wedge resection of 3-5 cm underlying liver, and dissection

of hepatoduodenal lymph nodes

Prognosis

• poor 5 yrsurvival (20%) as gallbladder carcinoma is often detected late

• better outcomes when detected incidentally following cholecystectomy

Cholangiocarcinoma

Definition

• malignancy of the epithelial cells of extra- or intrahepatic bile ducts

Risk Factors

• ages 50-70, gallstones, UC, primary sclerosing cholangitis, choledochal cyst, Clonorchissinensis

infection (liver fluke), chronic intrahepatic stones (hepatolithiasis), genetic disorders (Lynch

syndrome, Cl;

, multiple biliary papillomatosis, BARI tumour predisposition syndrome)

Clinical Features

• majority are adenocarcinomas

• gradual signs of biliary obstruction:jaundice, pruritus, dark urine, and pale stools

• anorexia, weight loss, RUQ pain,Courvoisicr’ssign (if CBD obstructed), hepatomegaly

• early metastases are uncommon, but commonly tumour grows into portal vein or hepatic artery,

peritoneum, lungs, pleura, liver

• Klatskin tumour: cholangiocarcinoma located at bifurcation of CHD

Obstructive jaundice Is the most

common presenting symptom for

cholangiocarcinoma

Investigations

• Ll'

T'

sshow obstructive picture, carbohydrate antigen 19-9 (CA 19-9),CEA may be elevated

• U/S,CT:bile ducts usually dilated, but not necessarily

• ERCP or PTC:to determine resectability,for biopsies

• CXR,bone scan:for metastatic w orkup

Treatment

• if resectable:biliary drainage and wide excision margin

• intrahepatic lesions:liver resection after clear discussion at multidisciplinary tumour boards and

prognosis understood

upper third lesions:duct resection + Roux-en-Y hepaticojejunostomy, ± liver resection

middle third lesions (uncommon):duct resection + Roux-en-Y hepaticojejunostomy

lower third lesions:Whipple procedure

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GS60 General and Thoracic Surgery Toronto Notes 2023

•unresectablc lesions:stent or choledochojejunostomy (surgical bypass)

•chemotherapy ± radiotherapy

•role for transplantation in select patients with Klatskin tumours or NET with no evidence of

extrahepatic disease and relative stability

Prognosis

•overall 5 yrsurvival:localized 30%, regional 24%, distant 2%

Pancreas

Acute Pancreatitis

• see < i \troi iiternh >g\ , ti IS

GALLSTONE PANCREATITIS (45% of Acute Pancreatitis)

Pathogenesis

• obstruction of pancreatic duct by large orsmall gallstones and biliary sludge

• backup of pancreatic enzymes can cause autodigestion of the pancreas

Clinical Features (Pancreatitis of Any Etiology)

• pain (epigastric pain radiating to back), N/V,ileus, peritonealsigns, jaundice, and fever

• Inglefinger’

ssign: pain worse when supine, and better when sitting forward

• may have coexistent cholangitis or pancreatic necrosis

• Kanson'

s criteria for determining prognosis of acute pancreatitis (see sidebar)

• APACHE 11 score for determining prognosis of severe acute pancreatitis

• physical exam may show tachypnea,tachycardia, hypotension,abdominal distention and tenderness,

Cullen’ssign, and Grey Turner’ssign

Investigations

• lipase (most sensitive and specific), elevated amylase (higher than alcoholic pancreatitis), and

leukocytosis

• elevated ALT (>I50 1U/L), AST strongly suggest gallstone etiology of pancreatitis

• U/S may show multiple stones (may have passed spontaneously), and edematous pancreas

• CXK, AXR, and CT (if severe to evaluate for complications)

Ranson'

s Criteria

A.At admission

1. Ages >55yr

2. WBC >16*

tO’

/L

3. Glucose >11 mmol/L

4. LDH >3S0 IU/l

5.AST >250 IU/L

B. During initial 48 h

1. Hct drop >10%

2. BUN rise >1.8 mmol/l

3. Arterial POJ <60 mmHg

4.Base deficit >4 mmol/L

5.Calcium <2 mmol/L

6.Fluid sequestration >6 L

C. Interpretation

<3-severe pancreatitis unlikely (2%

mortality)

23- high mortality (218%)

