2. Etiology:
MALIGNANT BILIARY DISEASE
Gallbladder Cancer
Bile Duct Cancer
Cancer head of pancrease
Duodenal cancer
Ampulloma
Malignant Liver tumors invading or compressing
biliary system.
Metastatic and Other Tumors
5. carcinoma head of pancreas
Malignant
Obstructive Jaundice
Carcinoma
Head of Pancreas
Periampullary
Carcinoma
Cholangiocarcinoma Carcinoma
Gallbladder
6. US + CT
Resectable Unresectable No mass
detected
Reassess
Resectibility
Resect
(Whipple Procedure)
Palliation
Chemotherapy
Radiotherapy
Pain Jaundice Du Obstruction
ERCP or EUS
Malignant
Evaluate
Further
Resect
(Whipple Procedure)
7. resectibility vs. unresectibility
Findings contraindicating
resection :
Liver/Visceral metastasis (any size)
Peritoneal implants
Celiac lymph node involvement
Invasion of transverse mesocolon
Hepatic hilar lymph node involvement
Arterial Invasion – Venous Occlusion
Findings not contraindicating
resection:
Invasion of duodenum or distal
stomach
Involvement of peripancreatic lymph
node
8. resection
Only shot at Cure (but recurrence is common)
At presentation – only 15% resectable
Two techniques –
- Standard Whipple Procedure
- Modified Whipple (PPPD)
Pancreatic Ca.
Resection Palliation
9. kausch - whipple
procedure
3 phases –
- Assessment phase
- Resection phase
- Reconstruction phase
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
Sir Allen Oldfather Whipple
(1881-1963)
Important Landmarks
- 1909 – Kausch first performed Pancreatoduodenectomy
- 1935 – Whipple perfected the technique (two-stage)
- 1941 – One-stage procedure was described
- 1978 – Traverso and Longmire introduced PPPD
10. a. assessment
Why Reassess???
Specificity of CECT for Resectibility = 80%... Why?
Laparoscopy or Laparotomy???
Gen. Anesthesia – Midline/Bilateral Subcostal incision
Look for –
- Metastasis
- Inoperable LN involvement
- Kocher Maneuver
- Aberrant Right Hepatic Artery
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
12. b. resection
Viscera removed
- Distal 1/3rd of Stomach (not in PPPD)
- Duodenum
- Proximal 10 cm of jejunum
- Head, Neck and Uncinate Process of Pancreas
- Gallbladder with
cystic duct and CBD
- Regional Lymph Nodes
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
13.
14. c. reconstruction
3 steps –
- Pancreatico-jejunostomy
- Hepatico-jejunostomy
- Gastro-jejunostomy
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
15. PPPD vs. Whipple
Advantages of PPPD
Prevention of Reflux
Prevents marginal ulceration
Normal Acid Secretion and Hormone Release
Improved gastric function
Better Weight Gain
Disadvantages of PPPD
Compromise with the resection margin
Delayed Gastric Emptying
Pancreatic Ca.
Resection Palliation
16. complications
Common Complication
Delayed Gastric Emptying (19%)
Pancreatic Fistula (14%)
Wound Infection/Sepsis (10%)
Hemorrhage (intraop. or postop.)
Other Complications
Intra-abdominal Abscess
Cholangitis
Pneumonia
Bile Leak
Pancreatitis
Marginal Ulcer
(upto 40% of cases)
Pancreatic Ca.
Resection Palliation
17. palliation
85% cases unresectable at presentation
Not curative
Aimed at improving the quality of life
Three major problems –
- Pain
- Jaundice
- Duodenal Obstruction
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
18. a. pain
Medical – Opioids ; NSAIDs
Celiac Plexus Nerve Block
(Percutaneous - USG or CT Guided)
(Transgastric or Laparotomic)
Pancreatic Ca.
Resection Palliation
Du Obstruction
JaundicePain
26. periampullary carcinoma
Distal CBD carcinoma
Ampullary Carcinoma
Duodenal Carcinoma (surrounding Ampulla)
- Prognosis is better
- Management – similar to Ca head of Pancreas
27. 5 year survival
Ca head of Pancreas
3%
Periampullary Ca
30%
prognostic markers
- CA 19-9
- CA 494
32. Gall bladder Cancer ( Introduction)
Aggressive malignancy
Occurs predominantly in elderly people.
The prognosis for most patients is poor.
