274051_633942135524030000
Content
Dept. of Surgery
: Is a condition characterized by
as a result of an elevated Sr. Bilirubin conc. due to an obstructive cause. cause.
: Is a condition characterized by
as a result of an elevated Sr. Bilirubin conc. due to an obstructive cause. cause.
Type I : Tumors : Ca. head of Pancreas Ligation of the CBD Cholangio carcinoma Parenchymal Liver diseases
Duodenal diverticula
Papillomas of the bile duct Intra biliary parasites Hemobilia
TYPE IV : Segmental Obstruction
Traumatic
Hepatodocholithiasis
Sclerosing cholangitis
Cholangio carcinoma
Alterations in – Systemic and renal hemodynamics – Hepatic function • Protein synthesis, • Reticulo-endothelial function • Hepatic metabolism
– – – –
Hemostatic mechanism Gastrointestinal barrier Immune function Wound healing
Prolonged bile duct obstruction leads to significant defects in clotting factors Before surgery these defects should be corrected by Fresh frozen plasma and Vitamin K Even if there is no measurable coagulation dysfunction Vitamin K should be given to all patients with obstructive jaundice
Obstruction
Hepatitis
Cirrhosis
/
/
/
/
Bilirubin
/
What are reliable signs & symptoms (more than 90% certainty) that a patient with obstructive jaundice need urgent intervention ? • Fever, persistent (90%) • Abdominal pain (70%) • Jaundice (60%) • Tea-colored urine/pale stools • Altered mental status (10-20%) • Hypotension (30%) • RUQ tenderness
Obstructive Jaundice • Relief of Obstruction • Prevent Complication
• Prevent Recurrence
Are the ducts dilated What is the level of obstruction What is the cause What is the best therapeutic approach
Jaundice AXR Ultrasound
Dilated ducts Surgical Gall stones Pancreatic cancer
Undilated ducts Medical Hepatitis
AXR US CT HIDA Scintigram MRI/MRCP
ERCP PTC Operative cholangiogram T-tube cholangiogram Angiogram Biopsy
Clinical features favoring CBD stones: ◦ ◦ ◦ ◦
Age < 45 Biliary colic Fever Transient spike in AST or amylase
Clinical features favoring cancer: ◦ ◦ ◦ ◦
Painless jaundice Weight loss Palpable gallbladder Bilirubin > 10
production
exceeds ability of liver to conjugate Ex. Hemolytic anemia's, hemoglobinopathie s, in-born errors of metab., transfusion rxn.
Can produce but not excrete Intra- or extra hepatic obstruction Metabolic defect
Defined as stones in the CBD : intermittent obstruction of CBD Often asymptomatic Symptoms are indistinguishable from other causes of Biliary pain Predisposes to Cholangitis & Acute Pancreatitis Elevated sr. bilirubin & Alk. Phos.
Primary diagnostic and therapeutic modality Sphincterotomy and stone extraction Placement of stent if stone extraction unsuccessful Mortality rate 1.5%
Presence of multiple stones (more than 5) Stones > 1 cm Multiple intra hepatic stones Distal bile duct strictures
Failure of ERCP
Recurrence of CBD stones after sphincterotomy
Common bile duct exploration with T-tube decompression Choledochoduodenostomy Transduodenal sphincterotomy and sphincterplasty Roux-en-Y Choledocho jejunostomy
Congenital anomalies of the biliary tract that manifest as cystic dilatation of the extra hepatic and intra hepatic bile ducts Females are most commonly affected
ETIOLOGY : Congenital weakness of the bile duct wall Congenital obstruction of the bile ducts Reo virus association is seen in 78% of patients 40% of anomalies are seen at the junction of pancreatic and common bile ducts
Proposed by Todani & colleagues TYPE I : accounts for 80 – 90 % of cases exhibit segmental or diffuse fusiform dilatation of the CBD. TYPE II : consists of a true Choledochal diverticulum TYPE III : consists of dilatation of the intra duodenal portion of the CBD. TYPE IV : multiple intra hepatic & extra hepatic cysts TYPE V or CAROLIS disease : consists of single or multiple dilatation of the intra hepatic ductal system
Clinical features :
Disease often appears during first months of life 80% of pts. have cholestatic jaundice & acholic stools Vomiting , irritability & failure to thrive may occur Spontaneous perforation of a Choledochal cysts may occur Progressive hepatic injury due to biliary obstruction
DIAGNOSIS :
BEST established by USG Abdomen In Older children PTC or ERCP may help define the anatomy of the cyst.
