Hepatobiliary Surgery JC055: Painless Jaundice And Epigastric Mass: Obstructive Jaundice, Pancreatic And CBD Cancers

Question 1

Malignant biliary obstruction (MBO)

Answer 1

Obstruction of biliary tract by cancer growth within / around biliary tract

Question 2

Case 1:
- 50 yo male
- yellow sclera + skin
- tea colour urine
- recent weight loss 5lb
- hepatomegaly
- blood tests:
—> ↑ Bilirubin (normal: ~20)
—> ↑ ALP (normal: ~100-120)
—> mild ↑ AST / ALT (normal: 40)
—> WBC: normal
—> Platelet: normal
—> PT: prolonged

Answer 2

Hepatomegaly: can still occur in Biliary obstruction (usually mild distension, smooth surface)
- ↑ Bilirubin
- ↑ ALP
- mild ↑ AST / ALT
- ***Prolonged PT (∵ Vitamin K absorption impaired in Obstructive jaundice)
—> Obstructive jaundice

(Acute hepatitis: much higher AST, ALT (>1000))

Imaging:
- USG: Dilated Intrahepatic duct
- CT: Mass at pancreatic head —> compressing onto lower CBD
- ERCP to outline biliary tree: narrowed CBD

Diagnosis:
- Pancreatic head carcinoma —> Obstructive jaundice

(Pancreas: not pain sensitive organ unless acute pancreatitis
Pancreatic carcinoma: may only present with vague epigastric / RUQ pain, only seek help when Obstructive jaundice occur)

Management:
1. ***Endoprosthesis (stenting in biliary tree) via ERCP
- allow bile flow, relieve jaundice
- metallic (~6 month lifespan) / plastic stent (~3 month lifespan)
- sediments from bile may eventually block stent

2. FDG-PET: exclude distant metastasis before consider surgical resection
3. Surgical resection (**Whipple operation / **Pancreaticoduodenectomy)
   - need to exclude distant metastasis
   - Pancreatic head + Duodenum + Lower CBD
   - Reconstruction: 3 anastomosis
   —> **Pancreatojejunostomy: Pancreas remnant to Jejunum
   —> **Choledochojejunostomy: Proximal bile duct to Jejunum
   —> ***Gastrojejunostomy: Stomach to Jejunum
4. Chemo Adjuvant therapy

Pathology report:
- Adenocarcinoma
- T2N0M0 / stage 1B (Early)

Prognosis:
- > 4 years survival

Question 3

Case 2:
- 62 yo male
- yellow sclera + skin
- tea colour urine
- RUQ globular mass
- blood tests:
—> ↑ Bilirubin (normal: ~20)
—> ↑ ALP (normal: ~100-120)
—> mild ↑ AST / ALT (normal: 40)
—> WBC: normal
—> Platelet: normal
—> PT: prolonged

Answer 3

• RUQ globular mass —> Refers to ***Distended gall bladder

Imaging:
1. CT: pancreatic head mass with suspected liver nodule
—> liver metastasis
2. ERCP: narrowing of CBD

Management:
1. Endoprosthesis via ERCP

2. ***PTBD (Percutaneous transhepatic biliary drainage) (if narrowing too severe that ERCP cannot enter)
   - External-Internal PTBD (connect biliary tree to duodenum): allows internal drainage + more secure (but enhance chance of infection: bacteria enter from duodenum to biliary tree)
3. Operation
   - Biopsy of liver metastasis
   - Hepaticojejunostomy for palliation of jaundice (if metastasis was not expected prior to surgery)
   —> Roux-en-Y: 2 anastomosis (Hepaticojejunostomy + ***Jejunojejunostomy)
   —> avoid reflux of food into bile duct (cause reflux cholangitis)

Pathology report:
- Adenocarcinoma
- T2N1M1 / stage 4

Survival:
- 4 months

Question 4

Causes of Jaundice

Answer 4

1. Medical causes
   - Pre-hepatic jaundice: **Haemolytic anaemia
   - Hepatic jaundice: **Hepatitis, ***Cirrhosis
2. Surgical causes (i.e. Obstruction of biliary tree)
   - Benign stricture of bile duct: Recurrent damage to bile duct (e.g. **CBD stone, Rare: **RPC, TB)
   - Malignant: ***Tumour (rarely benign tumour e.g. adenoma of Ampulla of Vater)

