Download MBBS Obstructive Jaundice Lecture PPT

OBSTRUCTIVE
JAUNDICE
S1 UNIT

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CONTENTS
? Surgical anatomy : Lakshmi Parvathy

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? Physiology and pathophysiology : Leon Francis
? Etiopathogenesis : Maria Mathew
? Clinical Evaluation : Marlin T Abraham
? Investigations : Martin K Sebastian
? Management of calculous conditions : Megha Thomas

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? Management of benign conditions : Muhammed Afnas
? Management of malignant conditions : Muhammed Galib

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SURGICAL
ANATOMY OF
HEPATOBILIARY

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Lakshmi Parvathy
SYSTEM
Roll No: 84

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SURGICAL ANATOMY OF LIVER

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Largest gland in our body
Lobes-right lobe,left

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EMBRYOLOGY

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LIGAMENTS OF LIVER

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LOBES OF LIVER

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ANATOMICAL RELATIONS

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CANTLIE'S LINE
? Imaginary vertical plane
? Divides liver into right and left lobes.
? Extends from IVC (posteriorly) to middle of
fossa for GB (anteriorly).

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SEGMENTAL ANATOMY

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SEGMENTS OF LIVER
COUINAUD SEGMENTS

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FUNCTIONAL UNIT

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BLOOD SUPPLY

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LYMPHATIC DRAINAGE

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LIVER HISTOLOGY

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EXTRAHEPATIC BILIARY SYSTEM

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COMMON BILE DUCT- PARTS
Sphincters-
superior & inferior choledochal sphincters,
ampullary sphincter, pancreatic sphincter

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GALL BLADDER
HARTMANN'S POUCH
Site for impaction of stone-
leads to mucocele GB.

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?Above-inferior surface of liver
?Below- cystic duct
?Left-Common hepatic duct

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PANCREAS
Retroperitonial (L1-L2 )
Behind stomach and lesser sac

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PANCREAS -RELATIONS

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PANCREAS - EMBRYOLOGY

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PANCREAS - HISTOLOGY

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EHBS & PANCREAS -Arterial supply

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PHYSIOLOGY
Leon Francis
Roll No:85

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BILE
? Complex fluid-
Inorganic & Organic
? Functions: digestion,
absorption, excretion

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? 600-1000ml/day

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COMPOSITION OF BILE
? Water(98%)
? Bile salts

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? Bile pigments
? Cholesterol
? Inorganic salts
? Fatty acids
? Phosphatidyl choline

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? Fat

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MECHANISM OF SECRETION
OF BILE
? Heptocyte secrete bile Biliary

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canaliculi
? Additional secretion of Na & HCO3 ions
from epithelial cells lining biliary
duct(Secretin)

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PHYSIOLOGICAL ROLE OF

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BILE
?Digestion and absorption of fats
BILE ACID
?Major excretory route of lipid soluble
waste products

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BILIRUBIN

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PATHOPHYSIOLOGY

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JAUNDICE
? Normal serum bilirubin- 0.2 ? 0.8mg/dl.
? Manifested in sclera exceeds 2-

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2.5mg/dl.
? Cutaneous icterus >5mg/dl
? Yellowish discoloration of skin , sclera
& mucous membrane

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CLASSIFICATION OF

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JAUNDICE
? PRE-HEPATIC (hemolytic) ? excessive
destruction of RBC
? HEPATIC (hepatocellular) ?liver
damage

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? POST-HEPATIC(obstructive)-
obstruction to the bile flow

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In obstructive jaundice (complete
obstruction)
? urine contains bilirubin and bile salts

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? urine urobilinogen is absent
? stool devoid of stercobilinogen ? clay
coloured stools

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? CARDIOVASCULAR
? Decreased cardiac contractility

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? Bradycardia due to direct effect of bile salts
on SA node
? Decreased peripheral vascular resistance
? Reduced left ventricular pressure

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? RENAL

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? Renal vasoconstriction
? Shunting of blood from renal cortex
? Tubular and cortical necrosis
? Renal failure

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? IMMUNITY

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? Bacterial translocation from the gut

? WOUND HEALING
? Delayed wound healing
? High incidence of wound dehiscence

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? Defective synthesis of collagen

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AETIOPATHOGENESI
S OF
OBSTRUCTIVE
JAUNDICE

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Maria Mathew
ROLL NO:86

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OBSTRUCTIVE JAUNDICE
? Due to obstruction to the outflow of bile.