Surgical excision of the cyst with Reconstruction of the extra hepatic biliary tree
Biliary drainage is accomplished by Choledocho – jejunostomy with a Roux – en – Y anastamosis
Long term follow up is necessary because of complications like cholangitis , lithiasis , anastomotic stricture
90% are extra-hepatic
60’s and 70’s
Highest incidence in Japan, Israel, and Native Americans
Increased 3 fold in the last 30yrs in the USA
M/F=3/2
Ulcerative Colitis
Thorotrast Exposure
Sclerosing Cholangitis
Typhoid Carrier
Choledochal Cysts
Adult Polycystic Kidney Disease
Hepatolithiasis Liver Flukes Papillomatosis of Bile Ducts
Right or left hepatic duct = 10%
Bifurcation = 20%
Proximal CBD = 30%
Distal CBD = 30%
Jaundice
Wt loss, anorexia, abdominal pain, fever US then CT (CTA?) Followed by ERCP, PTC or MRCP CEA and CA 19-9 can be elevated
Suspicious mass on CT. Quadruple phase CT with 0.5 cm cuts through the liver and portal hepatitis. Consider CTA reconstruction.
Treatment
If adenoncarcinoma: look for primary with a chest CT and upper/lower endoscopy. Colon, pancreas, and stomach are common primary sites.
Extent of surgical therapy is determined by the location, hepatic function, and underlying cirrhosis. Anatomic resections have lowest recurrence rates. However non anatomic resection increases potential surgical candidates and improves survival Hepatic devascularization prior to resection is preferred Ablative therapy gives good local control.
Klatskin tumor
Adeno carcinoma accounts for 95%
Arises from 4 different tissues of origin Head of pancreas Distal Bile duct Ampullary of Vater Periampullary duodenum
Prognosis for each of these are different.
Five year survival for pancreas: 18% Five year for ampulla: 36% Five year for distal bile duct: 34% Five year for duodenum: 33% Determination of tissue origin is important for prognosis, extent of resection.
Determination of tissue origin from FNA, endoscopic biopsy. Also from thin section CT scan, ERCP Determination of k-Ras also helps (95% of pancreatic cancer).
Loco regional spread results from lymphatic invasion and direct tumor spread to adjacent soft tissue. Ampullary lesions spread to LN 33%, typically to a single LN in the posterior pancreatcoduodenal group.
Duodenal has intermediate spread.
Pancreas metastasizes 88% to multiple sites.
Standard Whipple pancreaticoduodenectomy thought to provide adequate tumor clearance in the case of non-pancreatic ampullary tumor, because tumor spread is localized. Biopsy proven paraduodenal LN is thought by most to preclude curative resection
Low risk patients had 5 year local control and survival of 100% and 80% respectively. High risk patients had 5 year local control and survival of 50% and 38%, respectively. Based on these findings, some have proposed a course of preoperative chemoradiation to improve local disease control in these high risk patients.
Five basic techniques are used to resect pancreatic cancers Standard pancreaticoduodenectomy Pylorus preserving pancreaticoduodenectomy Total pancreatectomy Regional pancreatectomy Extended resection (MD Anderson)
Autopsy series show that 85% of patients will experience recurrence in operative field. 70% have metastases to liver. So need to address local control (radiation) and distant disease (chemotherapy). Most commonly used is 5 FU and this only has a 15-28% response on its own, but it’s a radio sensitizer, so it improves response to chemo.