記住: Obstructive jaundice: 通常 Stone / Malignancy (Top 2 DDx)

Question 5

***DDx: Pathology causing Malignant biliary obstruction

Answer 5

Any malignancy **around biliary tree
1. **Carcinoma of pancreas (Head most common, body / tail —> usually indirectly compress via spread to LN to compress)
2. **Cholangiocarcinoma at hilum / Klatskin tumour
3. HCC (direct infiltration / compression / tumour fragments in CBD)
4. **Carcinoma of gallbladder (cystic duct LN, direct infiltration of CBD, tumour fragments)
5. **Periampullary carcinoma
6. **Carcinoma of duodenum
7. Lymphoma involving nearby LN (cystic duct LN, hilar LN)

Question 6

***History taking for Jaundice

Answer 6

1. ***Painful / Painless, Pattern of pain
   - severe colicky RUQ pain: Stone
   - painless / vague pain: Malignancy
2. ***Progressive / Intermittent jaundice
   - progressive: Malignancy
   - intermittent: Stone
3. Pale stool, ***Pruritis
   - differentiate from Non-obstructive jaundice (Medical cause: cirrhosis, hepatitis)
4. Any fever
   - infection (e.g. ***Cholangitis, can progress quickly to septicaemia)
5. GI symptoms
   - change of bowel habit
   - vomiting
6. Constitutional symptoms (e.g. weight loss)
7. History of hepatitis B / C
8. Drinking history

Question 7

P/E for Jaundice

Answer 7

General
1. Jaundice
2. Pallor
3. Cachexia
4. Chronic liver stigmata
5. Cervical LN (metastasis)

Abdomen
1. Hepatomegaly
2. Epigastric mass
3. Ascites

Others
- PR examination

Question 8

***Jaundice + Epigastric mass: DDx

Answer 8

1. **Hepatomegaly (usually mild) secondary to **Biliary obstruction
   - jaundice: Biliary obstruction
   - epigastric mass: Liver
2. **Hepatomegaly secondary to **HCC / Metastasis
   - jaundice: HCC / Metastasis
   - epigastric mass: Liver
3. LN metastasis to Celiac axis / Porta hepatis
   - jaundice: LN
   - epigastric mass: LN
4. Carcinoma of stomach with metastatic LN in Porta hepatis
   - jaundice: LN
   - epigastric mass: Stomach
5. ***Carcinoma of pancreas
   - jaundice: Pancreas
   - epigastric mass: Pancreas

Epigastric mass:
- Liver
- Gallbladder (Globular)
- Pancreas
- Stomach
- LN

Question 9

***Investigations in Jaundice

Answer 9

1. Blood tests
   - Bilirubin (normal: ~20)
   - ALP (normal: ~100-120)
   - AST / ALT (normal: 40)
   - WBC
   - Platelet
   - PT
   - Tumour markers
2. Imaging
   - USG
   - Endoscopic USG
   - ERCP
   - PTC + PTBD (Percutaneous transhepatic cholangiography + drainage)
   - CT
   - MRI + MRCP (cholangiopancreatography): non-invasive method mainly for diagnosis but cannot perform intervention
   - PET

Question 10

Endoscopic USG

Answer 10

• Identification of mass in pancreas, bile duct, gallbladder
• Assessment of vascular + **LN involvement
  —> **Portal vein, SMA, SMV
• ***FNA for suspected lesion for Histological diagnosis
• Highly operator dependent

Question 11

Double duct sign

Answer 11

Dilated Bile duct + Dilated Pancreatic duct
—> Pancreatic head carcinoma / Periampullary carcinoma

Question 12

PET scan

Answer 12

Whole body scan
- Diagnosis
- Identification of LN / distant metastasis
- Important for ***Pre-op staging + Selection for laparotomy

Hyper-metabolic spots / Hot spots
- high absorption of radioactive tracers

Question 13

***Signs of inoperability

Answer 13

Clinical examination:
1. Left supraclavicular LN
2. Irregular surface hepatomegaly —> multiple liver metastasis
3. Umbilical nodule / Sister Mary Joseph nodule —> metastasis
4. Ascites
5. Rectal-vesical pouch deposit on PR exam —> peritoneal metastasis

