3. PATIENT IS USUALLY ANEMIC-SO CORRECTION OF ANEMIA BY BLOOD
TRANSFUSION
HEPATOCELLULAR DYSFUNCTION->REDUCED GLYCOGEN STORAGE-SO
GLYCOGEN STORE REPLENISHED BY ADMINISTRATION OF PLENTY OF
GLUCOSE
CHRONIC DEHYDRATION-CORRECT DEHYDRATION BY ORAL & IV FLUIDS
VIT K DEFICIENCY->PROLONGED PT-INJ OF VIT K I.M. 10 MG FOR 5 -
7DAYS.
RENAL FUNCTION IMPAIRED,MAY LEAD TO CRF-ADEQUATE IV FLUID & IV
FRUSEMIDE /MANNITOL 100-200 ML BD WITH ORAL NEOMYCIN
4. CONT…
PRONE TO INFECTIONS,GM-VE SEPTICEMIA-BROAD SPECTRUM
ANTIBIOTICS(3RD GEN CEPHALOSPORIN-CEFTRIAXONE&
AMINOGLYCOSIDES COMBINATION)
IN CASE OF MALNOURISHED PATIENT-ENTERAL OR
PARENTERAL NUTRITION
FFP OFTEN REQURES AND IV CALCIUM CHLORIDE
SUPPEMENT
EVALUTION OF PULMONARY FUNCTION-CXR IS DONE
5.
6. case presentation:
60 yrs male patient presented with yellowish discolouration
of eyes and urine for last 6 months.
Patient is passing clay colored stool since the onset of
yellowish discolouration.
Patient also complains of anorexia and significant loss of wt
since last 6 months and fullness of RT upper quadrant
ofabdomen for last 3 months.
There is H/O passage of black Tarry stool 2 months back.
7. PALPATION:
A lump is palpable in the RT
hypochondriac region extending
to epigastric and rt lumber region
not palpable liver and spleen
PERCUSSION:
No free fluid in the abdomen
AUSCULTATION:
BOWEL SOUNDS AUDIBLE
Quick review for EXAMINATION:
GENERAL SURVEY:
NUTRITION IS POOR
PALLOR PRESENT
DEEPLY JAUNDICED
LOCAL EXAMINATION
ABDOMINAL:
INSPECTION:
SHAPE AND CONTOUR NORMAL
UMBILICUS IN MIDLINE AND
NORMAL IN SHAPE
9. PERIAMPULLARY CARCINOMA
PERIAMPULLARY CA IS WIDELY USED TERM TO DEFINE
HETEROGENOUS GROUP OF NEOPLASMS ARISING FROM THE
HEAD OF PANCREAS
AMPULLA OF VATER ITSELF
DISTAL COMMON BILE DUCT
THE 2ND PART OF DUODENUM
10. TUMORS UNDER PERIAMPULLARY
CARCINOMA
CA OF HEAD/UNCINATE PROCESS OF PANCREAS –ADENOCA
AMPULLARY CARCINOMA
DISTAL COMMON BILE DUCT CA-CHOLANGIOCA
PERIAMPULLARY ADENOCA OF 2ND PART OF DUODENUM
11. INCIDENCE OF DIFFERENT
PERIAMPULLARY CARCINOMA
ADENOCA OF HEAD OF PANCREAS 50%
AMPULLARY CA 30%
DISTAL CBD CA 10%
CA OF 2ND PART OF DUODENAM 10%
50%
30%
10% 10%
INCIDENCE OF DIFFERENT PACA
ADENOCA OF HEAD OF PANCREAS AMPULLARY CA DISTAL CBD CA CA OF 2ND PART OF DUODENAM
12. HISTORICAL BACKGROUND
WILLIAM STEWART HALSTED IN 1988,WAS THE FIRST WHO
ATTEMTED SUCCESSFULLY LOCAL RESECTION OF PACA
ALESSANDRO CODIVILLA WAS FIRST TO PERFORM ENBLOC
REMOVAL OF THE ENTIRE DUODENAM WITH CA OF HEAD OF
PANCREAS IN CA PANCREAS
WALTHER KAUSCH,ALSO SUCCESSFUL PERFORMER IN THE FIELD OF
CA PANCREAS
21. INTRODUCTION
CARCINOMA OF AMPULLA ARISING FROM AMPULLA OF VATER AT
LAST PART OF CBD WHERE IT PASSES THROUGH THE WALL OF
DUODENUM WITH PANCREATIC DUCT
29. FOR CONFIRMATION OF DIAGNOSIS:
LIVER FUNCTION TESTS:
SERUM BILLIRUBIN ESTIMATION-TOTAL/CONJUGTED/UNCONJUGATED BILLIRUBIN-
SERUM ALKALINE PHOSPHATASE
SERUM ALT/AST
SERUM ALBUMIN/GLOBULIN
HEMATOLOGY
PT ESTIMATION
SEROLOGY:
TUMOR MARKERS:
o CA 19/9-MOST RELIABLE FOR PRE AND POST TREATMENT SURVILLENCE