Treatment

• supportive:e.g. NPO, hydration, analgesia, and early enteral nutrition

• antibiotics are not indicated for initial diagnosis.This is reserved for clear signs of infection on

imaging

• stone often passes spontaneously (

—90%); usually no surgical management in uncomplicated acute

pancreatitis

• cholecystectomy during same admission (25-60% recurrence if no surgery)

. may need urgent ERCP + sphincterotomy if CBD stone impacted or cholangitis

• surgical indications in acute pancreatitis (rare):

drain placement and debridement for necrotizing pancreatitis if refractory to medical

management, if septic,or in 1CU without other sources of sepsis

Complications

• local complications

acute lluid collections

walled-off pancreatic fluid collection/pseudocyst (>4 wk old)

abscess/infection, necrosis

• systemic complications

splenic/mesenteric/portal vessel thrombosis

pancreatic ascites/pancreatic pleural effusion

DM (b/c pancreatic & insulin insufficiency)

ARDS/sepsis/multiorgan failure

coagulopathy/DIC

severe hypocalcemia ri

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Chronic Pancreatitis

• SCC (

iastroenUToIouv. (i50

Surgical Treatment

• treatment is generally medical

• indications for surgery

failure of medical treatment

debilitating abdominal pain

• pseudocyst complications: persistence, hemorrhage, infection, and rupture

CBD obstruction (e.g.strictures) and duodenal obstruction

• pancreatic fistula, variceal hemorrhage secondary to splenic vein obstruction

• rule out pancreatic cancer (present in 15% of chronic pancreatitis treated surgically)

anatomical abnormality causing recurrent pancreatitis

preoperative CT and/or ERCP are mandatory to delineate anatomy

• minimally invasive options

endoscopic pancreatic duct decompression: less effective than surgery’

extracorporeal shockwave lithotripsy: if pancreatic ductstones

celiac plexus block:lasting benefit in 30% patients, less effective in those <45 yr or with prior

pancreatic surgery

• surgical options

drainage procedures:only effective if ductalsystem is dilated

Puestow procedure (lateral pancreaticojejunostomy):improves pain in 80% of patients

pancreatectomy:best option in absence of dilated duct

Whipple procedure (pancreaticoduodenectomy): proximal disease

distal pancreatectomy ± Koux-en-Y pancreaticojejunostomy: distal disease

total pancreatectomy: refractory disease

• islet cells autotransplantation can be used to control insulin-related morbidity

denervation of celiac ganglion and splanchnic nerves

WALLED-OFF PANCREATIC FLUID COLLECTIONS (PSEUDOCYSTS)

• localized fluid collections rich in pancreatic enzymes, with a non-epithelialized wall consisting of

fibrous and granulation tissue

• complication of chronic and/or acute pancreatitis

• up to 40% resolve spontaneously

• cyst wall must be mature prior to drainage (4-6 wk)

• pseudoaneurysm an absolute contraindication to endoscopic drainage, must embolize first

Pseudocyst Management

• if asymptomatic:expectant management

• if symptomatic: choice of drainage procedure depends on location of fluid collection

endoscopic drainage: transmural vs. transpapillary (pseudoaneurysm an absolute

contraindication, must embolize first)

surgical drainage: cystogastrostomy vs. cystoduodenostomy vs. cystojejunostomy

percutaneous catheter drainage

resection

if draining,attempt to biopsy cyst wall to rule out cystadenocarcinoma

The hallmark of chronic pancreatitis is

epigastric pain radiating to the back

Total Panutattctuay and Islet

Autotransplantation:A Decade Nationwide

Analysis

World J transplant 2016.6|T):233’238

Purpose:to investigate outcomes and predictors

of in-hosprtal mortmAty and mortality alter total

pancreatectomy (TP) and islet autotransplantation.

Results:A total of 923 patients underwent IAT after

pancreatectomy during 2002-2012.Tire most common

indication of surgery was chronic pancreatitis

!( 6%|followed try acute pancreatitis(12%). Overall

morlality and morhdity ol patients weie 0% and

57.8 %. respectively. Post surgical hypolnsulioemia

was reported m 42.3% of patients.Indicating that

57.1% of patients were insulin independent during

hospitalization.Predictors of in-hospital morbidity

were obesity.fluid and electrolyte disorders,alcohol

use,and weight loss.

Conclusion:Total pancreatectomy islet

autotransplantaboo isa safe procedure with no

mortality, acceptable morbidity, and achieved high

rale of early insul>n independence.Obesity is the most

significant predictor of in-hospital morbidity.