Radiological examination:
1. Liver secondaries
2. LN metastasis
3. ***SMA encasement (SMV / PV encasement is relative CI: may still resect + anastomosis)
- ∵ cannot resect major artery

Question 14

Selection of patients with MBO for surgery

Answer 14

Why surgery?
- Removal of tumour —> only potential cure
- Relief of obstruction

Selection:
1. General status assessment —> Aim to define whether patient is fit for surgery
- Age
- Concomitant medical diseases (e.g. IHD, DM)
- Hidden medical illness
—> **Spirometry
—> **ECG
—> **Blood glucose
—> **Renal function

2. Tumour status assessment —> Aim to define where tumour is still confined to organ of origin
   - Clinical examination
   - USG
   - CT / MRI
   - PET

**Management flow:
General status
—> Good (+ Confined tumour) —> Laparotomy
——> if spread: **Bypass (e.g. Roux-en-Y)
——> if confined: **Radical resection
—> Bad —> **PTBD / ***Endoprosthesis

Tumour status
—> Confined (+ Good general status) —> Laparotomy
——> if spread: **Bypass (e.g. Roux-en-Y)
——> if confined: **Radical resection
—> Spread —> PTBD / Endoprosthesis

Question 15

Laparotomy

Answer 15

Indication
1. General condition is fit
2. Tumour is confined

BUT, ***no promise of resection until laparotomy shows no spread / no involvement of major vessels
- e.g. Tiny peritoneal nodules not picked up during PET / CT

Question 16

Radical resection

Answer 16

1. Tumour + Part of organ of origin
2. Regional LN
3. Tumour-free resection margin
   - send resection margin for frozen section —> confirm whether margin free / not

Surgical resection (**Whipple operation / **Pancreaticoduodenectomy)
- need to exclude distant metastasis
- Pancreatic head + Duodenum + Lower CBD
- Reconstruction: 3 anastomosis
—> **Pancreatojejunostomy: Pancreas remnant to Jejunum
—> **Choledochojejunostomy: Proximal bile duct to Jejunum
—> ***Gastrojejunostomy: Stomach to Jejunum

Question 17

Bypass for MBO

Answer 17

for Unresectable tumours

1. Single bypass
   - Choledochojejunostomy / Hepaticojejunostomy
2. Double bypass
   - + Gastrojejunostomy —> prevent duodenal obstruction
3. Triple bypass (rare)
   - + Pancreaticojejunostomy —> relief pancreatic duct obstruction

Question 18

Why is malignant biliary obstruction so risky for operation?

Answer 18

1. Cancer cachexia —> Malnutrition
2. **Liver function impairment
   - impaired ability to synthesise clotting factors + Vit K malabsorption —> **Bleeding risk
   - impaired protein synthesis —> ***Impaired healing
3. **Superimposed biliary infection
   - ∵ Biliary stasis ↑ bacterial colonisation —> **Septic complications

Question 19

Pathophysiological effects of malignant biliary obstruction

Answer 19

1. ***Impaired protein synthesis
2. ***Impaired clotting factor synthesis
3. Impaired gluconeogenesis
4. Impaired ketogenesis
5. ***Endotoxaemia (∵ Biliary tract infection + Impaired clearance of endotoxins)
6. ***↓ Reticuloendothelial function
7. ***↓ Cell-mediated immunity

Question 20

Clinical manifestation of pathophysiological disturbance of MBO in relation to complications during surgery for MBO

Answer 20

1. ***Bleeding tendency
2. ***Poor wound healing (pancreatic head, liver hilum: important vessels + vascular branches)
3. Poor anastomosis —> leakage
4. Renal failure (***Hepatorenal syndrome)
5. ***Infection
6. Gastric erosion (∵ ***Stress gastritis)

Question 21

Measures to reduce complications related to surgery for MBO

Answer 21

1. Nutritional support
2. ***IV Vit K (NOT oral Vit K ∵ impaired absorption)
3. ***FFP (Fresh frozen plasma) during surgery if necessary
4. ***Antibiotic cover
5. Adequate hydration (prevent renal failure)
6. H2 antagonist / PPI (reduce stress gastritis / ulcer)