5-year survival rates of only 5% to 38%.
Many of these tumors are unresectable at
presentation
Aggressive surgical approach for patients with
localized GB cancer has produced encouraging
results with an acceptable morbidity.
33. Incidence
The 5th most common GI cancer.
Sex: 2:3 times more common in women.
Age: > 75% of them occur in patients > 65 years.
The incidence varies with racial & geographic location.
In USA, GB cancer is more common in Native Americans.
34. Etiology
The pathogenesis is related to chronic inflammation.
Gall stones are the most common because of the high
prevalence in the general population.
The association between a porcelain gallbladder, and other
biliary disorders such as choledochal cysts and PSC and
gall bladder cancer has been recognized more recently.
36. Pathology and Staging
90% are classified as adenocarcinoma.
10 % are Squamous cell, oat cell, undifferentiated, and
adenosquamous cancers and carcinoid tumors.
At diagnosis:
- 25% are localized to the GB wall,
- 35% have regional LN or extension into adjacent organs,
- 40% have metastasized to distant sites.
Hepatic involvement can occur by:
- Direct invasion
- Angiolymphatic portal tract,
- Hematogenous spread.
37. TNM Staging for GB Cancer
T1 Tumor invades lamina propria (T1a) or muscular
(T1b) layer
T2 Tumor invades perimuscular connective tissue, no
extension beyond the serosa or into the liver
T3 Tumor perforates the serosa (visceral peritoneum)
and/or directly invades into liver and/or one other
adjacent organ or structure such as the stomach,
duodenum, colon, pancreas, omentum, or extrahepatic
bile ducts
T4 Tumor invades main PV or HA or invades multiple
extrahepatic organs and/or structures
N0 No lymph node metastases
N1 Regional lymph node metastases
M0 No distant metastases
M1 Distant metastases
38. Stage Stage Grouping
IA T1 N0 M0
IB T2 N0 M0
IIA T3 N0 M0
IIB T1 N1 M0
T2 N1 M0
T3 N1 M0
III T4 Any N M0
IV Any T Any N M1
39. Clinical Presentation
Pain.
Weight loss, jaundice, and an abdominal mass are less common.
40% of patients present with symptoms of chronic cholecystitis,
Acute cholecystitis, with a short duration of pain associated with
vomiting, fever, and tenderness.
GB cancer is often misdiagnosed as chronic cholecystitis,
pancreatic cancer, acute cholecystitis, choledocholithiasis, or
gallbladder hydrops.
40. Diagnosis
U/S….
CT scan.
MRI.
Cholangiography (long stricture of CHD).
Angiography, spiral CT, or MRI may identify encasement of PV
or HA.
Unresectable tumor (liver or peritoneal metastases, PV
encasement, or extensive hepatic invasion).
41. Management
Depends on the pathologic stage
Stage T1a or T1b:
- Identified after cholecystectomy
- 5-year survival (100% and 85%, respectively).
(Cholecystectomy is adequate for patients with T1 tumors).
Recurrent cancer at port sites have been reported,
therefore, all port sites should be excised.
Patients with suspected GB cancer should undergo open
cholecystectomy.
42. Stages II and III,
- “Extended cholecystectomy.”
( This includes cystic, pericholedochal, portal, right
celiac, and posterior pancreatoduodenal LNs.
(R0 resection should be the goal of surgery)
In cases with cystic duct stump margin positive, CBD
resection with Roux-en-Y reconstruction is mandatory.
Extended cholecystectomy should incorporate at least a
2-cm liver margin beyond the tumor.
Small tumors--------- wedge resection of the liver.
Large tumors (bisegmentectomy or extended right
hepatectomy)
43. Staging laparoscopy (50%-55%) have hepatic or extrahepatic
disease not detected by noninvasive modalities.
Palliative ttt for inoperable cases:
-Tissue diagnosis in patients with an unresectable tumor.
-Obst j. --- ERCP or PTC for biliary stent.
-Pain -- celiac block.
Chemotherapy have been quite poor.
External-beam and intraoperative radiation therapy
(unfortunately, no randomized data have demonstrated improved
survival with either chemotherapy or radiation).
44. Survival
Influenced by the pathologic stage.
Aggressive resection improved overall survival.
(T1a) -------- excellent prognosis.
(T1b) increases the risk for recurrent after curative resection.
(T2) -Increases the risk for regional LN metastases to 33% :
50%.
