malignant BANSAL (Surgical Obstructive Jaundice)

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A compendium of Surgical Obstructive Jaundice of Malignant origin.

A compendium of Surgical Obstructive Jaundice of Malignant origin.

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  • 1. malignantmalignantobstructive jaundiceobstructive jaundicebabul bansal
  • 2. carcinoma head ofcarcinoma head ofpancreaspancreasMalignantObstructive JaundiceCarcinomaHead of PancreasPeriampullaryCarcinomaCholangiocarcinoma CarcinomaGallbladder
  • 3. USG + CECTUSG + CECTResectableResectable UnresectableUnresectable No massNo massdetecteddetectedReassessReassessResectibilityResectibilityResectResect(Whipple Procedure)(Whipple Procedure)PalliationPalliationChemotherapyChemotherapyRadiotherapyRadiotherapyPainPain JaundiceJaundice Du ObstructionDu ObstructionERCP orERCP orEUSEUSMalignantMalignantEvaluateEvaluateFurtherFurtherResectResect(Whipple Procedure)(Whipple Procedure)
  • 4. resectibility vs.resectibility vs.unresectibilityunresectibilityFindings contraindicatingresection :Liver/Visceral metastasis (anysize)Peritoneal implantsCeliac lymph node involvementInvasion of transverse mesocolonHepatic hilar lymph nodeinvolvementArterial Invasion – VenousOcclusionFindings notcontraindicatingresection:Invasion of duodenum ordistal stomachInvolvement ofperipancreatic lymph node
  • 5. resectionresectionOnly shot at Cure (but recurrence is common)At presentation – only 15% resectableTwo techniques –- Standard Whipple Procedure- Modified Whipple (PPPD)Pancreatic Ca.Resection Palliation
  • 6. kausch - whipplekausch - whippleprocedureprocedure3 phases –- Assessment phase- Resection phase- Reconstruction phasePancreatic Ca.Resection PalliationAssessmentResectionReconstructionSir 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
  • 7. a. assessmenta. assessmentWhy Reassess???Specificity of CECT for Resectibility = 80%... Why?Laparoscopy or Laparotomy???Gen. Anesthesia – Midline/Bilateral Subcostal incisionLook for –- Metastasis- Inoperable LN involvement- Kocher Maneuver- Aberrant Right Hepatic ArteryPancreatic Ca.Resection PalliationAssessmentResectionReconstruction
  • 8. Kocher ManeuverPancreatic Ca.Resection PalliationAssessmentResectionReconstruction
  • 9. b. resectionb. resectionViscera removed- Distal 1/3rdof Stomach (not in PPPD)- Duodenum- Proximal 10 cm of jejunum- Head, Neck and Uncinate Process of Pancreas- Gallbladder withcystic duct and CBD- Regional Lymph NodesPancreatic Ca.Resection PalliationAssessmentResectionReconstruction
  • 10. c. reconstructionc. reconstruction3 steps –- Pancreatico-jejunostomy- Hepatico-jejunostomy- Gastro-jejunostomyPancreatic Ca.Resection PalliationAssessmentResectionReconstruction
  • 11. PPPD vs. WhipplePPPD vs. WhippleAdvantages ofPPPDPrevention of RefluxPrevents marginal ulcerationNormal Acid Secretion andHormone ReleaseImproved gastric functionBetter Weight GainDisadvantages ofPPPDCompromise with the resectionmarginDelayed Gastric EmptyingPancreatic Ca.Resection Palliation
  • 12. 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
  • 13. palliationpalliation• 85% cases unresectable at presentation• Not curative• Aimed at improving the quality of life• Three major problems –- Pain- Jaundice- Duodenal ObstructionPancreatic Ca.Resection PalliationPainDu ObstructionJaundice