Question 22

Pre-operative relief of biliary obstruction

Answer 22

1. ERCP + Endoprosthesis
2. PTBD

Target level for concomitant partial hepatectomy:
- Bilirubin <50 / <20

However nowadays some surgeries allow Bilirubin level to be high before surgery
—> save 1 additional procedure of draining bile

Question 23

Long term survival of pancreatic head cancer

Answer 23

Radical resection:
- 1-year survival: 65%
- 5-year survival: 25%

Palliative bypass:
- 1-year survival: 10%
- 5-year survival: 0%

Question 24

SpC Interactive tutorial: Malignant biliary obstruction
Types of Jaundice

Answer 24

Pre-hepatic:
- ***Haemolysis (spherocytosis, G6PD deficiency, malaria, sickle cell anaemia)

Hepatic:
- Hepatitis (e.g. **Hep B flare)
- **Cirrhosis
- Intrahepatic cholestasis
- Medications
- Gilbert’s syndrome

Post-hepatic:
- ***Obstructive jaundice (Obstruction from Hilar of Hepatic duct —> Ampulla of Vater)
—> Benign: Gallstones
—> Malignant

Question 25

DDx of Malignant biliary obstruction

Answer 25

Rmb based on anatomical level of biliary tree!
- Primary vs Secondary (Metastatic LN, Direct invasion)

Upper level (Hilar, CHD):
1. **Klatskin tumour
2. **Extrinsic compression by Porta hepatis LN (from HBP malignancy / CR malignancy)

Middle level (Mid CBD):
1. **Cholangiocarcinoma (Mid CBD Cholangiocarcinoma)
2. **Extrinsic compression by LN
3. Extrinsic compression by gallbladder cancer

Lower level (Distal CBD):
***Periampullary cancer
1. Pancreatic head cancer
2. Ampulla of Vater cancer
3. Duodenal cancer
4. Cholangiocarcinoma (Distal CBD Cholangiocarcinoma)

NB:
- Cholangiocarcinoma: Must tell proximal / distal type —> management is different!
- Intraluminal malignant causes of jaundice: **Tumour thrombus, **Haemobilia —> Both are ***extremely rare
—> Tumour thrombus / Haemobilia: most likely HCC invading bile duct then bleed (still very rare, even rarer in Cholangiocarcinoma, Liver metastasis)

Question 26

P/E of Malignant biliary obstruction

Answer 26

1. Jaundice
2. Stigmata of chronic liver disease
3. Pruritus (Excoriation marks) (~PSC)
4. ***Courvoisier’s law
5. Troisier’s sign (Virchow’s node (i.e. palpable left supraclavicular fossa LN))
6. Hepatomegaly
7. ***Sister Joseph nodule (peritoneal metastasis along falciform ligament)
8. ***Ascites (peritoneal metastasis)

Troisier’s sign + Hepatomegaly (cannot caused by biliary obstruction) —> Advanced / Inoperable disease

Question 27

***Investigations of MBO

Answer 27

1. Blood test
   - CBC (Hb, WBC, Plt)
   —> chronic liver disease can give neutropenia, thrombocytopenia
   —> cholangitis: leukocytosis

• LRFT
  —> Elevated direct bilirubin level
  —> ALP predominantly raised (but more common to have mixed pattern rather than purely hepatitic / obstructive pattern)
• Clotting profile
  —> Prolonged INR (∵ impaired Vit K absorption)

2. Tumour markers (Normal does NOT exclude cancer, High does NOT include cancer)
   - AFP (HCC)
   - CEA (Colorectal, Lung, Breast)
   - CA19.9 (Cholangiocarcinoma, Cholangitis, Liver failure)
   —> Take only for confirmed malignancy: Prognostication + Monitoring
3. Imaging of Biliary tree
   - USG / CT (with contrast) / MRI (Anatomical imaging)
   —> Size of bile duct
   —> Level of obstruction (look for transition point)
   —> Cause of obstruction
   —> Staging for malignancy
   —> Complications from benign disease (e.g. Gallstone)

