Transplant and Hepato-Pancreato-Biliary (HPB) Institute

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   Transplant and Hepato-Pancreato-Biliary (HPB) Institute

Understanding Your Gallbladder & Biliary System

Your gallbladder and bile ducts are located in your right upper abdomen. The bile duct and hepatic ducts (biliary system), transport bile from your liver into the intestine. Bile helps with digesting fat. The gallbladder stores bile.

gall bladder
Gallbladder

Problems with your Gallbladder and Biliary System

Cholecystitis

Cholecystitis and Cholangitis

  • About Cholecystitis and Cholangitis

    What are cholecystitis and cholangitis?

    Cholecystitis is the inflammation and infection of the gallbladder, which occurs in some patients with gallstones. Cholangitis is an infection of the bile duct, which can occur, when the bile duct is blocked by a gallstone.

    What are the signs and symptoms of cholecystitis and cholangitis?

    Cholecystitis and cholangitis can present with fevers, chills, low blood pressure and pain in the right upper abdomen. If the bile duct is blocked with a gallstone, the patient might also have jaundice (yellowing of the eyes and skin).

    jaundice eyes

    Why do I get cholecystitis and cholangitis?

    Some people are more prone to having gallstones, which can block the gallbladder duct (cystic duct) or bile duct, and cause inflammation and infection. In rare instances sick patients in the hospital have cholecystitis without gallstones. Rarely, patients can also form stones in the bile duct or hepatic duct, which can cause a blockage.

  • Diagnosis of Cholecystitis and Cholangitis

    How are Cholecystitis and Cholangitis diagnosed?

    If you have symptoms of cholecystitis or cholangitis, your doctor may order blood tests or scans of your abdomen. Sometimes you may also need a procedure.

    Blood tests

    • Your doctor may check blood tests to look for an infection and check he function of your liver to look for a blockage of your bile duct.
    blood tests

    Imaging

    • Abdominal Ultrasound to look for an infection of your gallbladder and or a blockage of your bile duct
    • CT or MRI scan of your belly (or of the abdomen and pelvis) to look for an infection of your gallbladder and or a blockage of your bile duct
    image of CT or MRI scan

    Procedures

    • An Endoscopic Retrograde Cholangiopancreatography (ERCP) can find and remove gallstones that cause cholangitis.
    ERCP
  • Treatment of Cholecystitis and Cholangitis

    How is Cholecystitis and Cholangitis treated?

    • Hospital admission and supportive care
    • Surgery for Cholecystitis and Cholangitis

    Hospital Admission

    Patients with Cholecystitis and Cholangitis will be admitted to the hospital, and treated with intravenous fluids, antibiotics and pain medications.

     

    Surgery and Procedures for Cholecystitis and Cholangitis

    Patients with Cholecystitis need to have their gallbladder removed surgically (cholecystectomy). Patients with cholangitis will have an endoscopic procedure called ERCP to remove the gallstone from the bile duct. Since the gallbladder is the most likely source of gallstones, patients will need a cholecystectomy after their acute cholangitis has resolved

    remove gall bladder


Gallbladder Cancer

Gallbladder and Bile Duct Cancer

  • About Gallbladder and Bile Duct Cancer

    What is gallbladder and bile duct cancer?

    Gallbladder cancer is a cancer in that occurs in the wall of the gallbladder. Bile duct cancer (cholangiocarcinoma) arises from the wall of the liver ducts. It can occur in the liver or in the ducts connecting the liver to the intestine.

    There are 3 different types of cholangiocarcinoma:

    • Distal bile duct cancer: occurs in close the where the bile duct meets the bowel
    • Hilar bile duct cancer: occurs in the bile duct between the liver and intestine
    • Intrahepatic bile duct cancer: occurs in the small bile ducts in the liver

    What are the signs and symptoms of gallbladder and bile duct cancer?

    Gallbladder and bile duct cancer is often silent in early stages. Patients may present with:

    • Abdominal and back pain
    • Poor appetite, nausea, vomiting, weight loss

    More advanced stages can present with:

    • Jaundice (yellow skin and eyes)
    • Clay-colored stools and dark urine
    • Abdominal and back pain
    • Poor appetite, nausea, vomiting, weight loss
    • Jaundice (yellow skin and eyes)
    • Bowel blockage
    • High blood sugars and Diabetes

    What is my risk for getting gallbladder and bile duct cancer?

    Increased risk for gallbladder cancer

    Gallbladder cancer is more common in older women.

