malignant malignant

obstructive jaundiceobstructive jaundice

babul bansal

carcinoma head of carcinoma head of pancreaspancreas

Malignant Obstructive Jaundice

Carcinoma Head of Pancreas

PeriampullaryCarcinoma

Cholangiocarcinoma CarcinomaGallbladder

USG + CECTUSG + CECT

ResectableResectable UnresectableUnresectable No mass No mass detecteddetected

Reassess Reassess ResectibilityResectibility

ResectResect(Whipple Procedure)(Whipple Procedure)

PalliationPalliation

Chemotherapy Chemotherapy

RadiotherapyRadiotherapy

PainPain JaundiceJaundice Du ObstructionDu Obstruction

ERCP or ERCP or EUSEUS

MalignantMalignant

Evaluate Evaluate FurtherFurther

ResectResect(Whipple Procedure)(Whipple Procedure)

resectibility vs. resectibility vs. unresectibilityunresectibility

Findings contraindicating resection :Liver/Visceral metastasis (any size)

Peritoneal implants

Celiac lymph node involvement

Invasion of transverse mesocolon

Hepatic hilar lymph node involvement

Arterial Invasion – Venous Occlusion

Findings not contraindicating resection:

Invasion of duodenum or distal stomach

Involvement of peripancreatic lymph node

resectionresection

Only shot at Cure (but recurrence is common)

At presentation – only 15% resectable

Two techniques – - Standard Whipple Procedure- Modified Whipple (PPPD)

Pancreatic Ca.

Resection Palliation

kausch - whipple kausch - whipple procedureprocedure

3 phases –- Assessment phase

- Resection phase

- Reconstruction phase

Pancreatic Ca.

Resection Palliation

Assessment

Resection

Reconstruction

Sir 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

a. assessmenta. assessment

Why Reassess???

Specificity of CECT for Resectibility = 80%... Why?

Laparoscopy or Laparotomy???

Gen. Anesthesia – Midline/Bilateral Subcostal incision

Look for – - Metastasis - Inoperable LN involvement - Kocher Maneuver - Aberrant Right Hepatic Artery

Pancreatic Ca.

Resection Palliation

Assessment

Resection

Reconstruction

Kocher Maneuver

Pancreatic Ca.

Resection Palliation

Assessment

Resection

Reconstruction

b. resectionb. resection

Viscera removed- Distal 1/3rd of Stomach (not in PPPD)- Duodenum- Proximal 10 cm of jejunum- Head, Neck and Uncinate Process of Pancreas- Gallbladder with

cystic duct and CBD- Regional Lymph Nodes

Pancreatic Ca.

Resection Palliation

Assessment

Resection

Reconstruction

c. reconstructionc. reconstruction 3 steps – - Pancreatico-jejunostomy- Hepatico-jejunostomy- Gastro-jejunostomy

Pancreatic Ca.

Resection Palliation

Assessment

Resection

Reconstruction

PPPD vs. WhipplePPPD vs. Whipple

Advantages of PPPDPrevention of Reflux

Prevents marginal ulceration

Normal Acid Secretion and Hormone Release

Improved gastric function

Better Weight Gain

Disadvantages of PPPDCompromise with the resection margin

Delayed Gastric Emptying

Pancreatic Ca.

Resection Palliation

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

palliationpalliation

• 85% cases unresectable at presentation• Not curative• Aimed at improving the quality of life• Three major problems –

- Pain

- Jaundice

- Duodenal Obstruction Pancreatic Ca.

Resection Palliation

Pain

Du Obstruction

Jaundice

a. paina. pain

• Medical – Opioids ; NSAIDs• Celiac Plexus Nerve Block (Percutaneous - USG or CT Guided)

(Transgastric or Laparotomic)

Pancreatic Ca.

Resection Palliation

Du Obstruction

JaundicePain

Pancreatic Ca.

