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malignant BANSAL (Surgical Obstructive Jaundice)

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A compendium of Surgical Obstructive Jaundice of Malignant origin.

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malignant BANSAL (Surgical Obstructive Jaundice)

  1. 1. malignantmalignantobstructive jaundiceobstructive jaundicebabul bansal
  2. 2. carcinoma head ofcarcinoma head ofpancreaspancreasMalignantObstructive JaundiceCarcinomaHead of PancreasPeriampullaryCarcinomaCholangiocarcinoma CarcinomaGallbladder
  3. 3. USG + CECTUSG + CECTResectableResectable UnresectableUnresectable No massNo massdetecteddetectedReassessReassessResectibilityResectibilityResectResect(Whipple Procedure)(Whipple Procedure)PalliationPalliationChemotherapyChemotherapyRadiotherapyRadiotherapyPainPain JaundiceJaundice Du ObstructionDu ObstructionERCP orERCP orEUSEUSMalignantMalignantEvaluateEvaluateFurtherFurtherResectResect(Whipple Procedure)(Whipple Procedure)
  4. 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. 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. 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. 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. 8. Kocher ManeuverPancreatic Ca.Resection PalliationAssessmentResectionReconstruction
  9. 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. 10. c. reconstructionc. reconstruction3 steps –- Pancreatico-jejunostomy- Hepatico-jejunostomy- Gastro-jejunostomyPancreatic Ca.Resection PalliationAssessmentResectionReconstruction
  11. 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. 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. 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. 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. 15. Pancreatic Ca.Resection PalliationDu ObstructionJaundicePain
  16. 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. 17. Pancreatic Ca.Resection PalliationPainDu ObstructionJaundice
  18. 18. Pancreatic Ca.Resection PalliationPainDu ObstructionJaundiceCholedochojejunostomyCholecystojejunostomy
  19. 19. c. duodenalc. duodenalobstructionobstructionPancreatic Ca.Resection PalliationPainDu ObstructionJaundiceNon-Surgical:Gastrostomy TubeExpandable metallic stentSurgical:Gastrojejunostomy
  20. 20. jaundice + duodenaljaundice + duodenalobstructionobstructionPancreatic Ca.Resection PalliationPainDu ObstructionJaundiceTriple BypassRoux-en-Y
  21. 21. chemotherapy |chemotherapy |radiotherapyradiotherapyChemotherapy• 5-fluorouracil• GemcitabineRadiotherapy• Low dose Radiotherapy
  22. 22. periampullaryperiampullarycarcinomacarcinomaMalignantObstructive JaundiceCarcinomaHead of PancreasPeriampullaryCarcinomaCholangiocarcinoma CarcinomaGallbladder
  23. 23. periampullary carcinomaperiampullary carcinoma• Distal CBD carcinoma• Ampullary Carcinoma• Duodenal Carcinoma (surrounding Ampulla)- Prognosis is better- Management – similar to Ca head of Pancreas
  24. 24. 5 year survival5 year survivalCa head of PancreasCa head of Pancreas3%Periampullary CaPeriampullary Ca30%prognostic markers- CA 19-9- CA 494
  25. 25. cholangiocarcinomcholangiocarcinomaaMalignantObstructive JaundiceCarcinomaHead of PancreasPeriampullaryCarcinomaCholangiocarcinoma CarcinomaGallbladder
  26. 26. cholangiocarcinomacholangiocarcinomaCurative Palliative
  27. 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. 28. Bismuth-Corlette ClassificationBismuth-Corlette ClassificationPerihilar CholangiocarcinomaPerihilar Cholangiocarcinoma
  29. 29. palliativepalliativeJaundice- Biliary Stenting- Segment III BypassPain- Opioids, NSAIDs- Celiac Plexus BlockChemotherapy (5-FU) + Radiotherapy
  30. 30. VIII IVIVVVIIVIIIIIISegment III BypassSegment III Bypass
  31. 31. prognosisprognosisMedian SurvivalMedian SurvivalResectable Disease – 32-38 monthsUnresectable Disease – 5-8 months
  32. 32. carcinomacarcinomagallbladdergallbladderMalignantObstructive JaundiceCarcinomaHead of PancreasPeriampullaryCarcinomaCholangiocarcinoma CarcinomaGallbladder
  33. 33. gallbladder carcinomagallbladder carcinomaCurative Palliative
  34. 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. 35. palliationpalliationJaundice- Biliary Stents- HepaticojejunostomyPain- NSAIDs, Opioids- Celiac Plexus BlockChemotherapy – GemcitabineRadiotherapy – No proven efficacy
  36. 36. prognosisprognosis5 year survival rateResectable – 60-100%Unresectable – 15%

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