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? Surgical jaundice
? Causes can be:
?Intrahepatic
?Extrahepatic

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INTRAHEPATIC

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BILIARY OBSTRUCTION
CAUSES
? Primary biliary cirrhosis
? Primary sclerosing cholangitis
? Viral hepatitis

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? Cirrhosis
? Alcohol
? Drug induced hepatitis
? Secondaries in liver

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EXTRAHEPATIC
BILIARY OBSTRUCTION
? INTRALUMINAL
? INTRAMURAL
? EXTRAMURAL

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IN THE LUMEN
? Choledocholithiasis
? Parasite
? Hemobilia
? Foreign body

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CHOLEDOCHOLITHIASIS
1.PRIMARY 4-12%
? Arise De novo
? Formed within CBD or intrahepatic duct.
CAUSES

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? Infections
? Congenital
? Biliary dyskinesia
? Diabetes,malnutrition

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PRIMARY CBD STONE

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FORMATION
Bacteria
Hydrolyzes
Infection
secrete an

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bilirubin
enzyme
glucuronides
Then
Form free

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precipitates
bilirubin

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2.SECONDARY
? Stones originate in gallbladder and pass

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into bile duct

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PATHOPHYSIOLOGY OF
GALL STONE FORMATION
? Depends on the concentration and
type of phospholipids and bile acids in

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bile.
? Micelles formed by phospholipid hold
cholestrol in stable state.

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? CHOLESTEROL STONES - Precipitation of cholesterol give
rise to stones.

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? PIGMENT STONES
1. BLACK- Bilirubin pigments mixed with calcium phosphate,
calcium bicarbonate
2. BROWN- Calcium bilirubinate, palmitate and stearate and
cholesterol

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? MIXED STONES - Contains cholesterol
monohydrate,calcium salts,bile pigments and
fatty acids.

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CHOLESTEROL
STONE
BLACK STONE

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BROWN STONE
MIXED STONE

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PARASITIC INFESTATION
BILIARY ASCARIASIS

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? Ascaris lumbricoides or
Round worm
? Enter biliary tree through
the ampulla of Vater
? Complications :

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-strictures
-supp. cholangitis
-liver abscess
-empyema of GB

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CHLONORCHIASIS
? Oriental cholangiohepatitis
? Chlonorchis sinensis
? Inhabits bile ducts including
intra hepatic ducts.

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? Fibrous thickening of the duct
walls

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BILIARY HYDATID
? Echinococcus granulosus

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? Large cyst obstruct the
hepatic ducts
? rupture into the biliary tree
and its contents cause
obstructive jaundice.

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HEMOBILIA
? Bleeding into biliary tree from an abnormal
communication between a blood vessel and
bile duct

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? Rare condition
? Causes: -Iatrogenic trauma
-Accidental trauma
-Gallstones
-Tumors

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-Inflammatory disorders
-Vascular disorders

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IN THE WALL
? Biliary atresia
? Primary sclerosing cholangitis

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? Tumors of bile duct
? Cholangitis
? Choledochal cyst
? Caroli's disease

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BILIARY ATRESIA

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? Extra hepatic ducts are progressively
destroyed by inflammatory process which
starts at time of birth.
? Intrahepatic changes
? Biliary cirrhosis and portal hypertension

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PRIMARY SCLEROSING
CHOLANGITIS
? Fibrosing inflammatory condition of biliary
tree

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? Age 30-60(males)
? Ass. with other autoimmune conditions

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TUMORS OF BILE DUCT
Benign

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? Papilloma and adenoma- mc
-arise from glandular epi lining bile
ducts
-more frequently in periampullary
region

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? Multiple biliary papillomatosis-rare
-multiple mucus secreting tumors of
biliary epithelium.
-malignant potential

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? Granular cell myoblastoma
? Leiomyoma
? Endocrine tumours

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CHOLANGIOCARCINOMA

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? Risk factors -
? c/c inflammatory conditions
Primary sclerosing cholangitis
.
Oriental cholangiohepatitis

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Hepatitis C infection
? parasitic infections
? congenital
? chemical agents & medications
? post surgical

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CHOLANGITIS
? Inflammation of biliary tree
? Obstruction of bile duct will lead to

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bacterial infection
? Organisms causing
E.coli
,Klebsiella,Enterococci,Pseudomonas,
Proteus

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OUTSIDE THE WALL
? Carcinoma head of pancreas
? Periampullary carcinoma
? Enlarged lymph nodes in porta hepatis
? Mirizzi syndrome

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? Pseudocyst of pancreas

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PANCREATIC CARCINOMA
? 70% at head of pancreas
and periampullary region

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? Ductal adenocarcinoma.
? Solid,scirrhous
tumours,characterised by
neoplastic tubular glands
within markedly

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desmoplastic fibrous
stroma.

