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This document discusses malignant obstructive jaundice, focusing on cancers of the gallbladder and bile duct. It provides details on the etiology, risk factors, staging, clinical presentation, diagnosis, and management of gallbladder cancer. Key points include that gallbladder cancer occurs more commonly in elderly women and is often diagnosed late, when many tumors are unresectable. Surgical resection aims to achieve R0 margins and may involve extended cholecystectomy or liver resection. Prognosis depends on pathological stage, with stage T1a having an excellent prognosis following cholecystectomy alone.

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MALIGNANT OBSTRUCTIVE JUNDICE MOSTAFAHEGAZY
Etiology:  MALIGNANT BILIARY DISEASE ▶ Gallbladder Cancer ▶ Bile Duct Cancer  Cancer head of pancrease  Duodenal cancer  Ampulloma Malignant Liver tumors invading or compressing biliary system.  Metastatic and Other Tumors
Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocar- cinoma Carcinoma Gallbladder
carcinoma head of pancreas Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
US + CT Resectable Unresectable No mass detected Reassess Resectibility Resect (Whipple Procedure) Palliation Chemotherapy Radiotherapy Pain Jaundice Du Obstruction ERCP or EUS Malignant Evaluate Further Resect (Whipple Procedure)
resectibility vs. unresectibility 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
resection 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 procedure 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. 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. 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. reconstruction 3 steps – - Pancreatico-jejunostomy - Hepatico-jejunostomy - Gastro-jejunostomy Pancreatic Ca. Resection Palliation Assessment Resection Reconstruction
PPPD 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
complications 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
palliation ▶ 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. pain ▶ Medical – Opioids ; NSAIDs ▶ Celiac Plexus Nerve Block (Percutaneous - USG or CT Guided) (Transgastric or Laparotomic) Pancreatic Ca. Resection Palliation Du Obstruction Jaundice Pain
Pancreatic Ca. Resection Palliation Du Obstruction Jaundice Pain
b. 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
Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice
Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice Choledochojejunostomy Cholecystojejunostomy
c. duodenal obstruction Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice Non-Surgical: Gastrostomy Tube Expandable metallic stent Surgical: Gastrojejunostomy
jaundice + duodenal obstruction Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice ripl pass Roux-en-Y
periampullary carcinoma Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
periampullary carcinoma ▶ Distal CBD carcinoma ▶ Ampullary Carcinoma ▶ Duodenal Carcinoma (surrounding Ampulla) - Prognosis is better - Management – similar to Ca head of Pancreas
5 year survival Ca head of Pancreas 3% Periampullary Ca 30% prognostic markers - CA 19-9 - CA 494
palliative Jaundice - Biliary Stenting - Segment III Bypass Pain - Opioids, NSAIDs - Celiac Plexus Block Chemotherapy (5-FU) + Radiotherapy
VIII IV IV VII V VI II III Segment III Bypass
prognosis Median Survival Resectable Disease – 32-38 months Unresectable Disease – 5-8 months
 MALIGNANT BILIARY DISEASE ▶ Gall bladder Cancer ▶ Bile Duct Cancer
Gall bladder Cancer ( Introduction) ▶ Aggressive malignancy ▶ Occurs predominantly in elderly people. ▶ The prognosis for most patients is poor. ▶ 5-year survival rates of only 5% to 38%. ▶ Many of these tumors are unresectable at presentation ▶ Aggressive surgical approach for patients with localized GB cancer has produced encouraging results with an acceptable morbidity.
Incidence ▶ The 5th most common GI cancer. ▶ Sex: 2:3 times more common in women. ▶ Age: > 75% of them occur in patients > 65 years. ▶ The incidence varies with racial & geographic location. ▶ In USA, GB cancer is more common in NativeAmericans.
Etiology ▶ The pathogenesis is related to chronic inflammation. ▶ Gall stones are the most common because of the high prevalence in the general population. ▶ The association between a porcelain gallbladder, and other biliary disorders such as choledochal cysts and PSC and gall bladder cancer has been recognized more recently.
Risk Factors for GB Carcinoma ▶ Gall stones ▶ Porcelain gall bladder ▶ Anomalous pancreatobiliary junction ▶ Choledochal cysts ▶ Adenomatous gallbladder polyps ▶ PSC ▶ Obesity ▶ Salmonella typhi infection
Pathology and Staging ▶ 90% are classified as adenocarcinoma. ▶ 10 % are Squamous cell, oat cell, undifferentiated, and adenosquamous cancers and carcinoid tumors. ▶ At diagnosis: - 25% are localized to the GB wall, - 35% have regional LN or extension into adjacent organs, - 40% have metastasized to distant sites. ▶ Hepatic involvement can occur by: - Direct invasion - Angiolymphatic portal tract, - Hematogenous spread.