: Is a condition characterized by
as a result of an elevated Sr. Bilirubin conc. due to an obstructive cause. cause.
: Is a condition characterized by
as a result of an elevated Sr. Bilirubin conc. due to an obstructive cause. cause.
Type I : Tumors : Ca. head of Pancreas Ligation of the CBD Cholangio carcinoma Parenchymal Liver diseases
Duodenal diverticula
Papillomas of the bile duct Intra biliary parasites Hemobilia
TYPE IV : Segmental Obstruction
Traumatic
Hepatodocholithiasis
Sclerosing cholangitis
Cholangio carcinoma
Alterations in – Systemic and renal hemodynamics – Hepatic function • Protein synthesis, • Reticulo-endothelial function • Hepatic metabolism
– – – –
Hemostatic mechanism Gastrointestinal barrier Immune function Wound healing
Prolonged bile duct obstruction leads to significant defects in clotting factors Before surgery these defects should be corrected by Fresh frozen plasma and Vitamin K Even if there is no measurable coagulation dysfunction Vitamin K should be given to all patients with obstructive jaundice
Obstruction
Hepatitis
Cirrhosis
/
/
/
/
Bilirubin
/
What are reliable signs & symptoms (more than 90% certainty) that a patient with obstructive jaundice need urgent intervention ? • Fever, persistent (90%) • Abdominal pain (70%) • Jaundice (60%) • Tea-colored urine/pale stools • Altered mental status (10-20%) • Hypotension (30%) • RUQ tenderness
Obstructive Jaundice • Relief of Obstruction • Prevent Complication
• Prevent Recurrence
Are the ducts dilated What is the level of obstruction What is the cause What is the best therapeutic approach
Jaundice AXR Ultrasound
Dilated ducts Surgical Gall stones Pancreatic cancer
Undilated ducts Medical Hepatitis
AXR US CT HIDA Scintigram MRI/MRCP
ERCP PTC Operative cholangiogram T-tube cholangiogram Angiogram Biopsy
Clinical features favoring CBD stones: ◦ ◦ ◦ ◦
Age < 45 Biliary colic Fever Transient spike in AST or amylase
Clinical features favoring cancer: ◦ ◦ ◦ ◦
Painless jaundice Weight loss Palpable gallbladder Bilirubin > 10
production
exceeds ability of liver to conjugate Ex. Hemolytic anemia's, hemoglobinopathie s, in-born errors of metab., transfusion rxn.
Can produce but not excrete Intra- or extra hepatic obstruction Metabolic defect
Defined as stones in the CBD : intermittent obstruction of CBD Often asymptomatic Symptoms are indistinguishable from other causes of Biliary pain Predisposes to Cholangitis & Acute Pancreatitis Elevated sr. bilirubin & Alk. Phos.
Primary diagnostic and therapeutic modality Sphincterotomy and stone extraction Placement of stent if stone extraction unsuccessful Mortality rate 1.5%
Presence of multiple stones (more than 5) Stones > 1 cm Multiple intra hepatic stones Distal bile duct strictures
Failure of ERCP
Recurrence of CBD stones after sphincterotomy
Common bile duct exploration with T-tube decompression Choledochoduodenostomy Transduodenal sphincterotomy and sphincterplasty Roux-en-Y Choledocho jejunostomy
Congenital anomalies of the biliary tract that manifest as cystic dilatation of the extra hepatic and intra hepatic bile ducts Females are most commonly affected
ETIOLOGY : Congenital weakness of the bile duct wall Congenital obstruction of the bile ducts Reo virus association is seen in 78% of patients 40% of anomalies are seen at the junction of pancreatic and common bile ducts
Proposed by Todani & colleagues TYPE I : accounts for 80 – 90 % of cases exhibit segmental or diffuse fusiform dilatation of the CBD. TYPE II : consists of a true Choledochal diverticulum TYPE III : consists of dilatation of the intra duodenal portion of the CBD. TYPE IV : multiple intra hepatic & extra hepatic cysts TYPE V or CAROLIS disease : consists of single or multiple dilatation of the intra hepatic ductal system
Clinical features :
Disease often appears during first months of life 80% of pts. have cholestatic jaundice & acholic stools Vomiting , irritability & failure to thrive may occur Spontaneous perforation of a Choledochal cysts may occur Progressive hepatic injury due to biliary obstruction
DIAGNOSIS :
BEST established by USG Abdomen In Older children PTC or ERCP may help define the anatomy of the cyst.