  • 14. a. paina. pain• Medical – Opioids ; NSAIDs• Celiac Plexus Nerve Block(Percutaneous - USG or CT Guided)(Transgastric or Laparotomic)Pancreatic Ca.Resection PalliationDu ObstructionJaundicePain
  • 15. Pancreatic Ca.Resection PalliationDu ObstructionJaundicePain
  • 16. b. jaundiceb. jaundiceNon-Surgical:- Biliary Stent PlacementEndoscopic (Metallic or Plastic Stent)Percutaneous TranshepaticSurgical:- Choledochojejunostomy- Cholecystojejunostomy- Hepaticojejunostomy(Roux-en-Y)Pancreatic Ca.Resection PalliationPainDu ObstructionJaundice
  • 17. Pancreatic Ca.Resection PalliationPainDu ObstructionJaundice
  • 18. Pancreatic Ca.Resection PalliationPainDu ObstructionJaundiceCholedochojejunostomyCholecystojejunostomy
  • 19. c. duodenalc. duodenalobstructionobstructionPancreatic Ca.Resection PalliationPainDu ObstructionJaundiceNon-Surgical:Gastrostomy TubeExpandable metallic stentSurgical:Gastrojejunostomy
  • 20. jaundice + duodenaljaundice + duodenalobstructionobstructionPancreatic Ca.Resection PalliationPainDu ObstructionJaundiceTriple BypassRoux-en-Y
  • 21. chemotherapy |chemotherapy |radiotherapyradiotherapyChemotherapy• 5-fluorouracil• GemcitabineRadiotherapy• Low dose Radiotherapy
  • 22. periampullaryperiampullarycarcinomacarcinomaMalignantObstructive JaundiceCarcinomaHead of PancreasPeriampullaryCarcinomaCholangiocarcinoma CarcinomaGallbladder
  • 23. periampullary carcinomaperiampullary carcinoma• Distal CBD carcinoma• Ampullary Carcinoma• Duodenal Carcinoma (surrounding Ampulla)- Prognosis is better- Management – similar to Ca head of Pancreas
  • 24. 5 year survival5 year survivalCa head of PancreasCa head of Pancreas3%Periampullary CaPeriampullary Ca30%prognostic markers- CA 19-9- CA 494
  • 25. cholangiocarcinomcholangiocarcinomaaMalignantObstructive JaundiceCarcinomaHead of PancreasPeriampullaryCarcinomaCholangiocarcinoma CarcinomaGallbladder
  • 26. cholangiocarcinomacholangiocarcinomaCurative Palliative
  • 27. curativecurativeIntrahepatic –- Mx - same as Hepatocellular ca- Sx - Partial HepatectomyProximal / Perihilar (Klatskin Tumor)- 2/3rdof Cholangiocarcinomas- Bismuth-Corlette Classification- Sx – Roux-en-YDistal Bile Duct- Mx – same as Periampullary Carcinoma- Sx – Whipple Procedure
  • 28. Bismuth-Corlette ClassificationBismuth-Corlette ClassificationPerihilar CholangiocarcinomaPerihilar Cholangiocarcinoma
  • 29. palliativepalliativeJaundice- Biliary Stenting- Segment III BypassPain- Opioids, NSAIDs- Celiac Plexus BlockChemotherapy (5-FU) + Radiotherapy
  • 30. VIII IVIVVVIIVIIIIIISegment III BypassSegment III Bypass
  • 31. prognosisprognosisMedian SurvivalMedian SurvivalResectable Disease – 32-38 monthsUnresectable Disease – 5-8 months
  • 32. carcinomacarcinomagallbladdergallbladderMalignantObstructive JaundiceCarcinomaHead of PancreasPeriampullaryCarcinomaCholangiocarcinoma CarcinomaGallbladder
  • 33. gallbladder carcinomagallbladder carcinomaCurative Palliative
  • 34. curativecurativeT1 lesion – limited to muscular layer- Sx – Simple CholecystectomyT2 lesion – invades the perimuscular conn. tissue- Sx – CholecystectomyRegional LymphadenectomyResection of Liver Segments ( IVb and V)T3 T4 lesion – invade liver and other organs- Usually inoperable
  • 35. palliationpalliationJaundice- Biliary Stents- HepaticojejunostomyPain- NSAIDs, Opioids- Celiac Plexus BlockChemotherapy – GemcitabineRadiotherapy – No proven efficacy
  • 36. prognosisprognosis5 year survival rateResectable – 60-100%Unresectable – 15%