TNM Staging for GB Cancer T1 Tumor invades lamina propria (T1a) or muscular (T1b) layer T2 Tumor invades perimuscular connective tissue, no extension beyond the serosa or into the liver T3 Tumor perforates the serosa (visceral peritoneum) and/or directly invades into liver and/or one other adjacent organ or structure such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts T4 Tumor invades main PV or HAor invades multiple extrahepatic organs and/or structures N0 No lymph node metastases N1 Regional lymph node metastases M0 No distant metastases M1 Distant metastases
Stage Stage Grouping IA T1 N0 M0 IB T2 N0 M0 IIA T3 N0 M0 IIB T1 N1 M0 T2 N1 M0 T3 N1 M0 III T4Any N M0 IV Any TAny N M1
Clinical Presentation ▶ Pain. ▶ Weight loss, jaundice, and an abdominal mass are less common. ▶ 40% of patients present with symptoms of chronic cholecystitis, ▶ Acute cholecystitis, with a short duration of pain associated with vomiting, fever, and tenderness. ▶ GB cancer is often misdiagnosed as chronic cholecystitis, pancreatic cancer, acute cholecystitis, choledocholithiasis, or gallbladder hydrops.
Diagnosis ▶ U/S…. ▶ CT scan. ▶ MRI. ▶ Cholangiography (long stricture of CHD). ▶ Angiography, spiral CT, or MRI may identify encasement of PV or HA. Unresectable tumor (liver or peritoneal metastases, PV encasement, or extensive hepatic invasion).
Management ▶ Depends on the pathologic stage  Stage T1a or T1b: - Identified after cholecystectomy - 5-year survival (100% and 85%, respectively). (Cholecystectomy is adequate for patients with T1 tumors).  Recurrent cancer at port sites have been reported, therefore, all port sites should be excised.  Patients with suspected GB cancer should undergo open cholecystectomy.
Stages II and III, - “Extended cholecystectomy.” ( This includes cystic, pericholedochal, portal, right celiac, and posterior pancreatoduodenal LNs. (R0 resection should be the goal of surgery)  In cases with cystic duct stump margin positive, CBD resection with Roux-en-Y reconstruction is mandatory.  Extended cholecystectomy should incorporate at least a 2-cm liver margin beyond the tumor. ▶ Small tumors--------- wedge resection of the liver. ▶ Large tumors (bisegmentectomy or extended right hepatectomy)
▶ Staging laparoscopy (50%-55%) have hepatic or extrahepatic disease not detected by noninvasive modalities. ▶ Palliative ttt for inoperable cases: -Tissue diagnosis in patients with an unresectable tumor. -Obst j. --- ERCP or PTC for biliary stent. -Pain -- celiac block. ▶ Chemotherapy have been quite poor. ▶ External-beam and intraoperative radiation therapy (unfortunately, no randomized data have demonstrated improved survival with either chemotherapy or radiation).
Survival ▶ Influenced by the pathologic stage. ▶ Aggressive resection improved overall survival. ▶ (T1a) -------- excellent prognosis. ▶ (T1b) increases the risk for recurrent after curative resection. ▶ (T2) -Increases the risk for regional LN metastases to 33% : 50%. (5-year survival is improved following extended chole (59%-61%) compared with simple cholecystectomy (17%-19%). ▶ 5-year overall survival rates for resected patients with stages IIA and IIB of 28% to 63% and 19% to 25%, respectively. ▶ Stage IV: The median survival is only 1 to 3 months.
Gall bladder Cancer Curative Palliative
curative 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
palliation Jaundice - Biliary Stents - Hepaticojejunostomy Pain - NSAIDs, Opioids - Celiac Plexus Block Chemotherapy – Gemcitabine Radiotherapy – No proven efficacy
prognosis 5 year survival rate Resectable – 60-100% Unresectable – 15%
Bile Duct Cancer
Introduction: ▶ Cholangio CA affect the IHBR or EHBR. ▶ 60%-80% --- located at the hepatic bifurcation ( KST). ▶ Present with jaundice, and should be considered in every patient with obstructive jaundice. ▶ Many patients (palliative bypass or intubation) aimed to provide biliary drainage and prevent cholangitis and hepatic failure. ▶ It’s a crime to drain the biliary system before MRCP staging. ▶ When possible, surgical resection offers a long-term survival.
Incidence ▶ 1 or 2 cases per 100,000 population.
Risk Factors ▶ PSC ▶ Choledochal cysts ▶ Hepatolithiasis. (bile duct stones, biliary stasis, and infection) ▶ Age (between 50: 70 years) except PSC or choedochal cyst. ▶ Sex: slightly higher in men. ▶ Hepatitis B and C. ▶ Genetic disorders : -Inherited “cancer family” syndrome termed Lynch syndrome II, - multiple biliary papillomatosis; ▶ Prior biliary-enteric anastomosis. ▶ Transduodenal sphincteroplasty and choledochoduodenostomy. ▶ Liver flukes, Thorotrast, industrial chemicals, dietary nitrosamines, and exposure to dioxin.
Staging and Classification • Three broad groups: 1. Intrahepatic 2. Perihilar 3. Distal
TNM ▶ Tis, carcinoma in situ; ▶ T1, tumor invades the subepithelial connective tissue; ▶ T2, tumor invades peri. fibromuscular connective tissue; ▶ T3, tumor invades adjacent organs. ▶ N0, no LN metastases; ▶ N1, hepatoduodenal ligament LN; ▶ N2, peripancreatic, periduodenal, periportal, celiac, and/or SMALN. ▶ M0, no distant metastasis; ▶ M1, distant metastasis.
