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JAUNDICE
S1 UNIT
CONTENTS
? Surgical anatomy : Lakshmi Parvathy
? Physiology and pathophysiology : Leon Francis
? Etiopathogenesis : Maria Mathew
? Clinical Evaluation : Marlin T Abraham
? Investigations : Martin K Sebastian
? Management of calculous conditions : Megha Thomas
? Management of benign conditions : Muhammed Afnas
? Management of malignant conditions : Muhammed Galib
SURGICAL
ANATOMY OF
HEPATOBILIARY
Lakshmi Parvathy
SYSTEM
Roll No: 84
SURGICAL ANATOMY OF LIVER
Largest gland in our body
Lobes-right lobe,left
EMBRYOLOGY
LIGAMENTS OF LIVER
LOBES OF LIVER
ANATOMICAL RELATIONS
CANTLIE'S LINE
? Imaginary vertical plane
? Divides liver into right and left lobes.
? Extends from IVC (posteriorly) to middle of
fossa for GB (anteriorly).
SEGMENTAL ANATOMY
SEGMENTS OF LIVER
COUINAUD SEGMENTS
FUNCTIONAL UNIT
BLOOD SUPPLY
LYMPHATIC DRAINAGE
LIVER HISTOLOGY
EXTRAHEPATIC BILIARY SYSTEM
COMMON BILE DUCT- PARTS
Sphincters-
superior & inferior choledochal sphincters,
ampullary sphincter, pancreatic sphincter
GALL BLADDER
HARTMANN'S POUCH
Site for impaction of stone-
leads to mucocele GB.
?Above-inferior surface of liver
?Below- cystic duct
?Left-Common hepatic duct
PANCREAS
Retroperitonial (L1-L2 )
Behind stomach and lesser sac
PANCREAS -RELATIONS
PANCREAS - EMBRYOLOGY
PANCREAS - HISTOLOGY
EHBS & PANCREAS -Arterial supply
PHYSIOLOGY
Leon Francis
Roll No:85
BILE
? Complex fluid-
Inorganic & Organic
? Functions: digestion,
absorption, excretion
? 600-1000ml/day
COMPOSITION OF BILE
? Water(98%)
? Bile salts
? Bile pigments
? Cholesterol
? Inorganic salts
? Fatty acids
? Phosphatidyl choline
? Fat
MECHANISM OF SECRETION
OF BILE
? Heptocyte secrete bile Biliary
canaliculi
? Additional secretion of Na & HCO3 ions
from epithelial cells lining biliary
duct(Secretin)
PHYSIOLOGICAL ROLE OF
BILE
?Digestion and absorption of fats
BILE ACID
?Major excretory route of lipid soluble
waste products
BILIRUBIN
PATHOPHYSIOLOGY
JAUNDICE
? Normal serum bilirubin- 0.2 ? 0.8mg/dl.
? Manifested in sclera exceeds 2-
2.5mg/dl.
? Cutaneous icterus >5mg/dl
? Yellowish discoloration of skin , sclera
& mucous membrane
CLASSIFICATION OF
JAUNDICE
? PRE-HEPATIC (hemolytic) ? excessive
destruction of RBC
? HEPATIC (hepatocellular) ?liver
damage
? POST-HEPATIC(obstructive)-
obstruction to the bile flow
In obstructive jaundice (complete
obstruction)
? urine contains bilirubin and bile salts
? urine urobilinogen is absent
? stool devoid of stercobilinogen ? clay
coloured stools
? CARDIOVASCULAR
? Decreased cardiac contractility
? Bradycardia due to direct effect of bile salts
on SA node
? Decreased peripheral vascular resistance
? Reduced left ventricular pressure
? RENAL
? Renal vasoconstriction
? Shunting of blood from renal cortex
? Tubular and cortical necrosis
? Renal failure
? IMMUNITY
? Bacterial translocation from the gut
? WOUND HEALING
? Delayed wound healing
? High incidence of wound dehiscence
? Defective synthesis of collagen
AETIOPATHOGENESI
S OF
OBSTRUCTIVE
JAUNDICE
Maria Mathew
ROLL NO:86
OBSTRUCTIVE JAUNDICE
? Due to obstruction to the outflow of bile.
