This document discusses the preoperative preparation and management of a patient with obstructive jaundice. It notes that such patients are usually anemic so blood transfusions may be needed. It also discusses correcting dehydration, vitamin K deficiency, renal impairment, infection risk and malnutrition. The case involves a 60-year old male with jaundice, clay-colored stools and weight loss being evaluated for obstructive jaundice. On examination, a lump is palpated in the right upper abdomen. Further sections discuss periampullary anatomy and carcinomas, investigations including blood tests, imaging and biopsies, and treatment options like Whipple procedure or palliative surgeries.

1. -MANOJIT SARKAR
FINAL PROF
MALDA MEDICAL COLLEGE AND HOSPITAL

2. PREOPERATIVE PREPARATION OF A
CASE OF OBSTRUCTIVE JAUNDICE

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

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

8. PERIAMPULLARY AREA
 ITS AN AREA WITHIN 2CM OF AMPULLA OF VATER IN
DUODENUM.

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

13. DESCRIPTIONS

14. ADENOCARCINOMA OF HEAD OF
PANCREAS

15. INTRODUCTION
 9TH MOST COMMON DIAGNOSIS IN US
 M>F 1.3:1
 5% INDIVIDUALS WILL SURVIVE 5YRS
 HIGH RISK: SIX DECADES

16. RISK FACTORS
ENVIRONMENTAL
 SMOKING-MOST COMMON,1-
3 FOLDS RISE OF
PANCREATIC CA
 ALCOHALISM-10-20 FOLDS
 DIET-HIGH PROTEIN & FAT
INTAKE
 CHRONIC PANCREATITIS-10-
20 FOLDS
 DM-60% RISK
 H.PYLORI INFECTION
HERIDITARY(7-10%)
GENE ASSOCITED
SYNDROME
RISK(FOLDS)
PRSS1 FAMILIAL
PANCREATITIS
40
STK11 PEUTZ JEGHERS SYN 100
CTFR CYSTIC FIBROSIS 30
BRCA2 HERIDITARY
BREAST/OVARIAN CA
10
MLH-1 LYNCH SYNDROME 8
APC FAMILIAL
ADENOMATOUS
POLYPOSIS
4

17. CLINICAL PRESENTATIONS
SYMPTOMS FREQUENCY(%)
JAUNDICE 75
WT LOSS 51
ABDOMINAL
PAIN
39
NAUSEA AND
VOMITING
13
PRURITUS 11
FEVER 3
GL BLEEDING 1

18. STAGING

20. AMPULLARY CARCINOMA

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

22. PRESENTATIONS
COMMON PRESTATIONS
JAUNDICE
ABDOMINAL PAIN
DYSPEPSIA
MALAISE
FEVER
CHILLS
ANOREXIA
PRURITUS
NAUSEA AND VOMITING
DIARRHEA
UPPER GI BLEED

23. CHOLANGIOCARCINOMA OF DISTAL BILE
DUCT

24. INTRODUCTION
 RARE ENTITY
 LESIONS PROX 1/3RD AND MIDDLE 3RD FORMS KLATSKIN TUMOR
WHEREAS DISTAL 3RD BELONGS TO PERIAMPULLARY CARCINOMA

25. PATHOLOGY
 3 VARITES
 SCLEROSING
 NODULAR
 PAPILLARY
NODULAR AND PAPILLARY CA OCCURS IN DISTAL BILE DUCT

26. PRESENTATIONS
COMMON PRESENTATIONS
JAUNDICE
ABDOMINAL PAIN
STEATORREA
PRURITUS
DARK URINE

27. PERIAMPULLARY DUODENAL CARCINOMA
 ADENOCARCINOMA
 PEAK INCIDENCE 70 YRS
 RARE VARIETY
 PROGNOSIS VERY POOR

28. INVESTIGATIONS

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

38. ADJUVANT CHEMOTHERAPY
 5-FLUROURACIL
+ CYCLOPHPSPHAMIDE
+ METHTREXATE/VINCRISTINE
OR
 5-FU + MITOMYCIN

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