American Joint Commission on Cancer TNM Staging System for Cholanangio CA Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1 or T2 N1 or N2 M0 Stage IVA T3 Any N M0 Stage IVB Any T Any N M1
Clinical Presentation ▶ > 90% present with jaundice. ▶ Less common (pruritus, fever, mild abdominal pain, fatigue, anorexia, and weight loss). ▶ Cholangitis develops after biliary manipulation. ▶ O/E is usually normal except for jaundice.
Diagnosis and Assessment of Resectability ▶ LABORATORY: -Bilirubin. -Alkaline phosphatase. -CA19-9 (elevated & may fall when obstruction is relieved). ▶ RADIOLOGY: -(US/ CT)- Delineate the extent of the tumor (involvement of BDs, liver, hilar vessels, and distant metastases). -MRCP, ERCP, PTC. -Hilar KST-- dilated IHBR & collapsed GB and EHBR. -Distal tumors lead to dilation of the GB, IH & EHBR. (The proximal extent of the tumor is the most important feature in determining resectability in patients with perihilar tumors and the PTC is the most reliable).
Serum and Bile markers for Cholangiocarcinoma
▶ PET , detect distant or hepatic mets in up to 30% of patients. ▶ Biliary drainage if bilirubin > 10 mg/dL, ( risk for cholangitis). ▶ FNA& brush biopsy, and cytologic examination of bile---, (sensitivity is low). ▶ 7 : 15% of patients with diagnosis of malig. Ob J will ultimately have benign lesions on histologic analysis of resection specimens. (Pseudo KST).
▶ Intrahepatic cholangioCA ttt : Hepatic resection, Outcomes: depend on disease stage (LN status & margins status). If complete resection (3year survival = 22%-66%).
Management ▶ Idea: ▶ Curative ttt is possible only with complete resection (R0). - Ipsilateral PV involvement. - Involvement of secondary biliary radicals. - Ipsilateral lobar atrophy. (Do not preclude resection)
Radiologic Criteria Of Unresectability of CH CA ▶ Bilateral HD involvement up to secondary radicals. ▶ Bilateral HAinvolvement ▶ Encasement of the PV proximal to its bifurcation ▶ Atrophy of one hepatic lobe with contralateral PV encasement ▶ Atrophy of one hepatic lobe with contralateral biliary radical involvement ▶ Distant metastasis
Palliative ttt ▶ Indication: unresectable cholangioCA ▶ Methods: ERCP & PTC - PTC in patients with KST, - ERCP in patients with distal cholangioca. ▶ Types of stents: - Metallic stents (patent longer time).
Operative Approach ▶ Exploration should be undertaken in good-risk patients in absence of mets or unresectable disease; however, intraoperatively, > half of these patients are found to have (peritoneal or hepatic mets or, locally unresectable disease). ▶ Laparoscopy in potentially resectable KST may avoid surgery in patients with metastatic disease. ▶ Exploration - extensive metastatic disease ? - Biliary stents left in place. - Cholecystectomy to avoid cholecystitis. ▶ In patients with locally advanced unresectable KST: - Roux-en-Y HJ to segment III or IV.
▶ Distal cholangioCA A)- Resectable ttt : (Whipple's op). Prognosis : 5-year survival 15% : 25% LN –ve ---54% B)- Unresectable ttt: cholecystectomy & triple by pass.
KST ▶ KSTbile duct resection alone leads to high local recurrence. ▶ Curative resections are possible in < half of patients, and most do not achieve long-term disease control. ▶ ttt depends on Bismuth classification: - Type I & II--- en bloc resection of EHBD & GB with 5:10 mm margins + LN resection with Roux-en-Y HJ. NB: type II & III often involve BD of the caudate, routine caudate lobectomy is advised. - Type IIIa & IIIb are amenable to curative resection in centers with expertise in these procedures.
▶ Curative resection for KST (hepatectomy + resection of caudate lobe + bile duct resection) - 5-year survival > 50% - mortality rates (8%-10%). ▶ Prognostic factors: - Margin status - Tumor stage - Location
Medical Therapy ▶ Radiotherapy improves survival in unresectable cases. ▶ Techniques: - Intraoperative radiotherapy and brachytherapy with iridium-192 through percutaneous or endoscopic stents. ▶ Chemotherapy doesn't improve survival in patients with either resected or unresected cholangiocarcinoma. ▶ Finally, photodynamic therapy is emerging as an important palliative option for patients with unresectable ch ca.