• EUS
  —> FNAC / Trucut biopsy for Pancreatic head cancer
• ERCP / MRCP
  —> Cholangiogram (X anatomical imaging (i.e. only look at bile duct, cannot look at liver))
  —> Therapeutic (e.g. drain bile system), Cytology / Biopsy for Cholangiocarcinoma
  —> Purely diagnostic + No endoscopic risk for MRCP (for cases not suspected to have biliary obstruction)

Biopsies:
- Ca of ampulla / duodenum —> just OGD biopsy
- Ca head of pancreas —> require EUS
- Cholangiocarcinoma —> brush biopsy by ERCP

Question 28

***Management of Biliary obstruction (Benign / Malignant)

Answer 28

1. Establish diagnosis
2. Delineate level + cause of obstruction
3. ***Treat suppurative cholangitis
4. Definitive treatment

MBO:
1. ***Treat sepsis
2. Assess tumour resectability
3. Patient general fitness
4. Liver function reserve (mainly for Klatskin tumour —> Major hepatectomy)
5. Resectable (20%) —> Surgery
6. Non-resectable (80%) —> Palliation

Palliation:
1. Treat sepsis
- Endoscopic / Percutaneous drainage (may need multiple drainage sites if intrahepatic ducts involved to drain left + right liver)
2. Relieve obstruction
- Biliary obstruction
- Intestinal obstruction (e.g. GOO)
3. Pain control

Question 29

Cholangitis

Answer 29

• Biliary obstruction + Infection
• Normal ductal pressure: 7-14 cmH2O
• Increased biliary pressure >25 cmH2O
  —> Bacteria reflux to hepatic veins and lymphatics
  —> Bacteraemia + Septic shock
• Excretion of antibiotics impaired in biliary obstruction —> ***Biliary drainage is mandatory!!!

Treatment:
1. Resuscitation
2. IV Antibiotics (Augmentin, RPC: 3rd gen Cephalosporin / Carbapenem)
3. ***Decompression of biliary system (Endoscopic vs Percutaneous (vs Open (rare)))
4. Definitive treatment

Question 30

***Role of surgery in MBO

Answer 30

1. ***Oncological clearance
   - R0 resection: Microscopic + Macroscopic clearance —> Surgery ONLY offered if R0 possible (NO palliative Whipple, Hepatectomy)
   - R1 resection: Macroscopic clearance
   - R2 resection: Gross tumour tissue left behind
2. ***Relieve obstruction
   - Biliary obstruction
   - Intestinal obstruction (e.g. GOO)
3. Pain control

Question 31

***Operability assessment

Answer 31

Patient factor:
1. Age
2. Medical background
3. Cardiovascular status
4. Nutrition, Fluid and electrolytes (e.g. GOO from Periampullary tumour ∵ duodenal involvement)
5. Sepsis
6. Coagulopathy

Tumour status:
1. TNM stage
- Locally advanced
- Distant metastasis
(PET scan not a must unlike CRC: ∵ some pancreatic cancer might not show uptake)

Question 32

***Surgery options and indications

Answer 32

1. Whipple operation (Classical vs PPPD)
   ***Periampullary cancer
   - Pancreatic head cancer
   - Ampulla of Vater cancer
   - Duodenal cancer
   - Cholangiocarcinoma (Distal CBD Cholangiocarcinoma)
2. **Radical cholecystectomy (remove gallbladder, porta hepatis LN, **surrounding liver (∵ venous + lymph drain through the gallbladder fossa of liver)) / Removal of CBD as well + ***Hepaticojejunostomy
   - Gallbladder cancer
3. **Major hepatectomy + **Caudate lobectomy together with confluence of bile ducts + ***Hepaticojejunostomy
   - Klatskin tumour (∵ caudate lobe directly drains into hilar bile duct)
   - Unilateral hepatic duct Cholangiocarcinoma

Question 33

“Radical” in surgery

Answer 33

Meaning:
- Removing organ + its draining LN

Question 34

Criteria of resectability in Pancreatic cancer

Answer 34

記**ok:
1. **No distant metastasis
2. **No arterial involvement (SMA, Celiac artery not involved)
3. **Venous involvement (Depends)
- Patent superior mesenteric-portal venous confluence
- Portal vein involvement is NOT absolute CI —> depends on extent of involvement + expertise
—> venous resection is appropriate to improve resectability + achieve R0 resection
—> significant morbidity and mortality
—> reasonable survival: median=13 months, 5 year=7%

Question 35

Biliary drainage before Whipple operation?