? Surgical jaundice
? Causes can be:
?Intrahepatic
?Extrahepatic
INTRAHEPATIC
BILIARY OBSTRUCTION
CAUSES
? Primary biliary cirrhosis
? Primary sclerosing cholangitis
? Viral hepatitis
? Cirrhosis
? Alcohol
? Drug induced hepatitis
? Secondaries in liver
EXTRAHEPATIC
BILIARY OBSTRUCTION
? INTRALUMINAL
? INTRAMURAL
? EXTRAMURAL
IN THE LUMEN
? Choledocholithiasis
? Parasite
? Hemobilia
? Foreign body
CHOLEDOCHOLITHIASIS
1.PRIMARY 4-12%
? Arise De novo
? Formed within CBD or intrahepatic duct.
CAUSES
? Infections
? Congenital
? Biliary dyskinesia
? Diabetes,malnutrition
PRIMARY CBD STONE
FORMATION
Bacteria
Hydrolyzes
Infection
secrete an
bilirubin
enzyme
glucuronides
Then
Form free
precipitates
bilirubin
2.SECONDARY
? Stones originate in gallbladder and pass
into bile duct
PATHOPHYSIOLOGY OF
GALL STONE FORMATION
? Depends on the concentration and
type of phospholipids and bile acids in
bile.
? Micelles formed by phospholipid hold
cholestrol in stable state.
? CHOLESTEROL STONES - Precipitation of cholesterol give
rise to stones.
? PIGMENT STONES
1. BLACK- Bilirubin pigments mixed with calcium phosphate,
calcium bicarbonate
2. BROWN- Calcium bilirubinate, palmitate and stearate and
cholesterol
? MIXED STONES - Contains cholesterol
monohydrate,calcium salts,bile pigments and
fatty acids.
CHOLESTEROL
STONE
BLACK STONE
BROWN STONE
MIXED STONE
PARASITIC INFESTATION
BILIARY ASCARIASIS
? Ascaris lumbricoides or
Round worm
? Enter biliary tree through
the ampulla of Vater
? Complications :
-strictures
-supp. cholangitis
-liver abscess
-empyema of GB
CHLONORCHIASIS
? Oriental cholangiohepatitis
? Chlonorchis sinensis
? Inhabits bile ducts including
intra hepatic ducts.
? Fibrous thickening of the duct
walls
BILIARY HYDATID
? Echinococcus granulosus
? Large cyst obstruct the
hepatic ducts
? rupture into the biliary tree
and its contents cause
obstructive jaundice.
HEMOBILIA
? Bleeding into biliary tree from an abnormal
communication between a blood vessel and
bile duct
? Rare condition
? Causes: -Iatrogenic trauma
-Accidental trauma
-Gallstones
-Tumors
-Inflammatory disorders
-Vascular disorders
IN THE WALL
? Biliary atresia
? Primary sclerosing cholangitis
? Tumors of bile duct
? Cholangitis
? Choledochal cyst
? Caroli's disease
BILIARY ATRESIA
? Extra hepatic ducts are progressively
destroyed by inflammatory process which
starts at time of birth.
? Intrahepatic changes
? Biliary cirrhosis and portal hypertension
PRIMARY SCLEROSING
CHOLANGITIS
? Fibrosing inflammatory condition of biliary
tree
? Age 30-60(males)
? Ass. with other autoimmune conditions
TUMORS OF BILE DUCT
Benign
? Papilloma and adenoma- mc
-arise from glandular epi lining bile
ducts
-more frequently in periampullary
region
? Multiple biliary papillomatosis-rare
-multiple mucus secreting tumors of
biliary epithelium.
-malignant potential
? Granular cell myoblastoma
? Leiomyoma
? Endocrine tumours
CHOLANGIOCARCINOMA
? Risk factors -
? c/c inflammatory conditions
Primary sclerosing cholangitis
.
Oriental cholangiohepatitis
Hepatitis C infection
? parasitic infections
? congenital
? chemical agents & medications
? post surgical
CHOLANGITIS
? Inflammation of biliary tree
? Obstruction of bile duct will lead to
bacterial infection
? Organisms causing
E.coli
,Klebsiella,Enterococci,Pseudomonas,
Proteus
OUTSIDE THE WALL
? Carcinoma head of pancreas
? Periampullary carcinoma
? Enlarged lymph nodes in porta hepatis
? Mirizzi syndrome
? Pseudocyst of pancreas
PANCREATIC CARCINOMA
? 70% at head of pancreas
and periampullary region
? Ductal adenocarcinoma.
? Solid,scirrhous
tumours,characterised by
neoplastic tubular glands
within markedly
desmoplastic fibrous
stroma.