Outcomes ▶ Survival is dependent on the stage of disease. ▶ Aggressive approach (partial hepatectomy + caudate lobe + biliary resection ) has increased 5-year survival rates to > 50%. ▶ KST tumors: - Unresectable (median survival 5 : 8 months). ▶ The perioperative mortality rates : - Local excision (2%-4%). - Extensive resections (8%-10% ) ▶ Distal cholangioCA: A)- Resectable: - The highest rate of resection, - Median survival (32 : 38 months) - 5-year survival of 28% : 45%. B)- unresectable: (with multimodality adjuvant therapy),
cholangiocarcinoma Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
cholangiocarcinoma Curative Palliative
curative 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 Perihilar Cholangiocarcinoma
Metastatic and Other Tumors ▶ Types: - HCC. - Hepatic cystadenoma & cystadenocarcinoma. - CRLM - Lymphoma. - Breast & ovarian metastasis. ▶ Mechanism of Obstructive jaundice: - Direct extension into the perihilar bile ducts. - Embolization into the biliary tree. - Hilar or pericholedochal LN++
chemotherapy | radiotherapy Chemotherapy ▶ 5-fluorouracil ▶ Gemcitabine Radiotherapy ▶ Low dose Radiotherapy
Congenital anomalies of the EHBD RISK OF MALIGNANCY. INDICATIONS OF SURGERY
Choledochal Cysts ▶ 1/13000 to 1/2 000 000 live births ▶ 3 times more often in females.
Carcinoma in choledochal cysts, age related incidence. Voyles CR et al. Arch Surg 1983; 118: 986-988 – O.7% in children less than 10 years of age – 6.8% in the second decade of life – 14.5% in patients more than 20 years old.
Management of ampullary tumors Role of local resection
Ampulloma DEFINITION: (Tumour of the sphincterized part of distal CBD, distal Wirsung duct, and common bilio-pancreatic duct, and intraluminal part of the papilla). « Extended » definition = ampullary and duodenal peri- papillary (< 1 cm) tumor. Differential diagnosis: - Tumours of the pancreas and distal CBD. -Non-tumoral disease (intra-ampullary impacted stone, dysfunction of Oddi’s sphincter). Malignancy : 70-90% (excluding FamilialAdenomatous Polyposis)
Ampulloma : pathology 1) Adenoma - dysplasia - carcinoma 2) Endocrine tumour 3) Neuroectodermal tumour 4) Adenomyoma (hamartoma) 5) Stromal tumour
Ampulloma : symptoms 50 - 80 - 70 ▶ Jaundice (permanent) ▶ Weight loss 25 ▶ Pain 20 - 65 ▶ Pruritus 25 - 50 ▶ Anemia 15 - 40 ▶ Cholangitis, transient jaundice 10 - 30 ▶ Acute pancreatitis < 10 ▶ Upper GI bleeding < 10 ▶ Duodenal stenosis < 5 ▶ No symptoms 10-20
Ampulloma : Management ▶ 1) To assert ampulloma / to eliminate another diagnosis ▶ 2) To assert benignity or malignancy ▶ 3) Evaluation of resecability ▶ 4) Choice of surgical procedure
Ampulloma : Imaging Tumor Ductal Visibility ▶ Ultrasound 20-70 % ▶ CT 70-85 % ▶ MRI 50-70 %
Ampulloma : Preoperative diagnosis of malignancy Symptoms: • permanent jaundice : 74% of malignant cases vs 29% of benign •weight loss : 53% of malignant cases vs 11% of benign Gross appearance at endoscopy: • Ulceration = infiltrative malignancy • Exophytic without ulceration = benign or non infiltrative malignant Biopsies after endoscopic sphincterotomy
Curative treatment of malignant ampullomas Pancreaticoduodenectomy
Curative treatment of malignant ampullomas Prognostic factors of survival • Positive LNs. • Nb of +ve LN > 3 • Lymphatic vessel invasion • Perineural invasion • Poorly differentiated tumor • Jaundice • Perioperative transfusions
ttt of ampullomas presumed to be benign ▶ Pancreaticoduodenectomy ▶ Endoscopic ampullectomy To be considered as a « macrobiopsy » Complications : haemorrhage, acute pancreatitis Limits : - appreciation of lateral limits of resection - tumor extension into CBD ▶ Surgical ampullectomy Early complications : more frequent than after endoscopy ?? Reliable peroperative evaluation of limits of resection (frozen section) Limit : needs reliable peroperative assessment of benignity
Ampulloma : Conclusions • Approximately 20% are benign. • Mainly responsible for biliary obstruction • CT-scan useful for positive diagnosis and staging •Biopsies after endoscopic sphincterotomy diagnose approximately 80% of cancers • At EUS, a tumor classified as uT1N0 is an invasive carcinoma in one fourth of cases.
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malignantobstructivejundicehegazy-191120103208.pptx

  • 1.
  • 2.
    Etiology:  MALIGNANT BILIARYDISEASE ▶ Gallbladder Cancer ▶ Bile Duct Cancer  Cancer head of pancrease  Duodenal cancer  Ampulloma Malignant Liver tumors invading or compressing biliary system.  Metastatic and Other Tumors
  • 3.
  • 5.
    carcinoma head ofpancreas Malignant Obstructive Jaundice Carcinoma Head of Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
  • 6.
    US + CT ResectableUnresectable No mass detected Reassess Resectibility Resect (Whipple Procedure) Palliation Chemotherapy Radiotherapy Pain Jaundice Du Obstruction ERCP or EUS Malignant Evaluate Further Resect (Whipple Procedure)
  • 7.
    resectibility vs. unresectibility Findingscontraindicating 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
  • 8.
    resection Only shot atCure (but recurrence is common) At presentation – only 15% resectable Two techniques – - Standard Whipple Procedure - Modified Whipple (PPPD) Pancreatic Ca. Resection Palliation
  • 9.
    kausch - whipple procedure 3phases – - 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
  • 10.
    a. assessment Why Reassess??? Specificityof 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
  • 11.
