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malignant BANSAL (Surgical Obstructive Jaundice)
- 3. carcinoma head ofcarcinoma head of pancreaspancreas Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
- 4. USG + CECTUSG + CECT ResectableResectable UnresectableUnresectable No massNo mass detecteddetected ReassessReassess ResectibilityResectibility ResectResect (Whipple Procedure)(Whipple Procedure) PalliationPalliation ChemotherapyChemotherapy RadiotherapyRadiotherapy PainPain JaundiceJaundice Du ObstructionDu Obstruction ERCP orERCP or EUSEUS MalignantMalignant EvaluateEvaluate FurtherFurther ResectResect (Whipple Procedure)(Whipple Procedure)
- 5. 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
- 6. 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
- 7. kausch - whipplekausch - 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
- 8. 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
- 9. Kocher Maneuver Pancreatic Ca. Resection Palliation Assessment Resection Reconstruction
- 10. 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
- 12. c. reconstructionc. reconstruction 3 steps – - Pancreatico-jejunostomy - Hepatico-jejunostomy - Gastro-jejunostomy Pancreatic Ca. Resection Palliation Assessment Resection Reconstruction
- 13. PPPD vs. WhipplePPPD vs. Whipple Advantages of PPPD Prevention of Reflux Prevents marginal ulceration Normal Acid Secretion and Hormone Release Improved gastric function Better Weight Gain Disadvantages of PPPD Compromise with the resection margin Delayed Gastric Emptying Pancreatic Ca. Resection Palliation
- 14. complicationscomplications Common 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
- 15. 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
- 16. 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
- 17. Pancreatic Ca. Resection Palliation Du Obstruction JaundicePain
- 18. b. jaundiceb. jaundice Non-Surgical: - Biliary Stent Placement Endoscopic (Metallic or Plastic Stent) Percutaneous Transhepatic Surgical: - Choledochojejunostomy - Cholecystojejunostomy - Hepaticojejunostomy (Roux-en-Y) Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice
- 19. Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice
- 20. Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice Choledochojejunostomy Cholecystojejunostomy
- 21. c. duodenalc. duodenal obstructionobstruction Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice Non-Surgical: Gastrostomy Tube Expandable metallic stent Surgical: Gastrojejunostomy
- 22. jaundice + duodenaljaundice + duodenal obstructionobstruction Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice Triple Bypass Roux-en-Y
- 23. chemotherapy |chemotherapy | radiotherapyradiotherapy Chemotherapy • 5-fluorouracil • Gemcitabine Radiotherapy • Low dose Radiotherapy
- 24. periampullaryperiampullary carcinomacarcinoma Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
- 25. periampullary carcinomaperiampullary carcinoma • Distal CBD carcinoma • Ampullary Carcinoma • Duodenal Carcinoma (surrounding Ampulla) - Prognosis is better - Management – similar to Ca head of Pancreas
- 26. 5 year survival5 year survival Ca head of PancreasCa head of Pancreas 3% Periampullary CaPeriampullary Ca 30% prognostic markers - CA 19-9 - CA 494
- 27. cholangiocarcinomcholangiocarcinom aa Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
- 29. 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
- 30. Bismuth-Corlette ClassificationBismuth-Corlette Classification Perihilar CholangiocarcinomaPerihilar Cholangiocarcinoma
- 31. palliativepalliative Jaundice - Biliary Stenting - Segment III Bypass Pain - Opioids, NSAIDs - Celiac Plexus Block Chemotherapy (5-FU) + Radiotherapy
- 32. VIII IV IV V VII VI II III Segment III BypassSegment III Bypass
- 33. prognosisprognosis Median SurvivalMedian Survival Resectable Disease – 32-38 months Unresectable Disease – 5-8 months
- 34. carcinomacarcinoma gallbladdergallbladder Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
- 35. gallbladder carcinomagallbladder carcinoma Curative Palliative
- 36. 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
- 37. palliationpalliation Jaundice - Biliary Stents - Hepaticojejunostomy Pain - NSAIDs, Opioids - Celiac Plexus Block Chemotherapy – Gemcitabine Radiotherapy – No proven efficacy
- 38. prognosisprognosis 5 year survival rate Resectable – 60-100% Unresectable – 15%