malignant bansal (surgical obstructive jaundice)
DESCRIPTION
A compendium of Surgical Obstructive Jaundice of Malignant origin.TRANSCRIPT
![Page 1: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/1.jpg)
malignant malignant
obstructive jaundiceobstructive jaundice
babul bansal
![Page 2: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/2.jpg)
![Page 3: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/3.jpg)
carcinoma head of carcinoma head of pancreaspancreas
Malignant Obstructive Jaundice
Carcinoma Head of Pancreas
PeriampullaryCarcinoma
Cholangiocarcinoma CarcinomaGallbladder
![Page 4: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/4.jpg)
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)
![Page 5: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/5.jpg)
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
![Page 6: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/6.jpg)
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
![Page 7: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/7.jpg)
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
![Page 8: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/8.jpg)
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
![Page 9: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/9.jpg)
Kocher Maneuver
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
![Page 10: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/10.jpg)
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
![Page 11: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/11.jpg)
![Page 12: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/12.jpg)
c. reconstructionc. reconstruction 3 steps – - Pancreatico-jejunostomy- Hepatico-jejunostomy- Gastro-jejunostomy
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
![Page 13: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/13.jpg)
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
![Page 14: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/14.jpg)
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
![Page 15: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/15.jpg)
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
![Page 16: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/16.jpg)
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
![Page 17: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/17.jpg)
Pancreatic Ca.
Resection Palliation
Du Obstruction
JaundicePain
![Page 18: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/18.jpg)
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
![Page 19: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/19.jpg)
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
![Page 20: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/20.jpg)
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
Choledochojejunostomy
Cholecystojejunostomy
![Page 21: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/21.jpg)
c. duodenal c. duodenal obstructionobstruction
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
Non-Surgical:Gastrostomy Tube
Expandable metallic stent
Surgical:Gastrojejunostomy
![Page 22: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/22.jpg)
jaundice + duodenal jaundice + duodenal obstructionobstruction
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
JaundiceTriple Bypass
Roux-en-Y
![Page 23: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/23.jpg)
chemotherapy | chemotherapy | radiotherapyradiotherapy
Chemotherapy• 5-fluorouracil• Gemcitabine
Radiotherapy• Low dose Radiotherapy
![Page 24: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/24.jpg)
periampullary periampullary carcinomacarcinoma
Malignant Obstructive Jaundice
Carcinoma Head of Pancreas
PeriampullaryCarcinoma
Cholangiocarcinoma CarcinomaGallbladder
![Page 25: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/25.jpg)
periampullary carcinomaperiampullary carcinoma
• Distal CBD carcinoma• Ampullary Carcinoma• Duodenal Carcinoma (surrounding Ampulla)
- Prognosis is better- Management – similar to Ca head of Pancreas
![Page 26: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/26.jpg)
5 year survival5 year survival
Ca head of PancreasCa head of Pancreas
3%
Periampullary CaPeriampullary Ca
30%
prognostic markers
- CA 19-9
- CA 494
![Page 27: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/27.jpg)
cholangiocarcinomcholangiocarcinomaa
Malignant Obstructive Jaundice
Carcinoma Head of Pancreas
PeriampullaryCarcinoma
Cholangiocarcinoma CarcinomaGallbladder
![Page 28: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/28.jpg)
cholangiocarcinomacholangiocarcinoma
Curative Palliative
![Page 29: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/29.jpg)
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
![Page 30: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/30.jpg)
Bismuth-Corlette Classification Bismuth-Corlette Classification
Perihilar CholangiocarcinomaPerihilar Cholangiocarcinoma
![Page 31: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/31.jpg)
palliativepalliative
Jaundice- Biliary Stenting- Segment III Bypass
Pain - Opioids, NSAIDs- Celiac Plexus Block
Chemotherapy (5-FU) + Radiotherapy
![Page 32: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/32.jpg)
VIII IV
IV
V
VII
VI
II
III
Segment III BypassSegment III Bypass
![Page 33: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/33.jpg)
prognosisprognosis
Median SurvivalMedian Survival
Resectable Disease – 32-38 months
Unresectable Disease – 5-8 months
![Page 34: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/34.jpg)
carcinoma carcinoma gallbladdergallbladder
Malignant Obstructive Jaundice
Carcinoma Head of Pancreas
PeriampullaryCarcinoma
Cholangiocarcinoma CarcinomaGallbladder
![Page 35: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/35.jpg)
gallbladder carcinomagallbladder carcinoma
Curative Palliative
![Page 36: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/36.jpg)
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
![Page 37: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/37.jpg)
palliationpalliation
Jaundice- Biliary Stents- Hepaticojejunostomy
Pain- NSAIDs, Opioids- Celiac Plexus Block
Chemotherapy – Gemcitabine
Radiotherapy – No proven efficacy
![Page 38: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/38.jpg)
prognosisprognosis
5 year survival rate
Resectable – 60-100%
Unresectable – 15%
![Page 39: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/39.jpg)
![Page 40: malignant BANSAL (Surgical Obstructive Jaundice)](https://reader033.vdocuments.site/reader033/viewer/2022061611/557e6dfcd8b42a03668b46b4/html5/thumbnails/40.jpg)