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PERIAMPULLARY CARCINOMA
? Carcinoma arising at or near the ampulla of
vater

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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%

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PORTA HEPATIC
METASTASIS AND NODES
Secondaries from ca-stomach, pancreas

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and duodenum
All causes compression on the bile duct
and leads to obstructive jaundice.

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MIRIZZI'S SYNDROME

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? Gallstone impacted in cystic
duct or neck of gall bladder
? cause compression on
common bile duct or common
hepatic duct.

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? Resultant inflammation cause
cholecystocholedochal
fistula

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PSEUDOCYST AT PANCREATIC

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HEAD
? collection of amylase rich
fluid enclosed in a wall of
fibrous or granulation
tissue

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? arises following an attack
of acute pancreatitis.
? Enlargement causes
pressure effects.
? ultimately leads to

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obstructive jaundice from
biliary compression ?
WADSWORTH SYNDROME

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CLINICAL EVALUATION

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Marlin T Abraham
Roll No:87

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HISTORY TAKING
Presenting complaints

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? Yellowish
discolouration-
skin , sclera and
mucus membrane
? Generalised

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itching
? Clay coloured
stools
? Dark coloured
urine

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? Epigastric
discomfort

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? Anorexia, weight loss in malignancy
? Melena / Dark silver stools
? Pain right upper quadrant

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? Intermittent fever

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PAST HISTORY
? h/o blood transfusion(Hepatitis B)
? h/o jaundice(Hepatitis B,C)
? h/o surgeries ? biliary surgery(post

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operative biliary strictures)
? h/o pancreatitis
? h/o sudden onset diabetes

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PERSONAL HISTORY
? Diet ? high consumption of meat

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? Cigarette smoking-carcinoma pancreas
? Use of alcohol ? chronic pancreatitis
? h/o injections,drug abuse,tattoos-Hepatitis B

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DRUG HISTORY

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? Cholestatic ?
? anabolic steroids
? chlorpromazine
? carbamazepine
? antibiotics ? erythromycin,

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rifampicin
? Hepatitis ?
?INH
?phenytoin
? halothane

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?methyl dopa

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EXAMINATION
General Examination
? Cachexic
? Pallor

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? Icterus
? Clubbing
? Pitting pedal edema
? Pulse rate ? Bradycardia
? Blood Pressure ? hypotension

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? Scratch marks, silver nails
? Stigmata of liver disease

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? Migratory thrombophlebitis - Trousseau's

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Sign of malignancy
? Indication of
Pancreatic carcinoma
Armand
Trousseau

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LOCAL EXAMINATION
Inspection
? Abdomen- distended/ scaphoid
? Gall bladder

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? Scars of previous surgery

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Palpation
? Tender right upper quadrant
[cholangitis]
? Liver ? non tender, nodular, rounded

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edge - metastases
? Gall bladder ? tense globular swelling
projecting downwards and forwards.
?Moves with respiration
?Better seen than felt

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?Dull on percussion

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COURVOISIER'S

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LAW
Ludwig Georg
Courvoisier

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EXCEPTIONS TO
COURVOISIER'S LAW

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? Double impaction of stone
? Pancreatic calculus obstructing the
ampulla
? Oriental cholangiohepatitis
? Mucocele/empyema of gall bladder

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? Carcinoma gall bladder with multiple
liver metastases
? Mirizzi's syndrome
? Nodes in porta hepatis.

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FEATURES OF METASTASIS
? Left supraclavicular lymph nodes
enlargement ? TROISIER'S SIGN [ Virchow's
node]

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Charles ?mile
Troisier

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? Per rectal examination ? BLUMER'S SHELF

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[secondaries in rectovesical/ rectouterine
pouch]
? Ascitis- liver secondaries

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CHOLEDOCHOLITHIASIS

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? Biliary colic
? Nausea and vomiting
? Intermittent symptoms
? Physical examination ?
mild epigastric/RUQ

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tenderness
mild icterus

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CHARCOT'S TRIAD
? Intermittent pain

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? Intermittent fever
? Intermittent jaundice
REYNOLD'S PENTAD
? Intermittent pain , fever and jaundice
? Shock

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? Altered mental status

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CA HEAD OF PANCREAS
? PAINLESS PROGRESSIVE
JAUNDICE ? 75% cases