PERIAMPULLARY CARCINOMA
? Carcinoma arising at or near the ampulla of
vater
It can arise from
? Head of pancreas close to the ampulla
? Ampulla of vater itself
? Distal common bile duct-10%
? Duodenal mucosa adjacent to ampulla-10%
PORTA HEPATIC
METASTASIS AND NODES
Secondaries from ca-stomach, pancreas
and duodenum
All causes compression on the bile duct
and leads to obstructive jaundice.
MIRIZZI'S SYNDROME
? Gallstone impacted in cystic
duct or neck of gall bladder
? cause compression on
common bile duct or common
hepatic duct.
? Resultant inflammation cause
cholecystocholedochal
fistula
PSEUDOCYST AT PANCREATIC
HEAD
? collection of amylase rich
fluid enclosed in a wall of
fibrous or granulation
tissue
? arises following an attack
of acute pancreatitis.
? Enlargement causes
pressure effects.
? ultimately leads to
obstructive jaundice from
biliary compression ?
WADSWORTH SYNDROME
CLINICAL EVALUATION
Marlin T Abraham
Roll No:87
HISTORY TAKING
Presenting complaints
? Yellowish
discolouration-
skin , sclera and
mucus membrane
? Generalised
itching
? Clay coloured
stools
? Dark coloured
urine
? Epigastric
discomfort
? Anorexia, weight loss in malignancy
? Melena / Dark silver stools
? Pain right upper quadrant
? Intermittent fever
PAST HISTORY
? h/o blood transfusion(Hepatitis B)
? h/o jaundice(Hepatitis B,C)
? h/o surgeries ? biliary surgery(post
operative biliary strictures)
? h/o pancreatitis
? h/o sudden onset diabetes
PERSONAL HISTORY
? Diet ? high consumption of meat
? Cigarette smoking-carcinoma pancreas
? Use of alcohol ? chronic pancreatitis
? h/o injections,drug abuse,tattoos-Hepatitis B
DRUG HISTORY
? Cholestatic ?
? anabolic steroids
? chlorpromazine
? carbamazepine
? antibiotics ? erythromycin,
rifampicin
? Hepatitis ?
?INH
?phenytoin
? halothane
?methyl dopa
EXAMINATION
General Examination
? Cachexic
? Pallor
? Icterus
? Clubbing
? Pitting pedal edema
? Pulse rate ? Bradycardia
? Blood Pressure ? hypotension
? Scratch marks, silver nails
? Stigmata of liver disease
? Migratory thrombophlebitis - Trousseau's
Sign of malignancy
? Indication of
Pancreatic carcinoma
Armand
Trousseau
LOCAL EXAMINATION
Inspection
? Abdomen- distended/ scaphoid
? Gall bladder
? Scars of previous surgery
Palpation
? Tender right upper quadrant
[cholangitis]
? Liver ? non tender, nodular, rounded
edge - metastases
? Gall bladder ? tense globular swelling
projecting downwards and forwards.
?Moves with respiration
?Better seen than felt
?Dull on percussion
COURVOISIER'S
LAW
Ludwig Georg
Courvoisier
EXCEPTIONS TO
COURVOISIER'S LAW
? Double impaction of stone
? Pancreatic calculus obstructing the
ampulla
? Oriental cholangiohepatitis
? Mucocele/empyema of gall bladder
? Carcinoma gall bladder with multiple
liver metastases
? Mirizzi's syndrome
? Nodes in porta hepatis.
FEATURES OF METASTASIS
? Left supraclavicular lymph nodes
enlargement ? TROISIER'S SIGN [ Virchow's
node]
Charles ?mile
Troisier
? Per rectal examination ? BLUMER'S SHELF
[secondaries in rectovesical/ rectouterine
pouch]
? Ascitis- liver secondaries
CHOLEDOCHOLITHIASIS
? Biliary colic
? Nausea and vomiting
? Intermittent symptoms
? Physical examination ?