o ALFA FETO PROTEIN
o CARCINOEMBRYONIC ANTIGEN
RADIOLOGY
USG
30. FOR ASSESSMENT OF SEVERITY:
CECT(TRIPHASIC) OF ABDOMEN:
NONCONTRAST,ARTERIAL AND PORTAL VENOUS PHASE
ITS HELPFUL FOR:
DELINIATION OF PANCREATIC MASS
LEVEL OF BILE DUCT OBSTRUCTION
ANY DILATATION OF PANCREATIC DUCT
ANY PATHOLOGY OF DISTAL CBD AND DUODENAM
ANY REGIONAL LN INVOLVENENT
PRESENCE OF ASCITES
31. ERCP: NOT ROUTINELY INDICATED.BUT SOMETIMES USED AS DIAGNOSTIC AND
THERAPUTIC PURPOSE
DIAGNOSTIC:
TO FIND OUT LONG IRREGULAR STRICTURE IN PANCREATIC DUCT WITH DISTAL
DILATATION-DOUBLE DUCT SIGN
BRUSH BIOPSY IN DISTAL CBD CA
THERAPUTIC:
IN PALLIATIVE STENTING
MRCP
TO FIND OUT BILLIARY TREE AND PANCREATIC DUCT PATHOLOGY
32. EUS:
TO DIAGNOSE CA PANCREAS-IN CASE OF:
SMALL LESION <2CM
DETECT LNs AND VASCULAR INVOVEMENT
INVASION OF AMPULLARY TUMOR INTO DUODENAL
WALL AND PANCREAS
PET-CT SCAN:IT DETECTS METASTASIS THAT ARE
TOO SMALL TO DIAGNOSIS BY CECT AND HELP TO
DIFFERENTIATE BENIGN AND MALIGNANT LESION
BIOSY:
DONE TO CONFIRM THE PRESENCE AND TYPE OF CANCER.IT
IS USUALLY REQURED BEFORE CHEMORADIATION OF
UNRESECTABLE PERIAMPULLARY TUMOR OR NEOADJUVANT
TREATMENT OF RESECTABLE TUMOR.
33. STAGING LAPAROSCOPY:
NOT VERY MUCH
HELPFUL.HOWEVER
INDICATED IN HIGH RISK
CASES..
LARGE TUMOR>3CM
SIGNIFICANT ELEVATION
OF TUMOR MARKERS
BODY AND TAIL TUMOR
34. TREATMENT
IF THERE IS NO SIGNS
AND SYMPTOMS OF
DISSEMINATED
DISEASE AND CT
REVEALS NO SIGNS OF
LOCAL SPREAD
I WOULD LIKE TO GO FOR
EXPLORATORY LAPAROTOMY
TO CONFIRM DIAGNOSIS
DEFINITIVE SURGICAL
TREATMENT WITH ADJUVANT
CHEMOTHERAPY-WHIPPLE’S
OPERATION-
(PANCREATICODUODENECTOMY)
IN CASE OF ADVANCED DISEASE
OR IN INOPERABLE CASE:
PALLIATIVE SURGICAL TREATMENT
Rx OF JAUNDICE
Rx OF GOO
RELIEF OF PAIN
35. SURGICAL TREATMENT
TUMOR LOCALISED TO PANCREAS
NO EVIDENCE OF SUP.MESENTERIC VEIN OR PORTAL
VEIN INVOLVEMENT
NO EVIDENCE OF DISTANT METASTASIS
CRITERIA OF RESECTABLE TUMOR:(IN
CASE OF CA PANCREAS)
36. WHIPPLE'S OPERATION:
MODIFIED WHIPPLE’S
OPERATION:DISTAL 3RD OF
STOMACH THE IS NOT
REMOVED.LINE OF RESECTION
IS 2CM DISTAL TO PYLORUS
PANCREATICODUODENECTOMY
STRUCTURS REMOVED:
WHOLE OF DUODENAM UPTO 10 CM
OF PROX.JEJUNUM
HEAD & NECK OF PANCREAS
DISTAL 40-50% STOMACH
LOWER END OF CBD
GB
PERICHOLEDOCHAL,PERIDUODENAL
,PERIPANCREATIC LN
37. PALLIATIVE TREATMENT
PALLIATIVE SURGICAL TREATMENT
RX OF JAUNDICE
BY ENDOSCOPIC STENTING OR
BY ROUX EN Y CHOLECYSTOJEJUNOSTOMY OR
CHOLEDOCHOJEJUNOSTOMY
RX OF GOO
GASTROJEJUNOSTOMY
RELIEF OF PAIN
BY NSAIDS OR
CELIAC PLEXUS BLOCK BYBUPIVACAINE OR ALCOHAL INJ TO CELIAC
PLEXUS
39. TAKEHOMEMESSAGE
ANATOMY OF BILLIARY TREE
DIFFERENT TYPES OF JAUNDICE
CAUSES OF OBSTRUCTIVE JAUNDICE
IMPORTANT INVESTIGATIONS OF
OBSTRUCTIVE JAUNDICE
TYPES OF CHOLEDOCHOLITHIASIS
AND TREATMENT
PERIAMPULLARY CARCINOMA-TYPES
WHIPPLE’S OPERATION
40. BAILEY AND LOVE’S SHORT PRACTICE OF SURGERY,26TH EDTN
SABISTON TEXTBOOK OF SURGERY,17TH EDTN
SRB’S MANNUAL OF SURGERY,5TH EDTN
MANIPAL MANNUAL OF SURGERY,4TH EDTN
SCHWARTZ PRINCIPLES OF SURGERY,10TH EDTN
BIBLIOGRAPHY