(5-year survival is improved following extended chole (59%-61%)
compared with simple cholecystectomy (17%-19%).
5-year overall survival rates for resected patients with stages IIA
and IIB of 28% to 63% and 19% to 25%, respectively.
Stage IV: The median survival is only 1 to 3 months.
50. Introduction:
Cholangio CA affect the IHBR or EHBR.
60%-80% --- located at the hepatic bifurcation ( KST).
Present with jaundice, and should be considered in every
patient with obstructive jaundice.
Many patients (palliative bypass or intubation) aimed to
provide biliary drainage and prevent cholangitis and hepatic
failure.
It’s a crime to drain the biliary system before MRCP
staging.
When possible, surgical resection offers a long-term
survival.
55. American Joint Commission on Cancer TNM
Staging System for Cholanangio CA
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1 or T2 N1 or N2 M0
Stage IVA T3 Any N M0
Stage IVB Any T Any N M1
56. Clinical Presentation
> 90% present with jaundice.
Less common (pruritus, fever, mild abdominal pain,
fatigue, anorexia, and weight loss).
Cholangitis develops after biliary manipulation.
O/E is usually normal except for jaundice.
57. Diagnosis and Assessment of Resectability
LABORATORY:
-Bilirubin. -Alkaline phosphatase.
-CA 19-9 (elevated & may fall when obstruction is relieved).
RADIOLOGY:
-(US/ CT)- Delineate the extent of the tumor (involvement of
BDs, liver, hilar vessels, and distant metastases).
-MRCP, ERCP, PTC.
-Hilar KST-- dilated IHBR & collapsed GB and EHBR.
-Distal tumors lead to dilation of the GB, IH & EHBR.
(The proximal extent of the tumor is the most important
feature in determining resectability in patients with perihilar
tumors and the PTC is the most reliable).
61. PET , detect distant or hepatic mets in up to 30% of patients.
Biliary drainage if bilirubin > 10 mg/dL, ( risk for
cholangitis).
FNA & brush biopsy, and cytologic examination of bile---,
(sensitivity is low).
7 : 15% of patients with diagnosis of malig. Ob J will
ultimately have benign lesions on histologic analysis of
resection specimens. (Pseudo KST).
62. Intrahepatic cholangioCA
ttt : Hepatic resection,
Outcomes: depend on disease stage (LN status &
margins status).
If complete resection (3year survival = 22%-66%).
63. Management
Idea:
Curative ttt is possible only with complete resection (R0).
- Ipsilateral PV involvement.
- Involvement of secondary biliary radicals.
- Ipsilateral lobar atrophy.
(Do not preclude resection)
64. Radiologic Criteria Of Unresectability of CH CA
Bilateral HD involvement up to secondary radicals.
Bilateral HA involvement
Encasement of the PV proximal to its bifurcation
Atrophy of one hepatic lobe with contralateral PV encasement
Atrophy of one hepatic lobe with contralateral biliary radical
involvement
Distant metastasis
65. Palliative ttt
Indication: unresectable cholangioCA
Methods: ERCP & PTC
- PTC in patients with KST,
- ERCP in patients with distal cholangioca.
Types of stents:
- Metallic stents (patent longer time).
66. Operative Approach
Exploration should be undertaken in good-risk patients in
absence of mets or unresectable disease; however,
intraoperatively, > half of these patients are found to have
(peritoneal or hepatic mets or, locally unresectable disease).
Laparoscopy in potentially resectable KST may avoid
surgery in patients with metastatic disease.
Exploration - extensive metastatic disease ?
- Biliary stents left in place.
- Cholecystectomy to avoid cholecystitis.
In patients with locally advanced unresectable KST:
- Roux-en-Y HJ to segment III or IV.
68. KST
KSTbile duct resection alone leads to high local
recurrence.
Curative resections are possible in < half of patients, and
most do not achieve long-term disease control.
ttt depends on Bismuth classification:
- Type I & II--- en bloc resection of EHBD & GB with
5:10 mm margins + LN resection with Roux-en-Y HJ.
NB: type II & III often involve BD of the caudate, routine
caudate lobectomy is advised.
- Type IIIa & IIIb are amenable to curative resection in
centers with expertise in these procedures.
69. Curative resection for KST (hepatectomy + resection of
caudate lobe + bile duct resection)
- 5-year survival > 50%
- mortality rates (8%-10%).