Answer 35

Support biliary drainage:
1. Jaundice
- **Coagulopathy, **Malabsorption, **Malnutrition, **Immune dysfunction
- **Higher anastomotic leak, **Haemorrhage, ***Renal failure (Hepatorenal syndrome)

Against biliary drainage:
1. Complications of biliary drainage
- **Bacterial contamination
- **Inflammation
- ***Procedure-related complications

Current consensus:
- NO need routine drainage (only in certain patient groups e.g. Cholangitis, Long waiting time for operation)

NOT for Klatskin tumour: Need hepatectomy —> cannot operate if bilirubin is high —> must drain first

Question 36

Pylorus preserving PD (PPPD) vs Classical Whipple

Answer 36

Classical Whipple:
- Remove pancreas —> PJ
- Remove duodenum —> HJ
- Remove antrum + pylorus (Hemigastrectomy) —> GJ

PPPD:
- Not remove antrum + pylorus + some duodenum —> DJ (Duodenojejunostomy)
—> Shorter operating time
—> Less blood loss
—> No difference in blood transfusion rate, hospital stay, mortality, morbidity

Deciding factor:
- Whether ***R0 resection (i.e. margin is enough) is possible

(Complications of Whipple (from Andre Tan):
Early:
1. **Delayed gastric emptying
2. **Pancreatic fistula
3. Wound infection
4. ***Anastomotic leak (Pancreatic, Biliary) —> Pseudocyst formation
5. Pancreatitis
6. Injury to organs
7. Bleeding

Late:
1. **Exocrine insufficiency (Malabsorption, Steatorrhoea)
2. **Endocrine insufficiency (DM)
3. Gastric stasis with pylorus-preserving Whipple
4. Diarrhoea (from autonomic nerve injury during LN dissection))

Question 37

Cause of mortality in MBO

Answer 37

1. ***Biliary sepsis
2. ***Cancer cachexia
3. ***Liver failure

Question 38

Pain control: Celiac plexus block

Answer 38

• Nociceptive fibres from pancreas transmitted to celiac plexus
• Neurolytic celiac plexus block has been employed to control intractable pain from CA pancreas
• Different methods available
  —> Open approach during surgical exploration
  —> Endoscopic approach
  —> Inject alcohol to plexus

Question 39

Palliative bypass for MBO

Answer 39

1. Surgical
   - Single bypass
   —> **Choledochojejunostomy (CBD-Jejunum)
   —> **Hepaticojejunostomy (Hepatic duct-Jejunum) (higher level: more effective in drainage)
   (—> Cholecystojejunostomy (NOT done ∵ risk of cystic duct blockage by tumour))

• Double bypass
  —> CJ / HJ + GJ

2. Endoscopic stenting
   - Metal stent: 15-39 weeks (better than plastic, less risk of stent blockage / tumour ingrown)
   - Plastic stent: 7-20 weeks
   - Palliative patient: usually life expectancy is ~1 year —> 1 stent usually suffice
3. PTBD

Surgical bypass vs Endoscopic stenting / PTBD:
Surgical bypass:
- Higher early morbidity
- Require GA
- Risk of anastomotic leakage
- Longer hospital stay
- Better long term results

Endoscopic stenting / PTBD:
- Lower initial mortality / morbidity
- Not require GA
- More late biliary complications (e.g. due to stent blockage, dislodgement)
- More re-intervention

Klatskin:
- ONLY PTBD is applicable (∵ tumour too high up)

Question 40

(Complications of PTBD (from Andre Tan))

Answer 40

(1. **Cholangitis
2. Bacteraemia + Sepsis (∵ liver puncture)
3. **Haemobilia (∵ communication between biliary duct and vascular structure: Hepatic artery pseudoaneurysm, Hepatic artery-bile duct / portal vein fistula)
4. Bleeding (∵ puncture into liver vessels)
5. ***Biliary peritonitis
6. Dislodgement)