    Kocher Maneuver Pancreatic Ca. ResectionPalliation Assessment Resection Reconstruction
  • 12.
    b. 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
  • 14.
    c. reconstruction 3 steps– - Pancreatico-jejunostomy - Hepatico-jejunostomy - Gastro-jejunostomy Pancreatic Ca. Resection Palliation Assessment Resection Reconstruction
  • 15.
    PPPD vs. Whipple Advantagesof 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
  • 16.
    complications Common Complication ▶ DelayedGastric 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
  • 17.
    palliation ▶ 85% casesunresectable 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
  • 18.
    a. pain ▶ Medical– Opioids ; NSAIDs ▶ Celiac Plexus Nerve Block (Percutaneous - USG or CT Guided) (Transgastric or Laparotomic) Pancreatic Ca. Resection Palliation Du Obstruction Jaundice Pain
  • 19.
    Pancreatic Ca. Resection Palliation DuObstruction Jaundice Pain
  • 20.
    b. jaundice Non-Surgical: - BiliaryStent Placement Endoscopic (Metallic or Plastic Stent) Percutaneous Transhepatic Surgical: - Choledochojejunostomy - Cholecystojejunostomy - Hepaticojejunostomy (Roux-en-Y) Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice
  • 21.
  • 22.
    Pancreatic Ca. Resection Palliation Pain DuObstruction Jaundice Choledochojejunostomy Cholecystojejunostomy
  • 23.
    c. duodenal obstruction PancreaticCa. Resection Palliation Pain Du Obstruction Jaundice Non-Surgical: Gastrostomy Tube Expandable metallic stent Surgical: Gastrojejunostomy
  • 24.
    jaundice + duodenalobstruction Pancreatic Ca. Resection Palliation Pain Du Obstruction Jaundice ripl pass Roux-en-Y
  • 25.
    periampullary carcinoma Malignant Obstructive Jaundice Carcinoma Headof Pancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
  • 26.
    periampullary carcinoma ▶ DistalCBD carcinoma ▶ Ampullary Carcinoma ▶ Duodenal Carcinoma (surrounding Ampulla) - Prognosis is better - Management – similar to Ca head of Pancreas
  • 27.
    5 year survival Cahead of Pancreas 3% Periampullary Ca 30% prognostic markers - CA 19-9 - CA 494
  • 28.
    palliative Jaundice - Biliary Stenting -Segment III Bypass Pain - Opioids, NSAIDs - Celiac Plexus Block Chemotherapy (5-FU) + Radiotherapy
  • 29.
  • 30.
    prognosis Median Survival Resectable Disease– 32-38 months Unresectable Disease – 5-8 months
  • 31.
     MALIGNANT BILIARYDISEASE ▶ Gall bladder Cancer ▶ Bile Duct Cancer
  • 32.
    Gall bladder Cancer( Introduction) ▶ Aggressive malignancy ▶ Occurs predominantly in elderly people. ▶ The prognosis for most patients is poor. ▶ 5-year survival rates of only 5% to 38%. ▶ Many of these tumors are unresectable at presentation ▶ Aggressive surgical approach for patients with localized GB cancer has produced encouraging results with an acceptable morbidity.
  • 33.
    Incidence ▶ The 5thmost common GI cancer. ▶ Sex: 2:3 times more common in women. ▶ Age: > 75% of them occur in patients > 65 years. ▶ The incidence varies with racial & geographic location. ▶ In USA, GB cancer is more common in NativeAmericans.
  • 34.
    Etiology ▶ The pathogenesisis related to chronic inflammation. ▶ Gall stones are the most common because of the high prevalence in the general population. ▶ The association between a porcelain gallbladder, and other biliary disorders such as choledochal cysts and PSC and gall bladder cancer has been recognized more recently.
  • 35.
    Risk Factors forGB Carcinoma ▶ Gall stones ▶ Porcelain gall bladder ▶ Anomalous pancreatobiliary junction ▶ Choledochal cysts ▶ Adenomatous gallbladder polyps ▶ PSC ▶ Obesity ▶ Salmonella typhi infection
  • 36.
    Pathology and Staging ▶90% are classified as adenocarcinoma. ▶ 10 % are Squamous cell, oat cell, undifferentiated, and adenosquamous cancers and carcinoid tumors. ▶ At diagnosis: - 25% are localized to the GB wall, - 35% have regional LN or extension into adjacent organs, - 40% have metastasized to distant sites. ▶ Hepatic involvement can occur by: - Direct invasion - Angiolymphatic portal tract, - Hematogenous spread.
  • 37.
    TNM Staging forGB Cancer T1 Tumor invades lamina propria (T1a) or muscular (T1b) layer T2 Tumor invades perimuscular connective tissue, no extension beyond the serosa or into the liver T3 Tumor perforates the serosa (visceral peritoneum) and/or directly invades into liver and/or one other adjacent organ or structure such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts T4 Tumor invades main PV or HAor invades multiple extrahepatic organs and/or structures N0 No lymph node metastases N1 Regional lymph node metastases M0 No distant metastases M1 Distant metastases
  • 38.