mild epigastric/RUQ
tenderness
mild icterus
CHARCOT'S TRIAD
? Intermittent pain
? Intermittent fever
? Intermittent jaundice
REYNOLD'S PENTAD
? Intermittent pain , fever and jaundice
? Shock
? Altered mental status
CA HEAD OF PANCREAS
? PAINLESS PROGRESSIVE
JAUNDICE ? 75% cases
? Nausea,epigastric
discomfort,pain
? Loss of weight and appetite
? Chills and rigor(cholangitis)
? New onset diabetes
? Palpable liver
? Palpable gall bladder
PERIAMPULLARY
CARCINOMA
? Intermittent jaundice
? Waxing and waning
of symptoms
? Dark silvery stools
? Pain and weight loss
- late features
CHOLANGIOCARCINOMA
? Abdominal pain, early satiety,
anorexia and weight loss
? Pruritus,jaundice
? Cachexia
? Gall bladder palpable
(obstruction-distal CBD)
HEMOBILIA
? Triad of hemobilia(Sandbloom's
triad)
1. Biliary colic
2. Obstructive jaundice
3.Occult/gross intestinal bleeding
STRICTURES OF BILE DUCT
? Slowly progressive painless
jaundice
? h/o cholecystectomy
? Pain abdomen
? Features of ascending
cholangitis
? Hepatomegaly due to back
pressure
CAROLI'S DISEASE
? Presents with abdominal
pain or sepsis
? Biliary stasis & stone
formation-biliary sepsis
? Complication-
cholangiocarcinoma
SCLEROSING CHOLANGITIS
? Right abdominal quadrant
discomfort, jaundice, fever,
fatigue, pruritus and weight
loss
? secondary biliary cirrhosis
and cholangiocarcinoma
can develop(long standing)
PSEUDOCYST OF PANCREAS
? Epigastric pain
? Mild icterus and pallor
? Epigastric mass
? Resonant on percussion
? Mass - tender
? Does not move with
respiration
INVESTIGATIONS
Martin K Sebastian
Roll No :88
oBiochemical investigations
oHematological investigations
oImaging and other investigations
BIOCHEMICAL
INVESTIGATIONS
oBILIRUBIN
Normal
Total bilirubin: 0.2- 0.8mg/dL
Direct: 0- 0.2 mg/dL
Indirect :0.2-0.6 mg/dL
vConjugated hyperbilirubinemia
o Alkaline phosphatase
Normal: 60-300U/L
>500U/L : suggestive of obstructive
jaundice
o SGOT & SGPT
Modest Elevation
o 5' Nucleotide
Elevated
o Gamma Glutamyl Transpeptidase
Elevated
? CA 19-9
Gross elevation (normal:0-37 unit/ml)
suggest carcinoma
HEMATOLOGICAL TEST
o Prothrombin time
Normal :12-16 sec
vProlonged but correctable with vitamin
K in obstructive jaundice(10mg IM OD
5days)
IMAGING AND
OTHER
INVESTIGATIONS
PLAIN X-RAY
o Radio opaque gall stones in 10% of patients
o Mercedes- Benz or sea gull sign
o Porcelain gall bladder: calcification
of gall bladder
vAssociated with carcinoma up to
25% cases
ULTRASONOGRAPHY
o Accurate , readily available,
inexpensive and quick
o Intra hepatic and extra hepatic Biliary
dilation
o level of obstruction
o Cause of obstruction
? gall bladder , CHD or CBD stones
? Cholangiocarcinoma ,
CA head of pancreas
Gall stones in USG
COMPUTED TOMOGRAPHY
o More anatomical information
o Cause & site of biliary obstruction
o Staging CA liver,gallbladder,
o bile duct,pancreas
o Extend of primary tumour &
relationship to other organs & vessels
o Enlarged lymph nodes & metastasis
Carcinoma head of pancreas
MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY
Ductal obstruction,strictures,intraductal
abnormalities
o ADVANTAGES
vNon-invasive
vEqual or better imaging than ERCP
vLess complications
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
o Calculi or malignant strictures
o Bile aspirates
o Stone removal and stent placement
o COMPLICATIONS
vCholangitis ( 1-2% patients)
vProphylactic antibiotics
PERCUTANEOUS
TRANSHEPATIC
CHOLANGIOGRAPHY
o Strictures or obstruction
o Bile for cytology
o Catheter for external biliary drainage
o PRECAUTIONS
Exclude bleeding tendency
PT should be normal
Prophylactic antibiotics
o COMPLICATIONS
vInfections - cholangitis, septicemia
vBiliary leak
vHemorrhage
ENDOSCOPIC
ULTRASONOGRAPHY
v Endoscopy aided ultrasound
v Distal common bile duct and ampulla
v Staging & vascular invasion
RADIOISOTOPE SCANNING
v Hydroxy Iminodiacetic acid scan
[HIDA]
v Identification of bile flow
v Obstruction of biliary tree and bile
leaks
PEROPERATIVE
CHOLANGIOGRAPHY
v During open or laparoscopic
cholecystectomy
v Exclude presence of stones
within bile duct
OPERATIVE BILIARY
ENDOSCOPY
v Choledochoscopy
v Flexible fibreoptic endoscope passed
via cystic duct
v Enable stone identification & removal
under direct vision
v T-tube
LAPAROSCOPIC
ULTRASONOGRAPHY
v Biliary & pancreatic tumour staging
v Identify primary tumour and its
relationship to major vessels.