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? Nausea,epigastric
discomfort,pain
? Loss of weight and appetite
? Chills and rigor(cholangitis)
? New onset diabetes

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? Palpable liver
? Palpable gall bladder

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PERIAMPULLARY
CARCINOMA

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? Intermittent jaundice

? Waxing and waning
of symptoms
? Dark silvery stools

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? Pain and weight loss
- late features

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CHOLANGIOCARCINOMA
? Abdominal pain, early satiety,

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anorexia and weight loss
? Pruritus,jaundice
? Cachexia
? Gall bladder palpable
(obstruction-distal CBD)

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HEMOBILIA
? Triad of hemobilia(Sandbloom's
triad)
1. Biliary colic

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2. Obstructive jaundice
3.Occult/gross intestinal bleeding

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STRICTURES OF BILE DUCT

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? Slowly progressive painless
jaundice
? h/o cholecystectomy
? Pain abdomen
? Features of ascending

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cholangitis
? Hepatomegaly due to back
pressure

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CAROLI'S DISEASE

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? Presents with abdominal
pain or sepsis
? Biliary stasis & stone
formation-biliary sepsis
? Complication-

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cholangiocarcinoma

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SCLEROSING CHOLANGITIS
? Right abdominal quadrant
discomfort, jaundice, fever,

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fatigue, pruritus and weight
loss
? secondary biliary cirrhosis
and cholangiocarcinoma
can develop(long standing)

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PSEUDOCYST OF PANCREAS
? Epigastric pain
? Mild icterus and pallor
? Epigastric mass

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? Resonant on percussion
? Mass - tender
? Does not move with
respiration

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INVESTIGATIONS

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Martin K Sebastian
Roll No :88

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oBiochemical investigations
oHematological investigations
oImaging and other investigations

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BIOCHEMICAL
INVESTIGATIONS
oBILIRUBIN
Normal
Total bilirubin: 0.2- 0.8mg/dL

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Direct: 0- 0.2 mg/dL
Indirect :0.2-0.6 mg/dL
vConjugated hyperbilirubinemia

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o Alkaline phosphatase
Normal: 60-300U/L

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>500U/L : suggestive of obstructive
jaundice
o SGOT & SGPT
Modest Elevation
o 5' Nucleotide

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Elevated
o Gamma Glutamyl Transpeptidase
Elevated
? CA 19-9
Gross elevation (normal:0-37 unit/ml)

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suggest carcinoma

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HEMATOLOGICAL TEST
o Prothrombin time
Normal :12-16 sec
vProlonged but correctable with vitamin

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K in obstructive jaundice(10mg IM OD
5days)

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IMAGING AND
OTHER
INVESTIGATIONS

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PLAIN X-RAY
o Radio opaque gall stones in 10% of patients

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o Mercedes- Benz or sea gull sign

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o Porcelain gall bladder: calcification
of gall bladder

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vAssociated with carcinoma up to
25% cases

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ULTRASONOGRAPHY
o Accurate , readily available,
inexpensive and quick

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o Intra hepatic and extra hepatic Biliary
dilation
o level of obstruction
o Cause of obstruction
? gall bladder , CHD or CBD stones

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? Cholangiocarcinoma ,
CA head of pancreas

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Gall stones in USG

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COMPUTED TOMOGRAPHY

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o More anatomical information
o Cause & site of biliary obstruction
o Staging CA liver,gallbladder,
o bile duct,pancreas
o Extend of primary tumour &

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relationship to other organs & vessels
o Enlarged lymph nodes & metastasis

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Carcinoma head of pancreas

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MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY
Ductal obstruction,strictures,intraductal
abnormalities

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o ADVANTAGES
vNon-invasive
vEqual or better imaging than ERCP
vLess complications

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ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
o Calculi or malignant strictures
o Bile aspirates
o Stone removal and stent placement

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o COMPLICATIONS
vCholangitis ( 1-2% patients)
vProphylactic antibiotics

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PERCUTANEOUS
TRANSHEPATIC
CHOLANGIOGRAPHY

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o Strictures or obstruction

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o Bile for cytology
o Catheter for external biliary drainage

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o PRECAUTIONS
Exclude bleeding tendency
PT should be normal

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Prophylactic antibiotics
o COMPLICATIONS
vInfections - cholangitis, septicemia
vBiliary leak
vHemorrhage

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ENDOSCOPIC
ULTRASONOGRAPHY
v Endoscopy aided ultrasound
v Distal common bile duct and ampulla