    Stage Stage Grouping IAT1 N0 M0 IB T2 N0 M0 IIA T3 N0 M0 IIB T1 N1 M0 T2 N1 M0 T3 N1 M0 III T4Any N M0 IV Any TAny N M1
  • 39.
    Clinical Presentation ▶ Pain. ▶Weight loss, jaundice, and an abdominal mass are less common. ▶ 40% of patients present with symptoms of chronic cholecystitis, ▶ Acute cholecystitis, with a short duration of pain associated with vomiting, fever, and tenderness. ▶ GB cancer is often misdiagnosed as chronic cholecystitis, pancreatic cancer, acute cholecystitis, choledocholithiasis, or gallbladder hydrops.
  • 40.
    Diagnosis ▶ U/S…. ▶ CTscan. ▶ MRI. ▶ Cholangiography (long stricture of CHD). ▶ Angiography, spiral CT, or MRI may identify encasement of PV or HA. Unresectable tumor (liver or peritoneal metastases, PV encasement, or extensive hepatic invasion).
  • 41.
    Management ▶ Depends onthe pathologic stage  Stage T1a or T1b: - Identified after cholecystectomy - 5-year survival (100% and 85%, respectively). (Cholecystectomy is adequate for patients with T1 tumors).  Recurrent cancer at port sites have been reported, therefore, all port sites should be excised.  Patients with suspected GB cancer should undergo open cholecystectomy.
  • 42.
    Stages II andIII, - “Extended cholecystectomy.” ( This includes cystic, pericholedochal, portal, right celiac, and posterior pancreatoduodenal LNs. (R0 resection should be the goal of surgery)  In cases with cystic duct stump margin positive, CBD resection with Roux-en-Y reconstruction is mandatory.  Extended cholecystectomy should incorporate at least a 2-cm liver margin beyond the tumor. ▶ Small tumors--------- wedge resection of the liver. ▶ Large tumors (bisegmentectomy or extended right hepatectomy)
  • 43.
    ▶ Staging laparoscopy(50%-55%) have hepatic or extrahepatic disease not detected by noninvasive modalities. ▶ Palliative ttt for inoperable cases: -Tissue diagnosis in patients with an unresectable tumor. -Obst j. --- ERCP or PTC for biliary stent. -Pain -- celiac block. ▶ Chemotherapy have been quite poor. ▶ External-beam and intraoperative radiation therapy (unfortunately, no randomized data have demonstrated improved survival with either chemotherapy or radiation).
  • 44.
    Survival ▶ Influenced bythe pathologic stage. ▶ Aggressive resection improved overall survival. ▶ (T1a) -------- excellent prognosis. ▶ (T1b) increases the risk for recurrent after curative resection. ▶ (T2) -Increases the risk for regional LN metastases to 33% : 50%. (5-year survival is improved following extended chole (59%-61%) compared with simple cholecystectomy (17%-19%). ▶ 5-year overall survival rates for resected patients with stages IIA and IIB of 28% to 63% and 19% to 25%, respectively. ▶ Stage IV: The median survival is only 1 to 3 months.
  • 45.
  • 46.
    curative 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
  • 47.
    palliation Jaundice - Biliary Stents -Hepaticojejunostomy Pain - NSAIDs, Opioids - Celiac Plexus Block Chemotherapy – Gemcitabine Radiotherapy – No proven efficacy
  • 48.
    prognosis 5 year survivalrate Resectable – 60-100% Unresectable – 15%
  • 49.
  • 50.
    Introduction: ▶ Cholangio CAaffect the IHBR or EHBR. ▶ 60%-80% --- located at the hepatic bifurcation ( KST). ▶ Present with jaundice, and should be considered in every patient with obstructive jaundice. ▶ Many patients (palliative bypass or intubation) aimed to provide biliary drainage and prevent cholangitis and hepatic failure. ▶ It’s a crime to drain the biliary system before MRCP staging. ▶ When possible, surgical resection offers a long-term survival.
  • 51.
    Incidence ▶ 1 or2 cases per 100,000 population.
  • 52.
    Risk Factors ▶ PSC ▶Choledochal cysts ▶ Hepatolithiasis. (bile duct stones, biliary stasis, and infection) ▶ Age (between 50: 70 years) except PSC or choedochal cyst. ▶ Sex: slightly higher in men. ▶ Hepatitis B and C. ▶ Genetic disorders : -Inherited “cancer family” syndrome termed Lynch syndrome II, - multiple biliary papillomatosis; ▶ Prior biliary-enteric anastomosis. ▶ Transduodenal sphincteroplasty and choledochoduodenostomy. ▶ Liver flukes, Thorotrast, industrial chemicals, dietary nitrosamines, and exposure to dioxin.
  • 53.
    Staging and Classification •Three broad groups: 1. Intrahepatic 2. Perihilar 3. Distal
  • 54.