v Micrometastasis of liver
POSITRON EMISSION
TOMOGRAPHY SCAN
? Fluorodeoxyglucose
? Differenciate benign and malignant
? Diagnosis of metastatic diseases
? To detect cancerous tissues that
may not always be seen through
CT/MRI
MANAGEMENT OF
CALCULOUS
CONDITIONS
Megha Thomas
Roll No : 89
?ERCP
?Cholecystectomy
a. Laparoscopic Cholecystectomy
b. Open Cholecystectomy
?Common bile duct exploration
?Common bile duct drainage
procedures
?Trans duodenal Sphincterotomy
ERCP
?
Side viewing endoscope is used.
?
Ampulla of Vater is identified.
?
Sphincterotomy is done with a
sphincterotome
?
Extraction of stone with a balloon
sweep
?
Followed by cholecystectomy
CAUSES OF FAILURE
? large stones
? intrahepatic stones
? multiple stones
? altered gastric or
duodenal anatomy
? impacted stones
? duodenal diverticula
LAPAROSCOPIC
CHOLECYSTECTOMY
INDICATION
? Symptomatic gall stones
? Acute cholecystitis (early presentation)
? Acute biliary pancreatitis(after resolution of
signs and symptoms)
POSITION: supine,head end up
(Reverse trendelenburg position) and
right side up
PORTS: 10 mm port - subumbilicus -
to pass 10 mm telescope.
10 mm port - midline
epigastrium- working
channel.
Two 5 mm ports -
midclavicular & anterior
axil ary line in subcostal
region.
OPEN CHOLECYSTECTOMY
? Right subcostal incision(Kocher's)
? Right paramedian
? Horizontal incision
TECHNIQUE:
? Duct-first method:
?Calot's triangle is dissected.
Cystic artery and cystic duct
ligated close to the gallbladder.
?GB separated and removed.
? Fundus-first method:
? Done in the case of dense
adhesions.
? Fundus separated from the liver
bed. Dissection is carried
proximally until cystic duct and
cystic artery are identified, which
are then ligated.
COMPLICATIONS
?Bleeding from cystic artery,and from
liver bed
?Injury to CBD or hepatic duct
?Injuries to colon,duodenum,mesentry
?Infection and subphrenic abscess
?Bile leak and biliary fistula formation
?Biliary stricture formation
POST CHOLECYSTECTOMY
SYNDROME
? Recurrent, new or persistent symptoms
after cholecystectomy In patients who
have no demonstrable abnormality.
? d/t loss of reserving function of GB,or
continuous bile flow into duodenum -
esophagitis / gastritis or diarrhea and
colicky pain.
COMMON BILE DUCT
EXPLORATION:
1.LAPAROSCOPIC CBD
EXPLORATION
? Stone may be flushed with irrigation
? A balloon catheter passed , inflated &
withdrawn.
? A wire basket passed under
fluoroscopic guidance.
? if required a flexible choledochoscope
can be used
Trans cystic approach
? Cystic duct is dilated and flexible
choledochoscope is passed down into CBD.
? With identification of stone,wirebasket
passed to ensnare stone.
? C/I: Small ,friable cystic duct
Large stones( more than 1cm)
Stones in common hepatic duct above
the cystic duct insertion
Through CBD
INDICATION
? Jaundice,h/o jaundice or cholangitis
? Palpable stones in CBD
? Dilated CBD (>10 mm )
? Dilated cystic duct
? Abnormal LFT particularly elevated
ALP
? Multi faceted stones
C/I: small caliber CBD
PROCEDURE
? Longitudinal
Incision in common
bile duct
? flexible
choledochoscope
passed into duct
? clearance of stones
? Choledochotomy is
sutured with T tube left
inside with one end
taken out through the
abdominal wall
CARE OF T TUBE
? After 14 days ,water soluble dye injected
? X-ray taken
? If complete free flow - indicate no block
? T tube clamped for 24 hrs
? If no fever, jaundice or abdominal pain
? T tube is removed
? If blocked ? left for 6 weeks
? BURHENNE TECHNIQUE- After 6 weeks when T-
tube tract gets matured, Then either using
Dormia basket or Fogarty catheter or
choledochoscope,stone is removed through T-
tube tract under fluoroscopic guidance.