Surgical excision of the cyst with Reconstruction of the extra hepatic biliary tree
Biliary drainage is accomplished by Choledocho – jejunostomy with a Roux – en – Y anastamosis
Long term follow up is necessary because of complications like cholangitis , lithiasis , anastomotic stricture
90% are extra-hepatic
60’s and 70’s
Highest incidence in Japan, Israel, and Native Americans
Increased 3 fold in the last 30yrs in the USA
M/F=3/2
Ulcerative Colitis
Thorotrast Exposure
Sclerosing Cholangitis
Typhoid Carrier
Choledochal Cysts
Adult Polycystic Kidney Disease
Hepatolithiasis Liver Flukes Papillomatosis of Bile Ducts
Right or left hepatic duct = 10%
Bifurcation = 20%
Proximal CBD = 30%
Distal CBD = 30%
Jaundice
Wt loss, anorexia, abdominal pain, fever US then CT (CTA?) Followed by ERCP, PTC or MRCP CEA and CA 19-9 can be elevated
Suspicious mass on CT. Quadruple phase CT with 0.5 cm cuts through the liver and portal hepatitis. Consider CTA reconstruction.
Treatment
If adenoncarcinoma: look for primary with a chest CT and upper/lower endoscopy. Colon, pancreas, and stomach are common primary sites.
Extent of surgical therapy is determined by the location, hepatic function, and underlying cirrhosis. Anatomic resections have lowest recurrence rates. However non anatomic resection increases potential surgical candidates and improves survival Hepatic devascularization prior to resection is preferred Ablative therapy gives good local control.
Klatskin tumor
Adeno carcinoma accounts for 95%
Arises from 4 different tissues of origin Head of pancreas Distal Bile duct Ampullary of Vater Periampullary duodenum
Prognosis for each of these are different.
Five year survival for pancreas: 18% Five year for ampulla: 36% Five year for distal bile duct: 34% Five year for duodenum: 33% Determination of tissue origin is important for prognosis, extent of resection.
Determination of tissue origin from FNA, endoscopic biopsy. Also from thin section CT scan, ERCP Determination of k-Ras also helps (95% of pancreatic cancer).
Loco regional spread results from lymphatic invasion and direct tumor spread to adjacent soft tissue. Ampullary lesions spread to LN 33%, typically to a single LN in the posterior pancreatcoduodenal group.
Duodenal has intermediate spread.
Pancreas metastasizes 88% to multiple sites.
Standard Whipple pancreaticoduodenectomy thought to provide adequate tumor clearance in the case of non-pancreatic ampullary tumor, because tumor spread is localized. Biopsy proven paraduodenal LN is thought by most to preclude curative resection
Low risk patients had 5 year local control and survival of 100% and 80% respectively. High risk patients had 5 year local control and survival of 50% and 38%, respectively. Based on these findings, some have proposed a course of preoperative chemoradiation to improve local disease control in these high risk patients.
Five basic techniques are used to resect pancreatic cancers Standard pancreaticoduodenectomy Pylorus preserving pancreaticoduodenectomy Total pancreatectomy Regional pancreatectomy Extended resection (MD Anderson)
Autopsy series show that 85% of patients will experience recurrence in operative field. 70% have metastases to liver. So need to address local control (radiation) and distant disease (chemotherapy). Most commonly used is 5 FU and this only has a 15-28% response on its own, but it’s a radio sensitizer, so it improves response to chemo.
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