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v Staging & vascular invasion

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RADIOISOTOPE SCANNING
v Hydroxy Iminodiacetic acid scan
[HIDA]

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v Identification of bile flow
v Obstruction of biliary tree and bile
leaks

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PEROPERATIVE

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CHOLANGIOGRAPHY
v During open or laparoscopic
cholecystectomy
v Exclude presence of stones
within bile duct

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OPERATIVE BILIARY
ENDOSCOPY
v Choledochoscopy
v Flexible fibreoptic endoscope passed
via cystic duct

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v Enable stone identification & removal
under direct vision
v T-tube

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LAPAROSCOPIC
ULTRASONOGRAPHY

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v Biliary & pancreatic tumour staging
v Identify primary tumour and its
relationship to major vessels.
v Micrometastasis of liver

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POSITRON EMISSION
TOMOGRAPHY SCAN
? Fluorodeoxyglucose
? Differenciate benign and malignant
? Diagnosis of metastatic diseases

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? To detect cancerous tissues that
may not always be seen through
CT/MRI

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MANAGEMENT OF
CALCULOUS
CONDITIONS
Megha Thomas
Roll No : 89

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?ERCP
?Cholecystectomy
a. Laparoscopic Cholecystectomy
b. Open Cholecystectomy
?Common bile duct exploration

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?Common bile duct drainage
procedures
?Trans duodenal Sphincterotomy

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ERCP
?
Side viewing endoscope is used.
?
Ampulla of Vater is identified.

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?
Sphincterotomy is done with a
sphincterotome
?
Extraction of stone with a balloon

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sweep

?
Followed by cholecystectomy

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CAUSES OF FAILURE
? large stones
? intrahepatic stones
? multiple stones
? altered gastric or

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duodenal anatomy
? impacted stones
? duodenal diverticula

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LAPAROSCOPIC
CHOLECYSTECTOMY

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INDICATION
? Symptomatic gall stones
? Acute cholecystitis (early presentation)
? Acute biliary pancreatitis(after resolution of
signs and symptoms)

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POSITION: supine,head end up
(Reverse trendelenburg position) and
right side up
PORTS: 10 mm port - subumbilicus -

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to pass 10 mm telescope.
10 mm port - midline
epigastrium- working
channel.
Two 5 mm ports -

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midclavicular & anterior
axil ary line in subcostal
region.

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OPEN CHOLECYSTECTOMY
? Right subcostal incision(Kocher's)
? Right paramedian

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? Horizontal incision
TECHNIQUE:
? Duct-first method:
?Calot's triangle is dissected.
Cystic artery and cystic duct

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ligated close to the gallbladder.
?GB separated and removed.

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? Fundus-first method:
? Done in the case of dense
adhesions.
? Fundus separated from the liver
bed. Dissection is carried

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proximally until cystic duct and
cystic artery are identified, which
are then ligated.

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COMPLICATIONS
?Bleeding from cystic artery,and from

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liver bed
?Injury to CBD or hepatic duct
?Injuries to colon,duodenum,mesentry
?Infection and subphrenic abscess
?Bile leak and biliary fistula formation

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?Biliary stricture formation

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POST CHOLECYSTECTOMY
SYNDROME
? Recurrent, new or persistent symptoms
after cholecystectomy In patients who

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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.

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COMMON BILE DUCT
EXPLORATION:
1.LAPAROSCOPIC CBD
EXPLORATION
? Stone may be flushed with irrigation

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? A balloon catheter passed , inflated &
withdrawn.
? A wire basket passed under
fluoroscopic guidance.
? if required a flexible choledochoscope

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can be used

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Trans cystic approach
? Cystic duct is dilated and flexible
choledochoscope is passed down into CBD.

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? With identification of stone,wirebasket
passed to ensnare stone.

? C/I: Small ,friable cystic duct
Large stones( more than 1cm)

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Stones in common hepatic duct above
the cystic duct insertion

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Through CBD
INDICATION
? Jaundice,h/o jaundice or cholangitis

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? Palpable stones in CBD
? Dilated CBD (>10 mm )
? Dilated cystic duct
? Abnormal LFT particularly elevated
ALP

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? Multi faceted stones
C/I: small caliber CBD

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PROCEDURE

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? Longitudinal
Incision in common
bile duct
? flexible
choledochoscope

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passed into duct
? clearance of stones

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? Choledochotomy is
sutured with T tube left

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inside with one end
taken out through the
abdominal wall

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CARE OF T TUBE

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? 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

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? 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

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choledochoscope,stone is removed through T-
tube tract under fluoroscopic guidance.

