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PANCREATIC CARCINOMA/ Obstructive Jaundice

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Today I have uploaded a video on one more cause for Obstructive Jaundice- Pancreatic Carcinoma. Only cancer in head of pancreas cause Obstructive Jaundice. I have talked about cancer in body and tail of pancreas as well. I have discussed the risk factors, pathology, clinical features, investigations, treatment and complications of pancreatic carcinoma. I have included a mind map and two algorithms. I hope you will enjoy this video. You can watch all my surgical teaching video casts in the following link.
Surgicaleducator.blogspot.com
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PANCREATIC CARCINOMA/ Obstructive Jaundice

  1. 1. PANCREATIC CARCINOMA Dr.B.Selvaraj MS;Mch;FICS Professor of surgery Melaka Manipal Medical College Melaka 75150 Malaysia OBSTRUCTIVE JAUNDICE
  2. 2. Pancreas- Anatomy
  3. 3. Pancreas- Blood supply
  4. 4. Classical Clinical Vignette • 72 yrs old man presents with jaundice for 7days with dull abdominal discomfort for 2 months. He gives H/O loss of appetite and loss of weight. • His stools have become lighter in color and his urine is much darker than before • He has a 50+ pack-year smoking history before quitting last year • He was recently diagnosed with type 2 diabetes, but has no other medical problems
  5. 5. Classical Clinical Vignette • O/E: he has a yellow hue to his eyes and tongue, along with scratch marks on his skin. • A non-tender globular mass is palpated in the right upper quadrant (RUQ) of the abdomen • Labs: Laboratory testing reveals total and direct bilirubin of 18 mg/dL (normal 0.2–1.3 mg/dL) and 17.2 mg/dL (<0.3 mg/dL), respectively. • Alkaline phosphatase (ALP) elevated at 215 μ/L (33–131 μ/L). AST & ALT mildly elevated
  6. 6. • 3rd most common GIT cancer. • 4th most common cause of cancer death • Death to incidence ratio is one. ( lowest among all types of cancer). why??? • Male:Female ratio 2:1 • Peak age 65 to 75 yrs • Common in black americans Introduction
  7. 7. Risk factors • Cigarette smoking. • Increased age. • Chronic pancreatitis. • Family H/O Pancreatic Cancer in more than 2 first degree relatives • Increased saturated fat intake. • Exposure to non chlorinated solvents
  8. 8. Genetic Risk factors • Chronic familial relapsing pancreatitis. • Familial breast cancer ( BRCA2). • Peutz –Jeghers syndrome. • HNPCC (Hereditary non polyposis colorectal cancer) • Gardener syndrome. • Familial atypical mole and melanoma syndrome.
  9. 9. Genetic progression
  10. 10. Pathology • Site :55% head of pancreas;25% body 15% tail; 5% periampulary • Macroscopic : growth is hard & infiltrating • Histology :90% ductal adeno ca; 9% cystic neoplasms 1% endocrine neoplasms • Spread :Lymphatics to peritoneum & regional nodes Blood to liver & lung Perineural spread Back pain
  11. 11. Clinical features • Head&Periampulary : Painless progressive jaundice with palpable GB- “Courvoisier’s Law”; Vomiting due to duodenal block Tea color urine, clay color stool & pruritus • Body : back pain,anorexia,weight loss & steatorrhea • Tail : often presents with metastases,malignant ascites or unexplained anemia
  12. 12. Investigations • Lab : Elevated total & direct bilirubin High Alk Phosphatase& GGT Tumor marker CA19-9 >200U/ml • USG Abd : can detect huge tumors can’t pickup small mass • MDCT : Triple phase CT abdomen: with arterial & portal venous phase is sensitive to pickup even small hypodense lesions
  13. 13. Investigations • ERCP & MRCP : “Dual duct sign” Therapeutic ERCP for palliative stent in CBD & Duodenum • Endoscopic Ultrasound:(EUS) Excellent for staging the tumor EUS guided pancreatic biopsy
  14. 14. CT Abdomen
  15. 15. ERCP “Dual Duct Sign”
  16. 16. Periampulary Mass &EUS
  17. 17. Staging Stage1 :Tumor is limited to pancreas with no nodes or metastases Stage2 :Tumor extends into bile duct, peripancreatic tissues or duodenum. No nodes or metastases Stage3 :as stage 2 + positive nodes or celiac or SMA involvement
  18. 18. Staging Stage4a : Tumor extends to stomach,colon,spleen or major vessels with any nodal status and no distant metastases Stage4b : Distant metastases with any nodal status or tumor size
  19. 19. Staging & Prognosis
  20. 20. Treatment • Rescectable tumors • Borderline resectability • Unresectable tumors
  21. 21. Resectable tumors • Normal fat planes between tumor and SMA, SMV • Absence of extrapancreatic disease • Patent SMPV confluence • No direct extension to celiac axis or SMA
  22. 22. Borderline tumors • Short segment occlusion of SMPV confluence with an adequate vessel for grafting • Short segment (< 1 cm ) abutment of the common or proper hepatic artery or SMA on high quality CT
  23. 23. Unresectable tumors • Extrapancreatic disease- distant metastases • Encasement of coelic axis or SMA ( anything more than short abutment)
  24. 24. Treatment Algorithm
  25. 25. Whipple’s Operation
  26. 26. Complications • Delayed gastric emptying • Pancreatic fistula • Intra-abdominal abscess • Operative site hge • GI Hemorrhage
  27. 27. Palliative Surgery • Biliary obstruction:  Biliary enteric bypass  Endoscopic biliary stent placement  Radiographic transhepatic stent placement
  28. 28. Palliative Surgery • Gastric outlet obstruction:  Gastroenteric bypass  Endoscopically placed duodenal stent
  29. 29. Palliative Bypass
  30. 30. Adjuvant therapy • 85% local recurrence .→ RT • 70% liver metastasis.→CT • 5 FU is the only active agent. • Gemcitabine. • 5 FU + Gemcitabine
  31. 31. Mindmap
  32. 32. Treatment Algorithm

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