malignant bansal (surgical obstructive jaundice)
DESCRIPTION
A compendium of Surgical Obstructive Jaundice of Malignant origin.TRANSCRIPT
malignant malignant
obstructive jaundiceobstructive jaundice
babul bansal
carcinoma head of carcinoma head of pancreaspancreas
Malignant Obstructive Jaundice
Carcinoma Head of Pancreas
PeriampullaryCarcinoma
Cholangiocarcinoma CarcinomaGallbladder
USG + CECTUSG + CECT
ResectableResectable UnresectableUnresectable No mass No mass detecteddetected
Reassess Reassess ResectibilityResectibility
ResectResect(Whipple Procedure)(Whipple Procedure)
PalliationPalliation
Chemotherapy Chemotherapy
RadiotherapyRadiotherapy
PainPain JaundiceJaundice Du ObstructionDu Obstruction
ERCP or ERCP or EUSEUS
MalignantMalignant
Evaluate Evaluate FurtherFurther
ResectResect(Whipple Procedure)(Whipple Procedure)
resectibility vs. resectibility vs. unresectibilityunresectibility
Findings contraindicating resection :Liver/Visceral metastasis (any size)
Peritoneal implants
Celiac lymph node involvement
Invasion of transverse mesocolon
Hepatic hilar lymph node involvement
Arterial Invasion – Venous Occlusion
Findings not contraindicating resection:
Invasion of duodenum or distal stomach
Involvement of peripancreatic lymph node
resectionresection
Only shot at Cure (but recurrence is common)
At presentation – only 15% resectable
Two techniques – - Standard Whipple Procedure- Modified Whipple (PPPD)
Pancreatic Ca.
Resection Palliation
kausch - whipple kausch - whipple procedureprocedure
3 phases –- Assessment phase
- Resection phase
- Reconstruction phase
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
Sir Allen Oldfather Whipple
(1881-1963)
Important Landmarks
- 1909 – Kausch first performed Pancreatoduodenectomy
- 1935 – Whipple perfected the technique (two-stage)
- 1941 – One-stage procedure was described
- 1978 – Traverso and Longmire introduced PPPD
a. assessmenta. assessment
Why Reassess???
Specificity of CECT for Resectibility = 80%... Why?
Laparoscopy or Laparotomy???
Gen. Anesthesia – Midline/Bilateral Subcostal incision
Look for – - Metastasis - Inoperable LN involvement - Kocher Maneuver - Aberrant Right Hepatic Artery
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
Kocher Maneuver
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
b. resectionb. resection
Viscera removed- Distal 1/3rd of Stomach (not in PPPD)- Duodenum- Proximal 10 cm of jejunum- Head, Neck and Uncinate Process of Pancreas- Gallbladder with
cystic duct and CBD- Regional Lymph Nodes
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
c. reconstructionc. reconstruction 3 steps – - Pancreatico-jejunostomy- Hepatico-jejunostomy- Gastro-jejunostomy
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
PPPD vs. WhipplePPPD vs. Whipple
Advantages of PPPDPrevention of Reflux
Prevents marginal ulceration
Normal Acid Secretion and Hormone Release
Improved gastric function
Better Weight Gain
Disadvantages of PPPDCompromise with the resection margin
Delayed Gastric Emptying
Pancreatic Ca.
Resection Palliation
complicationscomplicationsCommon Complication• Delayed Gastric Emptying (19%)• Pancreatic Fistula (14%)• Wound Infection/Sepsis (10%)• Hemorrhage (intraop. or postop.)
Other Complications• Intra-abdominal Abscess• Cholangitis• Pneumonia• Bile Leak• Pancreatitis• Marginal Ulcer
(upto 40% of cases)
Pancreatic Ca.
Resection Palliation
palliationpalliation
• 85% cases unresectable at presentation• Not curative• Aimed at improving the quality of life• Three major problems –
- Pain
- Jaundice
- Duodenal Obstruction Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
a. paina. pain
• Medical – Opioids ; NSAIDs• Celiac Plexus Nerve Block (Percutaneous - USG or CT Guided)
(Transgastric or Laparotomic)
Pancreatic Ca.