    TNM ▶ Tis, carcinomain situ; ▶ T1, tumor invades the subepithelial connective tissue; ▶ T2, tumor invades peri. fibromuscular connective tissue; ▶ T3, tumor invades adjacent organs. ▶ N0, no LN metastases; ▶ N1, hepatoduodenal ligament LN; ▶ N2, peripancreatic, periduodenal, periportal, celiac, and/or SMALN. ▶ M0, no distant metastasis; ▶ M1, distant metastasis.
  • 55.
    American Joint Commissionon Cancer TNM Staging System for Cholanangio CA Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1 or T2 N1 or N2 M0 Stage IVA T3 Any N M0 Stage IVB Any T Any N M1
  • 56.
    Clinical Presentation ▶ >90% present with jaundice. ▶ Less common (pruritus, fever, mild abdominal pain, fatigue, anorexia, and weight loss). ▶ Cholangitis develops after biliary manipulation. ▶ O/E is usually normal except for jaundice.
  • 57.
    Diagnosis and Assessmentof Resectability ▶ LABORATORY: -Bilirubin. -Alkaline phosphatase. -CA19-9 (elevated & may fall when obstruction is relieved). ▶ RADIOLOGY: -(US/ CT)- Delineate the extent of the tumor (involvement of BDs, liver, hilar vessels, and distant metastases). -MRCP, ERCP, PTC. -Hilar KST-- dilated IHBR & collapsed GB and EHBR. -Distal tumors lead to dilation of the GB, IH & EHBR. (The proximal extent of the tumor is the most important feature in determining resectability in patients with perihilar tumors and the PTC is the most reliable).
  • 58.
    Serum and Bilemarkers for Cholangiocarcinoma
  • 61.
    ▶ PET ,detect distant or hepatic mets in up to 30% of patients. ▶ Biliary drainage if bilirubin > 10 mg/dL, ( risk for cholangitis). ▶ FNA& brush biopsy, and cytologic examination of bile---, (sensitivity is low). ▶ 7 : 15% of patients with diagnosis of malig. Ob J will ultimately have benign lesions on histologic analysis of resection specimens. (Pseudo KST).
  • 62.
    ▶ Intrahepatic cholangioCA ttt: Hepatic resection, Outcomes: depend on disease stage (LN status & margins status). If complete resection (3year survival = 22%-66%).
  • 63.
    Management ▶ Idea: ▶ Curativettt is possible only with complete resection (R0). - Ipsilateral PV involvement. - Involvement of secondary biliary radicals. - Ipsilateral lobar atrophy. (Do not preclude resection)
  • 64.
    Radiologic Criteria OfUnresectability of CH CA ▶ Bilateral HD involvement up to secondary radicals. ▶ Bilateral HAinvolvement ▶ Encasement of the PV proximal to its bifurcation ▶ Atrophy of one hepatic lobe with contralateral PV encasement ▶ Atrophy of one hepatic lobe with contralateral biliary radical involvement ▶ Distant metastasis
  • 65.
    Palliative ttt ▶ Indication:unresectable cholangioCA ▶ Methods: ERCP & PTC - PTC in patients with KST, - ERCP in patients with distal cholangioca. ▶ Types of stents: - Metallic stents (patent longer time).
  • 66.
    Operative Approach ▶ Explorationshould be undertaken in good-risk patients in absence of mets or unresectable disease; however, intraoperatively, > half of these patients are found to have (peritoneal or hepatic mets or, locally unresectable disease). ▶ Laparoscopy in potentially resectable KST may avoid surgery in patients with metastatic disease. ▶ Exploration - extensive metastatic disease ? - Biliary stents left in place. - Cholecystectomy to avoid cholecystitis. ▶ In patients with locally advanced unresectable KST: - Roux-en-Y HJ to segment III or IV.
  • 67.
    ▶ Distal cholangioCA A)-Resectable ttt : (Whipple's op). Prognosis : 5-year survival 15% : 25% LN –ve ---54% B)- Unresectable ttt: cholecystectomy & triple by pass.
  • 68.
    KST ▶ KSTbile ductresection alone leads to high local recurrence. ▶ Curative resections are possible in < half of patients, and most do not achieve long-term disease control. ▶ ttt depends on Bismuth classification: - Type I & II--- en bloc resection of EHBD & GB with 5:10 mm margins + LN resection with Roux-en-Y HJ. NB: type II & III often involve BD of the caudate, routine caudate lobectomy is advised. - Type IIIa & IIIb are amenable to curative resection in centers with expertise in these procedures.
  • 69.
    ▶ Curative resectionfor KST (hepatectomy + resection of caudate lobe + bile duct resection) - 5-year survival > 50% - mortality rates (8%-10%). ▶ Prognostic factors: - Margin status - Tumor stage - Location
  • 70.
    Medical Therapy ▶ Radiotherapyimproves survival in unresectable cases. ▶ Techniques: - Intraoperative radiotherapy and brachytherapy with iridium-192 through percutaneous or endoscopic stents. ▶ Chemotherapy doesn't improve survival in patients with either resected or unresected cholangiocarcinoma. ▶ Finally, photodynamic therapy is emerging as an important palliative option for patients with unresectable ch ca.
  • 71.