    • History of gallstones and chronic infection of the gallbladder (cholecystitis)
    • Gallbladder polyps

    Increased risk for bile duct cancer (cholangiocarcinoma)

    • Smoking and old age
    • Primary sclerosing cholangitis is a disease of the bile ducts, which causes narrowing of the ducts.
    • Absent or abnormal liver or bile ducts at birth
    • Cysts of the bile duct
    • Chronic liver disease
    • Infections with a liver parasite
  • Diagnosis of Gallbladder and Bile Duct Cancer

    How is gallbladder and bile duct cancer diagnosed?

    If you have any symptoms of gallbladder or bile duct cancer, your doctor may order blood tests and pictures (imaging) of your belly. You may also need a biopsy to confirm the diagnosis.

    Blood tests

    • Complete blood count (CBC) to check your blood count.
    • Comprehensive Metabolic Panel (CMP) to check your electrolytes and liver function.
    • Ca19-9 and CEA levels. These blood tests are called “tumor markers,” and will give your doctor a chance to follow your response to treatment.
    blood tests

    Imaging

    • CT or MRI scan of your belly (or of the abdomen and pelvis) to look for a mass in the gallbladder or liver. A special MRI called MRCP will show your surgeon if there is a blockage in your bile ducts. These tests will allow your doctor to evaluate, if your tumor can be removed with surgery.
    imaging

    Procedures

    • Endoscopic Ultrasound (EUS): Your doctor inserts a camera into your intestines through your mouth, so your bile ducts can be seen.
    • An Endoscopic Retrograde Cholangiopancreatography (ERCP) is another form of endoscopy that allows your doctor to place a stent into the bile duct for patients with jaundice. During this procedure. the doctor will be able to get bile duct cells, which are used for diagnosis. This can be done at the same time as the EUS.
    • Percutaneous Biopsy: If there is a mass in the liver or a large lymph node in the area, your doctor might order a biopsy, which is done by a radiologist. The radiologist will use ultrasound or CT scan to find the tumor or biopsy.
    ERCP
  • Treatment of Gallbladder and Bile Duct Cancer (Cholangiocarcinoma)

    How is gallbladder and biliary cancer treated?

    The treatment of gallbladder and bile duct cancer depends on the stage of the tumor, and involves a multidisciplinary team of doctors, nurses and medical support staff:

    • Medical Oncology
    • Gastroenterology
    • Surgery
    • Radiation
    • Dietary and Social work, Palliative care.

    Every patient seen here will be presented in our multidisciplinary tumor board, where we will devise your individual treatment plan. This plan may include:

    We strongly encourage and support all of our patients to participate in clinical trials. We are happy to talk to you about clinical trials during your clinic visit.



Choledochal

Bile Duct (Choledochal) Cysts

  • Bile Duct Cysts

    What are choledochal (bile duct) cysts?

    Bile duct cysts are abnormalities in the tubes connecting liver to the intestine. The bile ducts enlarge like balloons anywhere along their course towards the small bowel. There are different types of bile duct cysts, depending on where the ballooning occurs.

    What are the signs and symptoms of bile duct cysts?

    Choledochal cysts are usually diagnosed in children, but sometimes not recognized until adulthood. The may present as:

    • Intermittent pain in the right upper abdomen
    • Yellowing of the eyes and skin (Jaundice)
    • Inflammation of the bile duct (cholangitis)
    • Clay-colored stools and dark urine

    What are my risks for having bile duct cysts?

    Bile duct cysts are congenital, which means that they have been present since birth, and might not get recognized until adulthood.

    They can cause repeated infection and can turn into cancer. .

    Choledochal Cyst
  • Diagnosis of Bile Duct Cysts

    How are bile duct cysts diagnosed?

    If you have any symptoms of a bile duct cyst, your doctor may order blood tests and pictures (imaging) of your belly. You may also need a biopsy to confirm the diagnosis.

    Blood tests

    • Complete blood count (CBC) to check your blood count.
    • Liver function tests
    • Ca19-9 and CEA levels. These blood tests are called “tumor markers,” and will give your doctor assess that your cyst is not cancer.
    Blood Tests

    Imaging

    • The first picture (imaging study) of your abdomen is usually ultrasound, which can identify bile duct cysts.
    • CT or MRI scan of your belly (or of the abdomen and pelvis) will let your doctor look at the anatomy of the bile ducts. A special MRI called MRCP will provide important details about the location and size of your bile duct cysts.
    imaging

    Procedures

    • Endoscopic Ultrasound (EUS): Your doctor inserts a camera into your intestines through your mouth, so your bile ducts can be seen.
    • An Endoscopic Retrograde Cholangiopancreatography (ERCP) is another form of endoscopy that allows your doctor to place a stent into the bile duct for patients with jaundice. During this procedure, the doctor will be able to get bile duct cells, which are used for diagnosis. This can be done at the same time as the EUS.
    ERCP
  • Treatment of Bile Duct Cysts

    How are bile duct cysts treated?