Prognostic factors:
- Margin status
- Tumor stage
- Location
70. Medical Therapy
Radiotherapy improves survival in unresectable cases.
Techniques:
- Intraoperative radiotherapy and brachytherapy with
iridium-192 through percutaneous or endoscopic stents.
Chemotherapy doesn't improve survival in patients with
either resected or unresected cholangiocarcinoma.
Finally, photodynamic therapy is emerging as an important
palliative option for patients with unresectable ch ca.
71. Outcomes
Survival is dependent on the stage of disease.
Aggressive approach (partial hepatectomy + caudate lobe + biliary
resection ) has increased 5-year survival rates to > 50%.
KST tumors:
- Unresectable (median survival 5 : 8 months).
The perioperative mortality rates :
- Extensive resections (8%-10% ) - Local excision (2%-4%).
Distal cholangioCA:
A)- Resectable:
- The highest rate of resection,
- Median survival (32 : 38 months)
- 5-year survival of 28% : 45%.
B)- unresectable: (with multimodality adjuvant therapy),
74. curative
Intrahepatic –
- Mx - same as Hepatocellular ca
- Sx - Partial Hepatectomy
Proximal / Perihilar (Klatskin Tumor)
- 2/3rd of Cholangiocarcinomas
- Bismuth-Corlette Classification------------
- Sx – Roux-en-Y
Distal Bile Duct
- Mx – same as Periampullary Carcinoma
- Sx – Whipple Procedure
Bismuth-Corlette Classification
Perihilar Cholangiocarcinoma
75. Metastatic and Other Tumors
Types:
- HCC.
- Hepatic cystadenoma & cystadenocarcinoma.
- CRLM
- Lymphoma.
- Breast & ovarian metastasis.
Mechanism of Obstructive jaundice:
- Direct extension into the perihilar bile ducts.
- Embolization into the biliary tree.
- Hilar or pericholedochal LN++
81. Carcinoma in choledochal cysts,
age related incidence.
Voyles CR et al. Arch Surg 1983; 118: 986-988
– O.7% in children less than 10 years of age
– 6.8% in the second decade of life
– 14.5% in patients more than 20 years old.
85. Ampulloma
DEFINITION:
(Tumour of the sphincterized part of distal CBD, distal
Wirsung duct, and common bilio-pancreatic duct, and
intraluminal part of the papilla).
« Extended » definition = ampullary and duodenal peri-
papillary (< 1 cm) tumor.
Differential diagnosis:
- Tumours of the pancreas and distal CBD.
- Non-tumoral disease (intra-ampullary impacted stone,
dysfunction of Oddi’s sphincter).
Malignancy : 70-90% (excluding Familial Adenomatous
Polyposis)
90. Ampulloma : Management
1) To assert ampulloma / to eliminate another diagnosis
2) To assert benignity or malignancy
3) Evaluation of resecability
4) Choice of surgical procedure
95. Ampulloma : Preoperative
diagnosis of malignancy
Symptoms:
• permanent jaundice : 74% of malignant cases vs
29% of benign
• weight loss : 53% of malignant cases vs 11% of
benign
Gross appearance at endoscopy:
• Ulceration = infiltrative malignancy
• Exophytic without ulceration = benign or non
infiltrative malignant
Biopsies after endoscopic sphincterotomy
98. Curative treatment of malignant ampullomas
Prognostic factors of survival
• Positive LNs.
• Nb of +ve LN > 3
• Lymphatic vessel invasion
• Perineural invasion
• Poorly differentiated tumor
• Jaundice
• Perioperative transfusions
99. ttt of ampullomas presumed to be
benign
Pancreaticoduodenectomy
Endoscopic ampullectomy
To be considered as a « macrobiopsy »
Complications : haemorrhage, acute pancreatitis
Limits : - appreciation of lateral limits of resection
- tumor extension into CBD
Surgical ampullectomy
Early complications : more frequent than after endoscopy ??
Reliable peroperative evaluation of limits of resection (frozen
section)
Limit : needs reliable peroperative assessment of benignity
100.
101.
102.
103.
104.
105.
106.
107. Ampulloma : Conclusions
• Approximately 20% are benign.
• Mainly responsible for biliary obstruction
• CT-scan useful for positive diagnosis and staging
• Biopsies after endoscopic sphincterotomy diagnose
approximately 80% of cancers
• At EUS, a tumor classified as uT1N0 is an invasive
carcinoma in one fourth of cases.