Resection Palliation
Du Obstruction
JaundicePain
Pancreatic Ca.
Resection Palliation
Du Obstruction
JaundicePain
b. jaundiceb. jaundiceNon-Surgical:
- Biliary Stent PlacementEndoscopic (Metallic or Plastic Stent)Percutaneous Transhepatic
Surgical:- Choledochojejunostomy- Cholecystojejunostomy- Hepaticojejunostomy
(Roux-en-Y)
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
Choledochojejunostomy
Cholecystojejunostomy
c. duodenal c. duodenal obstructionobstruction
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
Non-Surgical:Gastrostomy Tube
Expandable metallic stent
Surgical:Gastrojejunostomy
jaundice + duodenal jaundice + duodenal obstructionobstruction
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
JaundiceTriple Bypass
Roux-en-Y
chemotherapy | chemotherapy | radiotherapyradiotherapy
Chemotherapy• 5-fluorouracil• Gemcitabine
Radiotherapy• Low dose Radiotherapy
periampullary periampullary carcinomacarcinoma
Malignant Obstructive Jaundice
Carcinoma Head of Pancreas
PeriampullaryCarcinoma
Cholangiocarcinoma CarcinomaGallbladder
periampullary carcinomaperiampullary carcinoma
• Distal CBD carcinoma• Ampullary Carcinoma• Duodenal Carcinoma (surrounding Ampulla)
- Prognosis is better- Management – similar to Ca head of Pancreas
5 year survival5 year survival
Ca head of PancreasCa head of Pancreas
3%
Periampullary CaPeriampullary Ca
30%
prognostic markers
- CA 19-9
- CA 494
cholangiocarcinomcholangiocarcinomaa
Malignant Obstructive Jaundice
Carcinoma Head of Pancreas
PeriampullaryCarcinoma
Cholangiocarcinoma CarcinomaGallbladder
cholangiocarcinomacholangiocarcinoma
Curative Palliative
curativecurative
Intrahepatic – - Mx - same as Hepatocellular ca
- Sx - Partial Hepatectomy
Proximal / Perihilar (Klatskin Tumor)- 2/3rd of Cholangiocarcinomas- Bismuth-Corlette Classification- Sx – Roux-en-Y
Distal Bile Duct - Mx – same as Periampullary Carcinoma- Sx – Whipple Procedure
Bismuth-Corlette Classification Bismuth-Corlette Classification
Perihilar CholangiocarcinomaPerihilar Cholangiocarcinoma
palliativepalliative
Jaundice- Biliary Stenting- Segment III Bypass
Pain - Opioids, NSAIDs- Celiac Plexus Block
Chemotherapy (5-FU) + Radiotherapy
VIII IV
IV
V
VII
VI
II
III
Segment III BypassSegment III Bypass
prognosisprognosis
Median SurvivalMedian Survival
Resectable Disease – 32-38 months
Unresectable Disease – 5-8 months
carcinoma carcinoma gallbladdergallbladder
Malignant Obstructive Jaundice
Carcinoma Head of Pancreas
PeriampullaryCarcinoma
Cholangiocarcinoma CarcinomaGallbladder
gallbladder carcinomagallbladder carcinoma
Curative Palliative
curativecurative
T1 lesion – limited to muscular layer
- Sx – Simple Cholecystectomy
T2 lesion – invades the perimuscular conn. tissue
- Sx – Cholecystectomy Regional Lymphadenectomy Resection of Liver Segments ( IVb and V)
T3 T4 lesion – invade liver and other organs
- Usually inoperable
palliationpalliation
Jaundice- Biliary Stents- Hepaticojejunostomy
Pain- NSAIDs, Opioids- Celiac Plexus Block
Chemotherapy – Gemcitabine
Radiotherapy – No proven efficacy
prognosisprognosis
5 year survival rate
Resectable – 60-100%
Unresectable – 15%