Pancreatic Cancer

Epidemiology

• 4th most common cause of cancer-related mortality in both men and women in Canada

• M:F=1.3:1, average ages:50-70

Risk Factors

• increased age

• smoking: 2-5x increased risk, most dearly established risk factor

• high fat/low fibre diets

• heavy alcohol use

• obesity

• DM, chronic pancreatitis

• partial gastrectomy

• cholecystectomy

• chemicals: p-naphthylamine, benzidine

• African descent

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Clinical Features

• the most common presenting symptoms are abdominal pain, jaundice, and weight loss

• head of the pancreas (70%)

pancreatic head tumours typically present with jaundice, steatorrhea, and weight loss

other features include anorexia, dark urine, hepatomegaly, cachexia, Courvoisier’s sign, recent

onset DM

• body or tail of pancreas (30%)

tendsto present later and usually inoperable (80% are unresectable at diagnosis)

• weight loss, vague mid-epigastric pain

• <10% jaundiced

Trousseau's Sign

Spontaneous peripheral venous

thrombosis, often associated with

pancreatic and other cancers

Vague abdominal pain with weight loss

Z jaundice in a patient over SO yr is

pancreatic cancer until proven otherwise

Investigations

• serum chemistry is non-specific, LFTs may show obstructive jaundice (elevated ALP and bilirubin)

• CA 19-9 most useful serum marker of pancreatic cancer

• U/S,CT (also evaluates metastasis and resectability) ± LRC.P, MR1, EUS Courvoisier'

s Sign

Palpable, nontender, distended

gallbladder due to CBD obstruction.

Present in 33% of patients with

pancreatic carcinoma. The distended

gallbladder could not be due to acute

cholecystitis orstone disease because

the gallbladder would actually be

scarred and smaller, not larger

Pathology

• ductal adenocarcinoma: most common type (75-80%); exocrine pancreas

• intraductal papillary mucinous neoplasm (1PMN )

• other: pancreatic NETs (non-functional, insulinoma, gastrinoma, VIPoma, glucagonoma,

somatostatinoma), mucinous cystic neoplasm (MCN), acinar cell carcinoma

• see Surgical tndocrinology, ( IS7I for functional pancreatic NETs

Treatment

• resectable (10-20% of pancreatic cancer)

• no involvement of liver, peritoneum, or vasculature (hepatic artery, SMA, SM V, portal vein, 1VC,

aorta), no distant metastasis

Whipple procedure (pancreaticoduodenectomy) for cure <5% mortality

distal pancreatectomy ± splenectomy, lymphadenectomy if carcinoma of midbody and tail of

pancreas

adjuvant chemotherapy recommended (gemcitabinc i capecitabine, 5-I U/leucovorin)

• locally advanced, borderline resectable

tumours that abut the SMA, SM V, portal vein, hepatic artery, or celiac artery

• locally advanced, non-resectable (palliative -> relieve pain,obstruction)

• encasement of major vascularstructuresincluding arteries

most body/tail tumours are not resectable (due to late presentation)

• relieve biliary/duodenal obstruction with endoscopic stenting or double bypass procedure

(choledochoenterostomy i gastroenterostomy)

• palliative chemotherapy (gemcitabine + nab- paclitaxel, EOLEIRINOX) ± radiotherapy

Prognosis

• most important poor prognostic indicators are lymph node status, margin status,size >3 cm,

perineural invasion (invasion of tumour into microscopic nerves of pancreas)

• overall 5 yr survival for all patients with pancreas cancer is 1%; following surgical resection 5 yr

survival is 20%

• median survival for unresectable disease:3-6 mo if metastatic, 8-12 mo if locally advanced at

presentation

Steps of a Whipple Resection

(Pancreaticoduodenectomy)

1. Assessment of metastatic disease (all

peritonealsurfaces)

2. Mobilization of the hepatic flexure of

the colon

3. Mobilization of the duodenum

(Kochcr maneuver) and head of the

pancreas

4. Identification of the superior

mesenteric vein and mobilization of

the pancreatic neck

5. Mobilization of the stomach:

dissection of the hepatoduodenal

ligament and cholecystectomy

6. Division of the stomach, proximal

jejunum, and CBD

7. Transection of the pancreatic neck

and dissection of the uncinate

processfrom the retroperitoneum

8. Restoration of gastrointestinal

continuity:construction of

a pancreaticojejunostomy,

hepaticojejunostomy,

gastrojejunostomy using a

neoduodenum

Remove

. CBD

• Gallbladder

• Duodenum

• Pancreatic head

• Distal stomach (sometimes)