OPEN CBD
EXPLORATION
? When endoscopic and laparoscopic
methods fails
? Palpate distal bile duct , find the stone
which may milked backward.
? Choledochotomy performed in the
supraduodenal part.
COMMON BILE DUCT
DRAINAGE PROCEDURES
? When stones cannot be cleared
? Duct is very dilated
CHOLEDOCHODUODENOSTOMY
mobilizing the second
part of the duodenum
and anastomosing it
side to side with the
common bile duct.
ADVANTAGE: Continues to allow
endoscopic access to entire biliary
system.
DISADVANTAGE: Bile duct distal to
anastomosis , doesnot drain well which
collect debris - obstruction of
anastomosis/pancreatic duct(SUMP
SYNDROME)
CHOLEDOCHOJEJUNOSTOMY
bringing up a 45-cm Roux-en-Y limb
of jejunum and anastomosing it end
to side to the common bile duct.
? ADVANTAGE: No risk of sump
syndrome and excellent drainage
? DISADVANTAGE: Does not allow future
endoscopic evaluation.
TRANSDUODENAL
SPHINCTEROTOMY
? Unsuccessful
endoscopic attempts
with nondilated
biliarytree.
? Longitudinal
duodenotomy to identify
ampulla
? The sphincter is then
incised at the 11 o'clock
position to avoid injury
to the pancreatic duct
? The impacted stones
are removed
MANAGEMENT OF
BENIGN
CONDITIONS
Muhammed Afnas
Roll no: 90
PRIMARY SCLEROSING
CHOLANGITIS
? No specific medical therapy
? Choleretic agent ursodeoxycholic acid
? Immunosuppresives
? Antibiotics ,Vitamin K,
Steroids
Mx:
1.Endoscopic balloon dilatation of dominant
strictures improve pruritis,cholangitis and
prolong survival
2.Biliary reconstruction -
pts with dominant
stricture at biliary
bifurcation
Resection of affected
part & long term
silastic stenting
3.Orthotopic liver
transplantation - only
life saving option
MIRIZZI SYNDROME
? Cholecystectomy, which may
require repair of the CBD
? In case of cholecysto-
choledochal fistula,
choledochojejunostomy
BILIARY STRICTURES
1.ERCP with
sphincterotomy,
balloon dilatation,
stent placement
2. Anastomosising a loop of jejunum
( Roux-en-Y jejunal limb) to dilated
portion above the stricture
CHOLEDOCHOJEJUNOSTOMY
HEPATICOJEJUNOSTOMY
CHOLEDOCHAL CYST
TYPE 1
? Complete surgical excision followed
by Roux- en- Y hepaticojejunostomy
TYPE II
? Excision of diverticulum
with suturing of CBD
? Anomalous pancreaticobiliary jn [
APBJ ] ?
biliary enteric diversion by
Roux-en-Y hepaticojejunostomy
TYPE III - CHOLEDOCHOCELE
? ERCP with sphincterotomy
- ( cyst < 3cm)
? Transduodenal excision or
sphincteroplasty - ( cyst >3cm )
TYPE IV
? Only extrahepatic biliary dilatation
excision and hepaticojejunostomy [ like
type I ]
? Intrahep extension ( 1 lobe ) partial
hepatectomy + reconstruction
TYPE V ?CAROLI'S DISEASE
? UNILOBAR Hepatic
lobectomy
? BILOBAR
liver
transplantation
LILLY `S TECHNIQUE
? If the cyst adheres to portal vein
secondary to inflammatory
reactions
posterior serosal wall of cyst is left
behind & mucosa of cyst is
obliterated
POLYPS OF GB
Rx:
?Laparoscopic cholecystectomy
?Risks factor for CA
- Radical cholecystectomy
?Asymptomatic/no risk factors / no USG
features of CA ? observation with seirial
USG
BENIGN BILIARY MASS
? ADENOMAS
Complete resection along with small
rim of normal epithelium by
transduodenal approach
? Papillomatosis
liver resection /
liver transplantation
BILIARY ATRESIA
EXTRA HEPATIC BILIARY ATRESIA
TYPE I
TYPE 2 & 3
Roux en Y
Kasai
hepaticojejunostomy
portoenterostomy
BILIARY ATRESIA
? INTRAHEPATIC- Liver transplantation
DUODENAL DIVERTICULUM
? A/C diverticulitis
IV antibiotics and bed rest
? Surgical removal is done as an interval
procedure when the
a/c attack subsides
HEMOBILIA
To stop bleeding and to
relieve biliary obstruction
? Antibiotics
? Blood transfusions
? Transarterial embolisation (TAE)
? Surgical intervention - ligation of
bleeding vessel or hepatic artery or
excision of aneurysm
PSEUDOCYST OF
PANCREATIC HEAD
? Endoscopic drainage under EUS guidance
with tube drain
? Cystoduodenostomy via
laparotomy
MANAGEMENT OF
MALIGNANT
CONDITIONS
Muhammed Galib
Roll no:91
? CARCINOMA HEAD OF THE PANCREAS