    Bile ducts cysts will always be removed with surgery. The type of surgery depends on the location of the cyst.

    If the cyst is the part of the bile duct outside the liver and pancreas, the patient will need a bile duct excision and reconstruction.

    If the bile duct cyst is not part of the main bile duct, it will be removed without removing and reconstructing the main bile duct.

    If the cyst is in the part of the bile duct, which runs through the pancreas, the patient will need a Whipple procedure.

    What is a Whipple Procedure?

    The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

    Bile Duct Cyst Surgery

Bile Duct Excision and Reconstruction

close up of bile duct cyst

Radiation Therapy

Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is therapy using ionizing radiation, generally as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator.

Chemotherapy

Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen. Chemotherapy may be given with a curative intent, or it may aim to prolong life or to reduce symptoms.

Gallstones

Gallstones are stones that are Made in the gallbladder. They Can be very small and resemble Fine sand grains (also known as "Sludge" or as big as pebbles and Rocks!

gallstones

Multidisciplinary Tumor Board

A Multidisciplinary Tumor Board is a team of doctors and nurses who discuss your individual case to recommend the best treatment options for you based on your specific information. The members of Tumor Board include:

  • Surgeons
  • Oncologists
  • Radiologists
  • Pathologists
  • Gastroenterologists
Tumor Board
Tumor Board Meeting

When does Tumor Board meet?

Usually once a week

When will I be presented at Tumor Board?

The Tumor Board needs to have the latest imaging available to make accurate recommendations. Patients are typically presented after all of the appropriate tests are completed.

Am I allowed to participate in Tumor Board?

Because multiple patients are presented at a single Tumor Board, having patients attend is discouraged for privacy concerns. However, you will learn the recommendations of the Tumor Board at your next clinical appointment.

Cholecystectomy

cholecystectomy

Patients, who have recovered from pancreatitis due to gallstones, may need to have their gallbladder removed surgically. The procedure is called a cholecystectomy, and can be done with a camera and small incisions (laparoscopic) or through a larger cut (open). During the operation the cystic duct and artery have to be clipped and cut. The gallbladder will be separated from the liver, and removed.

Patients can usually leave the hospital the day after the operation after laparoscopic surgery. They able to eat a regular diet, and will be given medication for pain at their incision (cut).

Liver Ablation

  • About Liver Ablation Surgery

    About Liver Ablation Surgery

    Liver ablation is an effective way of treating liver tumors. During an ablation, a needle is guided into the tumor at which point energy is applied to heat tumors to the point where the tumor is destroyed. After the tissue is destroyed, your body will reabsorb the cellular material. Ablations can be performed using an abdominal surgical incision (“open surgery”) or laparoscopic “keyhole” surgery.

    ultrasound picture
    An ultrasound Is performed to locate the tumor

    Before
    Before

    After
    After


    laparoscopic surgery scar
    Laparoscopic Surgery Scar

    How big will my incision be for an ablation?

    Most ablations are performed laparoscopically (via “keyhole” surgery). Sometimes, depending on the location of the tumor, the ablation will need to be performed using an “open” incision.

    chevron surgery incision
    Chevron Incision


    Do I need to remove stitches after ablation?  Is it painful?

    Typically, stitches and medical “Super-Glue” will be used to close your incisions, and there is no need to take out the stitches afterward because they will dissolve.  If you have surgical staples, these will need to be removed by your doctor approximately 5-15 days after the surgery.  Taking out the staples is painless for most patients!

    Surgical staples
    Surgical Staples


    When Can I Shower after Ablation?

    We prefer that you shower after ablation, and that can be done as soon as the first day after ablation!  We recommend against baths, jacuzzis, or submerged water.  You do not need to cover your incision when you shower.



    When Can I Resume Exercise after Ablation?

    It will be safe to resume full exercise by about six weeks postoperatively.  Between 1-6 weeks you are at high risk for a hernia developing in your incision, so please do not lift anything heavy (anything more than a milk jug!)  Please discuss with your doctor before resuming activity.

  • What to Expect During Your Hospital Stay

    What to Expect During Your Hospital Stay

    After your operation, you will need to recover in the hospital anywhere between 1-3 days depending on the extent of your ablation.  During this time, we will repeatedly encourage and assist you with walking and deep breathing exercises.


    What Room Will I Be In?

    Patients are typically send to the Med/Surg unit after the procedure to continue the recovery process.



    Will I Have A Private Room?

    All rooms at St Vincent are private and you will not share your room with another patient (???? Don’t know if this is correct)



    Can My Family Stay With Me?