    Outcomes ▶ Survival isdependent on the stage of disease. ▶ Aggressive approach (partial hepatectomy + caudate lobe + biliary resection ) has increased 5-year survival rates to > 50%. ▶ KST tumors: - Unresectable (median survival 5 : 8 months). ▶ The perioperative mortality rates : - Local excision (2%-4%). - Extensive resections (8%-10% ) ▶ Distal cholangioCA: A)- Resectable: - The highest rate of resection, - Median survival (32 : 38 months) - 5-year survival of 28% : 45%. B)- unresectable: (with multimodality adjuvant therapy),
  • 72.
    cholangiocarcinoma Malignant Obstructive Jaundice Carcinoma Head ofPancreas Periampullary Carcinoma Cholangiocarcinoma Carcinoma Gallbladder
  • 73.
  • 74.
    curative 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 Perihilar Cholangiocarcinoma
  • 75.
    Metastatic and OtherTumors ▶ Types: - HCC. - Hepatic cystadenoma & cystadenocarcinoma. - CRLM - Lymphoma. - Breast & ovarian metastasis. ▶ Mechanism of Obstructive jaundice: - Direct extension into the perihilar bile ducts. - Embolization into the biliary tree. - Hilar or pericholedochal LN++
  • 76.
    chemotherapy | radiotherapy Chemotherapy ▶5-fluorouracil ▶ Gemcitabine Radiotherapy ▶ Low dose Radiotherapy
  • 78.
    Congenital anomalies ofthe EHBD RISK OF MALIGNANCY. INDICATIONS OF SURGERY
  • 79.
    Choledochal Cysts ▶ 1/13000to 1/2 000 000 live births ▶ 3 times more often in females.
  • 81.
    Carcinoma in choledochalcysts, age related incidence. Voyles CR et al. Arch Surg 1983; 118: 986-988 – O.7% in children less than 10 years of age – 6.8% in the second decade of life – 14.5% in patients more than 20 years old.
  • 84.
    Management of ampullarytumors Role of local resection
  • 85.
    Ampulloma DEFINITION: (Tumour of thesphincterized part of distal CBD, distal Wirsung duct, and common bilio-pancreatic duct, and intraluminal part of the papilla). « Extended » definition = ampullary and duodenal peri- papillary (< 1 cm) tumor. Differential diagnosis: - Tumours of the pancreas and distal CBD. -Non-tumoral disease (intra-ampullary impacted stone, dysfunction of Oddi’s sphincter). Malignancy : 70-90% (excluding FamilialAdenomatous Polyposis)
  • 86.
    Ampulloma : pathology 1)Adenoma - dysplasia - carcinoma 2) Endocrine tumour 3) Neuroectodermal tumour 4) Adenomyoma (hamartoma) 5) Stromal tumour
  • 89.
    Ampulloma : symptoms 50- 80 - 70 ▶ Jaundice (permanent) ▶ Weight loss 25 ▶ Pain 20 - 65 ▶ Pruritus 25 - 50 ▶ Anemia 15 - 40 ▶ Cholangitis, transient jaundice 10 - 30 ▶ Acute pancreatitis < 10 ▶ Upper GI bleeding < 10 ▶ Duodenal stenosis < 5 ▶ No symptoms 10-20
  • 90.
    Ampulloma : Management ▶1) To assert ampulloma / to eliminate another diagnosis ▶ 2) To assert benignity or malignancy ▶ 3) Evaluation of resecability ▶ 4) Choice of surgical procedure
  • 91.
    Ampulloma : Imaging TumorDuctal Visibility ▶ Ultrasound 20-70 % ▶ CT 70-85 % ▶ MRI 50-70 %
  • 95.
    Ampulloma : Preoperative diagnosisof malignancy Symptoms: • permanent jaundice : 74% of malignant cases vs 29% of benign •weight loss : 53% of malignant cases vs 11% of benign Gross appearance at endoscopy: • Ulceration = infiltrative malignancy • Exophytic without ulceration = benign or non infiltrative malignant Biopsies after endoscopic sphincterotomy
  • 97.
    Curative treatment ofmalignant ampullomas Pancreaticoduodenectomy
  • 98.
    Curative treatment ofmalignant ampullomas Prognostic factors of survival • Positive LNs. • Nb of +ve LN > 3 • Lymphatic vessel invasion • Perineural invasion • Poorly differentiated tumor • Jaundice • Perioperative transfusions
  • 99.
    ttt of ampullomaspresumed to be benign ▶ Pancreaticoduodenectomy ▶ Endoscopic ampullectomy To be considered as a « macrobiopsy » Complications : haemorrhage, acute pancreatitis Limits : - appreciation of lateral limits of resection - tumor extension into CBD ▶ Surgical ampullectomy Early complications : more frequent than after endoscopy ?? Reliable peroperative evaluation of limits of resection (frozen section) Limit : needs reliable peroperative assessment of benignity
  • 107.
    Ampulloma : Conclusions •Approximately 20% are benign. • Mainly responsible for biliary obstruction • CT-scan useful for positive diagnosis and staging •Biopsies after endoscopic sphincterotomy diagnose approximately 80% of cancers • At EUS, a tumor classified as uT1N0 is an invasive carcinoma in one fourth of cases.
  • 108.