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OPEN CBD
EXPLORATION

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? When endoscopic and laparoscopic
methods fails
? Palpate distal bile duct , find the stone
which may milked backward.
? Choledochotomy performed in the

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supraduodenal part.

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COMMON BILE DUCT
DRAINAGE PROCEDURES
? When stones cannot be cleared

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? Duct is very dilated
CHOLEDOCHODUODENOSTOMY
mobilizing the second
part of the duodenum
and anastomosing it

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side to side with the
common bile duct.

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ADVANTAGE: Continues to allow

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endoscopic access to entire biliary
system.
DISADVANTAGE: Bile duct distal to
anastomosis , doesnot drain well which
collect debris - obstruction of

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anastomosis/pancreatic duct(SUMP
SYNDROME)

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CHOLEDOCHOJEJUNOSTOMY
bringing up a 45-cm Roux-en-Y limb

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of jejunum and anastomosing it end
to side to the common bile duct.

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? ADVANTAGE: No risk of sump
syndrome and excellent drainage
? DISADVANTAGE: Does not allow future

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endoscopic evaluation.

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TRANSDUODENAL
SPHINCTEROTOMY
? Unsuccessful

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endoscopic attempts
with nondilated
biliarytree.
? Longitudinal
duodenotomy to identify

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ampulla
? The sphincter is then
incised at the 11 o'clock
position to avoid injury
to the pancreatic duct

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? The impacted stones
are removed

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MANAGEMENT OF
BENIGN
CONDITIONS
Muhammed Afnas
Roll no: 90

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PRIMARY SCLEROSING
CHOLANGITIS
? No specific medical therapy
? Choleretic agent ursodeoxycholic acid

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? Immunosuppresives
? Antibiotics ,Vitamin K,
Steroids

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Mx:
1.Endoscopic balloon dilatation of dominant
strictures improve pruritis,cholangitis and
prolong survival

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2.Biliary reconstruction -
pts with dominant
stricture at biliary
bifurcation

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Resection of affected
part & long term
silastic stenting
3.Orthotopic liver
transplantation - only

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life saving option

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MIRIZZI SYNDROME
? Cholecystectomy, which may
require repair of the CBD
? In case of cholecysto-
choledochal fistula,

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choledochojejunostomy

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BILIARY STRICTURES

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1.ERCP with
sphincterotomy,
balloon dilatation,
stent placement

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2. Anastomosising a loop of jejunum
( Roux-en-Y jejunal limb) to dilated
portion above the stricture

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CHOLEDOCHOJEJUNOSTOMY
HEPATICOJEJUNOSTOMY

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CHOLEDOCHAL CYST

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TYPE 1
? Complete surgical excision followed
by Roux- en- Y hepaticojejunostomy

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TYPE II

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? Excision of diverticulum
with suturing of CBD
? Anomalous pancreaticobiliary jn [
APBJ ] ?
biliary enteric diversion by

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Roux-en-Y hepaticojejunostomy

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TYPE III - CHOLEDOCHOCELE
? ERCP with sphincterotomy
- ( cyst < 3cm)

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? Transduodenal excision or
sphincteroplasty - ( cyst >3cm )

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TYPE IV
? Only extrahepatic biliary dilatation

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excision and hepaticojejunostomy [ like
type I ]
? Intrahep extension ( 1 lobe ) partial
hepatectomy + reconstruction

---

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TYPE V ?CAROLI'S DISEASE
? UNILOBAR Hepatic
lobectomy
? BILOBAR
liver

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transplantation

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LILLY `S TECHNIQUE
? If the cyst adheres to portal vein
secondary to inflammatory
reactions

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posterior serosal wall of cyst is left
behind & mucosa of cyst is
obliterated

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POLYPS OF GB
Rx:
?Laparoscopic cholecystectomy
?Risks factor for CA
- Radical cholecystectomy

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?Asymptomatic/no risk factors / no USG
features of CA ? observation with seirial
USG

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BENIGN BILIARY MASS

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? ADENOMAS
Complete resection along with small
rim of normal epithelium by
transduodenal approach

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? Papillomatosis
liver resection /
liver transplantation

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BILIARY ATRESIA

---

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EXTRA HEPATIC BILIARY ATRESIA
TYPE I
TYPE 2 & 3
Roux en Y
Kasai

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hepaticojejunostomy
portoenterostomy

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BILIARY ATRESIA

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? INTRAHEPATIC- Liver transplantation