? PERIAMPULLARY CARCINOMA
? CHOLANGIOCARCINOMA
CARCINOMA HEAD OF THE
PANCREAS
MANAGEMENT
? SURGICAL RESECTION
? ADJUVANT THERAPY
? NEOADJUVANT THERAPY
? PALLIATIVE THERAPY
SURGICAL RESECTION
SIGNS OF INOPERABILITY
a)Distant metastasis including non regional LN
b)Head/uncinate process:
-solid tumor contact of >180deg with SMA or
CA
-solid tumor contact with 1st jejunal SMA
branch
-unreconstructible SMV/PV d/t
tumor/occlusion
-contact with most proximal draining jejunal
branch into SMV
c)Body and tail:
-solid tumor contact of >180deg with SMA or
CA
-solid tumor contact with CA & aortic
involvement
-unreconstructible SMV/PV d/t
tumor/occlusion
PREOPERATIVE PREPARATIONS
i. Hydration
ii. Nutrition(glucose orally or iv)
iii. Vitamin K 10mg IM started 3 days prior to
surgery
iv. Correction of anemia
v. ERCP stenting (severe cholangitis)
vi. Antibiotics 1 day prior to surgery
vii.Total parenteral nutrition if needed
WHIPPLE'S RESECTION
(PANCREATICODUODENECTOMY
) STEPS
Incision: midline from xiphoid to
umbilicus or bilateral sub costal
Liver, peritoneal surfaces assessed for
metastasis
Hepatic flexure of colon is reflected
medially (Cattell Braasch maneuver)
Kocher's maneuver done and duodenum
along with head of pancrease is mobilised
to midline
SMV identified and
assessed
Gastroepiploic vein and
artery ligated
Porta hepatis examined
Assess operability
? CHOLECYSTECTOMY AND
RESECTION OF
COMMON HEPATIC DU CT
RESECTION OF ANTRUM OF
STOMACH
Stomach resected at
the level of the third
or fourth transverse
vein on the lesser
curvature
WHOLE DUODENUM ALONG
WITH 20 ? 30 CM OF JEJUNUM
REMOVED
DIVISION OFF NECK AND
REMOVAL OF HEAD OF
PANCREAS
Tributaries from the portal
vein and superior mesenteric
vein ligated and divided
? PANCREATICOJE JUNOSTOMY
HEPATICOJEJUNOSTOMY
GASTROJEJUNOSTOMY
TRAVERSO-LONGMIRE PYLORUS
PRESERVING
PANCREATICO-DUODENECTOMY(PPPD)
POST OP MANAGEMENT
? High dependency observation for1-2 days
? Drain may be put
? Early feeding can be commenced
? Fluid and electrolyte balance
? Observation for feeding and DIC
? Respiratory support(ventilation may be
necessary)
? Vitamin K continued for 5 days
? Monitor urine output
? Octreotide for 5 days to prevent leak
COMPLICATIONS
a. Infections
b. Haemorrhage
c. Leak from anastomosis between bowel and
pancreas(octreotide)
d. Pancreatic fistula
e. Recurrence
f. Hepatorenal syndrome
g. Delayed gastric emptying
h. Bile leak
i. Mortality 3%(sepsis,hemorrhage,
cardiovascular events)
ADJUVANT THERAPY
? High recurrence rate following
resection
? CHEMOTHERAPY AND RADIATION
? 5FU
? Gemcitabine (less toxic)
? I125 external radiotherapy
? Immunotherapy (allogenic tumor cell
vaccine)
NEOADJUVANT THERAPY
? Administration of chemotherapy with or
without radiotherapy before surgery
? For borderline resectable
? ADVANTAGES
? Increased R0 resection status
? Reduces node positivity rate
? Reduce tumour burden
? Decrease recurrence
? Decrease chance of fistula
PALLIATIVE THERAPY
BILIARY OBSTRUCTION
? Surgical biliary
bypass(choledochojejunostomy &
gastroenterostomy)
? ERCP stenting
? PTC stenting
? PTBD
1.internal drainage
2.external drainage
DUODENAL OBSTRUCTION
? Gastrojejunostomy
? Duodenal stent
PAIN
? Antiinflammatory drugs
? Opioids
? Celiac nerve block(inj.3ml 0.25% bupivacaine and
10 ml absolute alcohol)
ROUX EN Y CHOLEDOCHOJEJUNOSTOMY
AND GASTROJEJUNOSTOMY
It is a palliative procedure done along with gastrojejunostomy after
cholecystectomy
ADVANTAGES
Ease of flow of food
Decreased risk of cholangitis
Easier management of biliary
anastomotic leaks
PALLIATIVE CHEMOTHERAPY AND
RADIATION
? Locally advanced unresectable
disease and stage 4 diseases
? Folfirinox(5FU+Oxaliplatin+Irinotecan+leuco
vorin)
? Gemcitabine+nabpaclitaxel(albumin
bounded paclitaxel particle)
? Gemcitabine,erlotinib
? 5FU and capecitabine with radiotherapy
PROGNOSIS
? After surgical resection and adjuvant
therapy for CA pancreas,the median
survival is approximately 22 months.