Resection Palliation

Du Obstruction

JaundicePain

b. jaundiceb. jaundiceNon-Surgical:

- Biliary Stent PlacementEndoscopic (Metallic or Plastic Stent)Percutaneous Transhepatic

Surgical:- Choledochojejunostomy- Cholecystojejunostomy- Hepaticojejunostomy

(Roux-en-Y)

Pancreatic Ca.

Resection Palliation

Pain

Du Obstruction

Jaundice

Pancreatic Ca.

Resection Palliation

Pain

Du Obstruction

Jaundice

Pancreatic Ca.

Resection Palliation

Pain

Du Obstruction

Jaundice

Choledochojejunostomy

Cholecystojejunostomy

c. duodenal c. duodenal obstructionobstruction

Pancreatic Ca.

Resection Palliation

Pain

Du Obstruction

Jaundice

Non-Surgical:Gastrostomy Tube

Expandable metallic stent

Surgical:Gastrojejunostomy

jaundice + duodenal jaundice + duodenal obstructionobstruction

Pancreatic Ca.

Resection Palliation

Pain

Du Obstruction

JaundiceTriple Bypass

Roux-en-Y

chemotherapy | chemotherapy | radiotherapyradiotherapy

Chemotherapy• 5-fluorouracil• Gemcitabine

Radiotherapy• Low dose Radiotherapy

periampullary periampullary carcinomacarcinoma

Malignant Obstructive Jaundice

Carcinoma Head of Pancreas

PeriampullaryCarcinoma

Cholangiocarcinoma CarcinomaGallbladder

periampullary carcinomaperiampullary carcinoma

• Distal CBD carcinoma• Ampullary Carcinoma• Duodenal Carcinoma (surrounding Ampulla)

- Prognosis is better- Management – similar to Ca head of Pancreas

5 year survival5 year survival

Ca head of PancreasCa head of Pancreas

3%

Periampullary CaPeriampullary Ca

30%

prognostic markers

- CA 19-9

- CA 494

cholangiocarcinomcholangiocarcinomaa

Malignant Obstructive Jaundice

Carcinoma Head of Pancreas

PeriampullaryCarcinoma

Cholangiocarcinoma CarcinomaGallbladder

cholangiocarcinomacholangiocarcinoma

Curative Palliative

curativecurative

Intrahepatic – - Mx - same as Hepatocellular ca

- Sx - Partial Hepatectomy

Proximal / Perihilar (Klatskin Tumor)- 2/3rd of Cholangiocarcinomas- Bismuth-Corlette Classification- Sx – Roux-en-Y

Distal Bile Duct - Mx – same as Periampullary Carcinoma- Sx – Whipple Procedure

Bismuth-Corlette Classification Bismuth-Corlette Classification

Perihilar CholangiocarcinomaPerihilar Cholangiocarcinoma

palliativepalliative

Jaundice- Biliary Stenting- Segment III Bypass

Pain - Opioids, NSAIDs- Celiac Plexus Block

Chemotherapy (5-FU) + Radiotherapy

VIII IV

IV

V

VII

VI

II

III

Segment III BypassSegment III Bypass

prognosisprognosis

Median SurvivalMedian Survival

Resectable Disease – 32-38 months

Unresectable Disease – 5-8 months

carcinoma carcinoma gallbladdergallbladder

Malignant Obstructive Jaundice

Carcinoma Head of Pancreas

PeriampullaryCarcinoma

Cholangiocarcinoma CarcinomaGallbladder

gallbladder carcinomagallbladder carcinoma

Curative Palliative

curativecurative

T1 lesion – limited to muscular layer

- Sx – Simple Cholecystectomy

T2 lesion – invades the perimuscular conn. tissue

- Sx – Cholecystectomy Regional Lymphadenectomy Resection of Liver Segments ( IVb and V)

T3 T4 lesion – invade liver and other organs

- Usually inoperable

palliationpalliation

Jaundice- Biliary Stents- Hepaticojejunostomy

Pain- NSAIDs, Opioids- Celiac Plexus Block

Chemotherapy – Gemcitabine

Radiotherapy – No proven efficacy

prognosisprognosis

5 year survival rate

Resectable – 60-100%

Unresectable – 15%