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DUODENAL DIVERTICULUM
? A/C diverticulitis

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IV antibiotics and bed rest
? Surgical removal is done as an interval
procedure when the
a/c attack subsides

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HEMOBILIA
To stop bleeding and to
relieve biliary obstruction
? Antibiotics
? Blood transfusions

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? Transarterial embolisation (TAE)
? Surgical intervention - ligation of
bleeding vessel or hepatic artery or
excision of aneurysm

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PSEUDOCYST OF
PANCREATIC HEAD
? Endoscopic drainage under EUS guidance
with tube drain
? Cystoduodenostomy via

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laparotomy

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MANAGEMENT OF
MALIGNANT
CONDITIONS
Muhammed Galib

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Roll no:91

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? CARCINOMA HEAD OF THE PANCREAS
? PERIAMPULLARY CARCINOMA
? CHOLANGIOCARCINOMA

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CARCINOMA HEAD OF THE
PANCREAS

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MANAGEMENT
? SURGICAL RESECTION

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? ADJUVANT THERAPY
? NEOADJUVANT THERAPY
? PALLIATIVE THERAPY

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SURGICAL RESECTION
SIGNS OF INOPERABILITY

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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

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branch
-unreconstructible SMV/PV d/t
tumor/occlusion
-contact with most proximal draining jejunal
branch into SMV

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c)Body and tail:
-solid tumor contact of >180deg with SMA or
CA
-solid tumor contact with CA & aortic
involvement

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-unreconstructible SMV/PV d/t
tumor/occlusion

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PREOPERATIVE PREPARATIONS
i. Hydration
ii. Nutrition(glucose orally or iv)

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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

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vii.Total parenteral nutrition if needed

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WHIPPLE'S RESECTION
(PANCREATICODUODENECTOMY
) STEPS

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Incision: midline from xiphoid to
umbilicus or bilateral sub costal
Liver, peritoneal surfaces assessed for
metastasis
Hepatic flexure of colon is reflected

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medially (Cattell Braasch maneuver)
Kocher's maneuver done and duodenum
along with head of pancrease is mobilised
to midline

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SMV identified and

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assessed
Gastroepiploic vein and
artery ligated
Porta hepatis examined
Assess operability

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? CHOLECYSTECTOMY AND
RESECTION OF
COMMON HEPATIC DU CT

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RESECTION OF ANTRUM OF
STOMACH

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Stomach resected at
the level of the third
or fourth transverse
vein on the lesser
curvature

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WHOLE DUODENUM ALONG
WITH 20 ? 30 CM OF JEJUNUM
REMOVED

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DIVISION OFF NECK AND
REMOVAL OF HEAD OF
PANCREAS
Tributaries from the portal
vein and superior mesenteric

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vein ligated and divided

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? PANCREATICOJE JUNOSTOMY

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---

HEPATICOJEJUNOSTOMY

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GASTROJEJUNOSTOMY

---

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TRAVERSO-LONGMIRE PYLORUS
PRESERVING

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PANCREATICO-DUODENECTOMY(PPPD)

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POST OP MANAGEMENT
? High dependency observation for1-2 days
? Drain may be put
? Early feeding can be commenced

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? Fluid and electrolyte balance
? Observation for feeding and DIC
? Respiratory support(ventilation may be
necessary)
? Vitamin K continued for 5 days

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? Monitor urine output
? Octreotide for 5 days to prevent leak

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COMPLICATIONS
a. Infections
b. Haemorrhage

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c. Leak from anastomosis between bowel and
pancreas(octreotide)
d. Pancreatic fistula
e. Recurrence
f. Hepatorenal syndrome

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g. Delayed gastric emptying
h. Bile leak
i. Mortality 3%(sepsis,hemorrhage,
cardiovascular events)

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ADJUVANT THERAPY

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? High recurrence rate following
resection
? CHEMOTHERAPY AND RADIATION
? 5FU
? Gemcitabine (less toxic)

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? I125 external radiotherapy
? Immunotherapy (allogenic tumor cell
vaccine)

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NEOADJUVANT THERAPY
? Administration of chemotherapy with or

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without radiotherapy before surgery
? For borderline resectable
? ADVANTAGES
? Increased R0 resection status
? Reduces node positivity rate

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? Reduce tumour burden
? Decrease recurrence
? Decrease chance of fistula

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PALLIATIVE THERAPY

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BILIARY OBSTRUCTION
? Surgical biliary
bypass(choledochojejunostomy &
gastroenterostomy)
? ERCP stenting