    Yes, we encourage family to visit and keep patients company during the day.  Family are not discouraged to stay overnight, however, so that patients can receive adequate sleep.



    Am I Allowed to Eat Food From Home?

    Yes, once approved by your care team it is allowed and encouraged to bring home-cooked meals.  However, if you are on a special restricted diet (for example, low sodium), we ask that family do not bring food from home.



    Am I Allowed to Smoke/Vape While in the Hospital?

    Unfortunately since smoking has been shown to inhibit wound healing, we prohibit smoking in our patients.  Additionally, because of the fire danger with smoking and oxygen cannulas (which most of our patients have!) any smoking is prohibited. We will prescribe you nicotine patches or gum when appropriate.



    How Will You Control My Pain?

    All patients will have their pain controlled after the operation.  This is typically achieved by using a combination of oral medications, epidural pumps, and patient controlled anesthesia (PCA) pumps.   Be aware though:  narcotic medications can cause constipation and if your bowels are not moving after surgery, then sometimes it is necessary to decrease the amount of pain medications we give you.

    pain control pump
    Patient Controlled Anesthesia (PCA) Pump


    How Will I know I am Ready for Discharge?

    The goals for discharge include:

    • Eating and drinking adequately with bowel function
    • Able to walk and carry out basic functions independently
    • Appropriate pain control and no longer needing IV medications
    • No signs of untreated infection or bleeding

    Sometimes patients will require the assistance of physical therapy at home or may even need to be discharged to a rehabilitation facility.  Our social workers will work with you to arrange this care.



    Can I Stay Extra Days in the Hospital to Recover?

    Once you are cleared to go home, the safest option for you is to leave the hospital.  Because the hospital is full of other sick patients, you have a greater chance of exposure the longer you stay.

  • Discharge and Follow-Up

    Discharge and Follow-Up

    On the day of discharge, a member of your care team will review your discharge paperwork, medications, and follow-up instructions with you and your family.  In the case you Have questions or would like to Speak to a member of the team, Please call 213-484-5551.  If you feel the emergency is life-threatening, please call 911!


    Common Reasons to Call your Care Team

    • Fevers of Chills higher than 101°F (38.3 °C)
    • Drainage of fluid from your incision (especially if foul smelling)
    • Swelling, warmth, or increased redness around your incision
    • Any sudden increase in abdominal pain
    • Inability to eat and drink or persistent nausea or vomiting
    • Your skin or eyes turn yellow, or your urine becomes dark
    • Constipation or inability to pass gas for longer than 3 days

    Can I Drive After Ablation?

    Driving a car or operating heavy machinery is safe when you are no longer taking pain medications and are able to have appropriate reaction times.


    Can I Drink Alcohol after Ablation?

    Drinking alcohol after liver ablation is not advised, because your liver is still healing.



Gallbladder and Liver Surgery

If your tumor can be removed with surgery, your surgeon will recommend one of the following operations. The type of operation is dependent on the location of your tumor.

Radical Cholecystectomy

For very early stage cancers a cholecystectomy alone might be sufficient. Most patients with gallbladder cancer, that can be removed, will need a radical cholecystectomy. During surgery, the gallbladder, the adjacent liver, a portion of the bile duct (tube connecting liver to intestines) and lymph nodes in the area will be removed. The goal of the surgery is to remove the entire tumor.

Cholecystectomy

cholecystectomy

Patients, who have recovered from pancreatitis due to gallstones, may need to have their gallbladder removed surgically. The procedure is called a cholecystectomy, and can be done with a camera and small incisions (laparoscopic) or through a larger cut (open). During the operation the cystic duct and artery have to be clipped and cut. The gallbladder will be separated from the liver, and removed.

Patients can usually leave the hospital the day after the operation after laparoscopic surgery. They able to eat a regular diet, and will be given medication for pain at their incision (cut).

The bile duct needs to be reconnected to the intestine, so bile can reach the digestive tract. This is done with a hepaticojejunostomy, which means that the bile duct will be sewn to a piece of small intestine.

Resection and Reconstruction of the Bile duct

For bile duct cancer outside of the liver and pancreas (hilar cholangiocarcinoma), the bile duct, gallbaldder and lymph nodes in the area will be removed. The bile duct needs to be reconnected to the intestine with a hepaticojejunostomy.

Patients with bile duct cancer in the liver (intrahepatic cholangiocarcinoma) will need a liver resection (hepatectomy).

Hepatectomy

Hepatectomy is the surgical resection (removal of all or part) of the liver. While the term is often employed for the removal of the liver from a liver transplant donor, this article will focus on partial resections of hepatic tissue and hepatoportoenterostomy.

Patients with a distal bile duct cancer (cholangiocarcinoma) will need a Whipple procedure.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.