? 5 year survival of 15-20%
PERIAMPULLARY
CARCINOMAS
? Periampullary cancer includes tumors
arising from the distal bile duct, duodenal
mucosa, or pancreas just adjacent to the
ampulla
? Management : Pancreaticoduodenectomy
(PD) with or without pylorus preservation
CHOLANGIOCARCINOMA
? Cholangiocacinoma(bile duct carcinoma)
is a rare malignancy
Distal bile duct tumours
Proximal bile duct tumours
? Resection and hepaticojejunostomy
? Endoscopic stent placement
? Signs of unresectability : hepatic
metastasis,peritoneal metastasis
DISTAL CHOLANGIOCARCINOMA
? PANCREATICODUODENECTOMY
PROXIMAL
CHOLANGIOCARCINOMA
? En block resection of common bile
duct with hepatic parenchyma as
necessary to achieve negative margins
? Resection of regional lymph node
? Taj Mahal resection: central liver
resection> 1,4,5 segments& relevant
bile ducts removed
? No proven role for adjuvant therapy
? Adjuvant chemoradiation ?patient with nodal
disease,R1 resection,undergoing clinical
trial.
OUTCOMES
? Depend on stage at presentation
? Negative margins
COLORECTAL LIVER
METASTASIS
RESECTION
? To be resectable CRLM must be removable
with neg margins with min preservation 2
contiguous supported liver segments
? Vol of FLR depends on parenchymal function
-n/l liver:20%
-damaged by chemo:30 or 40%
SMALL FUTURE LIVER
REMNANT
CONVERSION
? Chemotherapy conversion-downsizing
unresectable liver d/s burden to
resectability
Eg: FOLFOX4 regimen
TWO STAGE LIVER RESECTION
Prior to hepatectomy>portal vein
occlusion> hypertrophy of small FLR
-operative ligation (PVL)
-percutaneous trans hepatic
embolization(PVE)
ASSOCIATING LIVER PARTITION &
PORTAL VEIN LIGATION(ALPPS)
? Stage 1: portal vein ligated & parenchyma
transected to separate FLR from
hepatectomy specimen
-rapid FLR hypertrophy(7-10 days)
? Stage 2: completion hepatectomy
p-ALPPS: partial transection of FLR in
stage 1
Salvage-ALPPS: FLR refractory to
hypertrophic stimulus of portal vein
occlusion
COMBINED INTRAOPERATIVE
ABLATION & RESECTION
? Resection of larger& superficial lesions +
ablation of sub 4cm, deeper lesions
? Minimizing parenchymal loss- FLR preserved
ABLATION
? Not sufficiently fit to undergo liver
resection are considered
? Ablation +systemic chemo
? Radiofrequency ablation
? Microwave ablation
IRREVERSIBLE ELECTROPORATION
? Non thermal technique
? Induce cell death with electric pulse
? Preservation of vessels and bile duct
? To manage anatomically challenging
lesions
Overview
? Jaundice due to obstruction of flow of
bile to intestine.
? Causes are Intrahepatic and
Extrahepatic.
? Clinical features are jaundice, clay
coloured stools, itching, epigastric
discomfort, anorexia etc.
? Investigations include USG, plain X-ray ,
MRCP, ERCP, CT scan, radioisotope
scanning, PTC and endoscopic
ultrasound.
? Management is mainly surgical and
depends on the cause.
This post was last modified on 12 August 2021