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? PTC stenting
? PTBD
1.internal drainage
2.external drainage

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DUODENAL OBSTRUCTION
? Gastrojejunostomy
? Duodenal stent
PAIN
? Antiinflammatory drugs

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? Opioids
? Celiac nerve block(inj.3ml 0.25% bupivacaine and
10 ml absolute alcohol)

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ROUX EN Y CHOLEDOCHOJEJUNOSTOMY
AND GASTROJEJUNOSTOMY

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It is a palliative procedure done along with gastrojejunostomy after
cholecystectomy
ADVANTAGES
Ease of flow of food
Decreased risk of cholangitis

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Easier management of biliary
anastomotic leaks

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PALLIATIVE CHEMOTHERAPY AND
RADIATION
? Locally advanced unresectable

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disease and stage 4 diseases
? Folfirinox(5FU+Oxaliplatin+Irinotecan+leuco
vorin)
? Gemcitabine+nabpaclitaxel(albumin
bounded paclitaxel particle)

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? Gemcitabine,erlotinib
? 5FU and capecitabine with radiotherapy

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PROGNOSIS
? After surgical resection and adjuvant
therapy for CA pancreas,the median

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survival is approximately 22 months.
? 5 year survival of 15-20%

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PERIAMPULLARY
CARCINOMAS
? Periampullary cancer includes tumors

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arising from the distal bile duct, duodenal
mucosa, or pancreas just adjacent to the
ampulla
? Management : Pancreaticoduodenectomy
(PD) with or without pylorus preservation

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CHOLANGIOCARCINOMA
? Cholangiocacinoma(bile duct carcinoma)
is a rare malignancy
Distal bile duct tumours
Proximal bile duct tumours

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? Resection and hepaticojejunostomy
? Endoscopic stent placement
? Signs of unresectability : hepatic
metastasis,peritoneal metastasis

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DISTAL CHOLANGIOCARCINOMA

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? PANCREATICODUODENECTOMY

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PROXIMAL
CHOLANGIOCARCINOMA
? En block resection of common bile
duct with hepatic parenchyma as

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necessary to achieve negative margins
? Resection of regional lymph node
? Taj Mahal resection: central liver
resection> 1,4,5 segments& relevant
bile ducts removed

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? No proven role for adjuvant therapy
? Adjuvant chemoradiation ?patient with nodal
disease,R1 resection,undergoing clinical
trial.
OUTCOMES

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? Depend on stage at presentation
? Negative margins

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COLORECTAL LIVER
METASTASIS
RESECTION

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? 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%

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-damaged by chemo:30 or 40%

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SMALL FUTURE LIVER
REMNANT
CONVERSION
? Chemotherapy conversion-downsizing

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unresectable liver d/s burden to
resectability
Eg: FOLFOX4 regimen
TWO STAGE LIVER RESECTION
Prior to hepatectomy>portal vein

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occlusion> hypertrophy of small FLR
-operative ligation (PVL)
-percutaneous trans hepatic
embolization(PVE)

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ASSOCIATING LIVER PARTITION &

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PORTAL VEIN LIGATION(ALPPS)
? Stage 1: portal vein ligated & parenchyma
transected to separate FLR from
hepatectomy specimen
-rapid FLR hypertrophy(7-10 days)

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? Stage 2: completion hepatectomy
p-ALPPS: partial transection of FLR in
stage 1
Salvage-ALPPS: FLR refractory to
hypertrophic stimulus of portal vein

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occlusion

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COMBINED INTRAOPERATIVE
ABLATION & RESECTION
? Resection of larger& superficial lesions +
ablation of sub 4cm, deeper lesions

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? Minimizing parenchymal loss- FLR preserved

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ABLATION
? Not sufficiently fit to undergo liver
resection are considered
? Ablation +systemic chemo

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? Radiofrequency ablation
? Microwave ablation

---

IRREVERSIBLE ELECTROPORATION
? Non thermal technique
? Induce cell death with electric pulse

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? Preservation of vessels and bile duct
? To manage anatomically challenging
lesions

---

Overview
? Jaundice due to obstruction of flow of

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bile to intestine.
? Causes are Intrahepatic and
Extrahepatic.
? Clinical features are jaundice, clay
coloured stools, itching, epigastric

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discomfort, anorexia etc.
? Investigations include USG, plain X-ray ,
MRCP, ERCP, CT scan, radioisotope
scanning, PTC and endoscopic
ultrasound.

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? Management is mainly surgical and
depends on the cause.

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