Table 27. TNM Classification System for Exocrine Tumours of the Pancreas (AJCC 8th edition)

Primary Tumour (T) Regional Lymph Nodes (N) Distant Metastasis (M)

TX Primary tumour cannot be assessed

TO No evidence ol primary tumour

Tis Carcinoma in situ

NX Regional lymph nodes cannot be assessed

NO No regional lymph node metastasis

N1 Metastasis in one to three regional lymph nodes

M0 No distant metastasis

Ml Distant metastasis

Oncological Benefits of Neoadjuvant

Chemoradiation with Gemcitabine vs. Upfront

S urgery in Patients with Borderline Resectable

Pancreatic Cancer:t Prospective, Randomised,

Open-label.Mullicenler Phase 2/3 Trial

Ann Surg 2018:268:215-222

Purpose: lo deter— r e whether neoadjinant

treatment increasessurvival in patients with

borderline resectable pancreatic cancer(BRPC).

Methods:A total of SO patients were randomized to

neoadjuvant gemutabine-based chemoradiotherapy

or upfront surgery.

Results:Ihe 2 yr survival rate|2YSR|and median

survival of patientstieated with ncoadiuvant

chemoradiation wassignificantly improved (40.7%

2YSR. 21mo median suivival) compared to upfront

surgery (26.1% 2YSR.12 mo median survival).Ihe RO

resection rate was also significantly increased in the

neoadjuvant chemoradiation group.

Conclusion: Neoadjuvant chemoradiation provides

survival and surgical benefits in patients with BRPC.

T1 Tumour

-:2 cm in greatest dimension

N2 Metastasis in four or more regional lymph

nodes

T 2 Tumour »2 cm and s4 cm in greatest

dimension

T3 Tumour >4 cm in greatest dimension

T4 Tumour involves celiac axis.SMA. or common

hepatic artery r -i

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Table 28. Staging and Treatment of Pancreatic Cancer

Stage Classification 5 Yr Survival Treatment

Tis,NO. MO

11, NO. MO

12, NO. MO

13,NO. MO

T1-3, N1. M0

11-3.N2.MO

14, any N,MO

anyI. anyN.M1

Surgical resection t chemotherapy

Same as above

Same as above

Same as above

Same as above

Borderline resectable, trial ol chemotherapy and radiation

0

IA m

IB 12%

IIA 7%

I IB 5%

III 3%

IV 1% Mon-resectable, palliative treatments

Lett and right hepatic ducts

ontmon hepatic

duct

Stomach

Liver

Gastrojejunostomy

Gallbladder

-Tail of pancreas

Cystic duct

Hepaticojejunostomy

CBD Pancreas

Ampulla of Vater Pancreatic duct Pancreaticojejunostomy

Duodenum

Jejunum

Resected portion

© Natalie Comiier 2015.after Caitlin O'Connell

Figure 26. Schematic of Whipple resection showing the resected components

Spleen

Splenic Trauma

Clinical Features

• most common intra-abdominal organ injury in blunt trauma (especially can occur in people with

splenomegaly)

• may have Kenr’s sign

- patients may be hemodynamically unstable with altered mentalstatus

• initial presentation may be masked by other injuries and contained ruptures may have few symptoms

Kehr’s Sign

Left shoulder pain due to diaphragmatic

irritation from splenic rupture, worsens

with inspiration

Investigations

• FAST'

(used in trauma with hemodynamically unstable patients)

• CT with oral or IV contrast (once stable or when l-

'

AST negative)

Treatment

• non-operative

in stable patients: extended bed rest with serial hematocrit levels, close monitoring for 3-5 d;

paediatric guidelinesfor days of bed rest is grade plus 1 (i.e. grade 3 splenic laceration requires 4

d of bed rest)

hemostatic control

• splenic artery embolization if patient stable and one of: active contrast extravasation,splenic

pseudoaneurysm, hemoperitoneum

• operative

hemodynamically unstable patients with positive FAST will undergo emergent operative surgical

exploration

• splenorrhaphy (suture of spleen) ± splenic wrapping with hemostatic mesh (if patient is

hemodynamically stable)

splenectomy if patient unstable or high-grade injury or ongoing bleeding with hemodynamic

instability

• packing the spleen with temporary abdominal closure and relook laparotomy in 48 h

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