Hepatobiliary Surgery JC055: Painless Jaundice And Epigastric Mass: Obstructive Jaundice, Pancreatic And CBD Cancers Flashcards
Malignant biliary obstruction (MBO)
Obstruction of biliary tract by cancer growth within / around biliary tract
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
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
- FDG-PET: exclude distant metastasis before consider surgical resection
- 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 - Chemo Adjuvant therapy
Pathology report:
- Adenocarcinoma
- T2N0M0 / stage 1B (Early)
Prognosis:
- > 4 years survival
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
- 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
- ***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) - 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
Causes of Jaundice
- Medical causes
- Pre-hepatic jaundice: **Haemolytic anaemia
- Hepatic jaundice: **Hepatitis, ***Cirrhosis - 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)
***DDx: Pathology causing Malignant biliary obstruction
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)
***History taking for Jaundice
- ***Painful / Painless, Pattern of pain
- severe colicky RUQ pain: Stone
- painless / vague pain: Malignancy - ***Progressive / Intermittent jaundice
- progressive: Malignancy
- intermittent: Stone - Pale stool, ***Pruritis
- differentiate from Non-obstructive jaundice (Medical cause: cirrhosis, hepatitis) - Any fever
- infection (e.g. ***Cholangitis, can progress quickly to septicaemia) - GI symptoms
- change of bowel habit
- vomiting - Constitutional symptoms (e.g. weight loss)
- History of hepatitis B / C
- Drinking history
P/E for Jaundice
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
***Jaundice + Epigastric mass: DDx
-
**Hepatomegaly (usually mild) secondary to **Biliary obstruction
- jaundice: Biliary obstruction
- epigastric mass: Liver -
**Hepatomegaly secondary to **HCC / Metastasis
- jaundice: HCC / Metastasis
- epigastric mass: Liver - LN metastasis to Celiac axis / Porta hepatis
- jaundice: LN
- epigastric mass: LN - Carcinoma of stomach with metastatic LN in Porta hepatis
- jaundice: LN
- epigastric mass: Stomach - ***Carcinoma of pancreas
- jaundice: Pancreas
- epigastric mass: Pancreas
Epigastric mass:
- Liver
- Gallbladder (Globular)
- Pancreas
- Stomach
- LN
***Investigations in Jaundice
- Blood tests
- Bilirubin (normal: ~20)
- ALP (normal: ~100-120)
- AST / ALT (normal: 40)
- WBC
- Platelet
- PT
- Tumour markers - 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
Endoscopic USG
- 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
Double duct sign
Dilated Bile duct + Dilated Pancreatic duct
—> Pancreatic head carcinoma / Periampullary carcinoma
PET scan
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
***Signs of inoperability
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
Selection of patients with MBO for surgery
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
- 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
Laparotomy
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
Radical resection
- Tumour + Part of organ of origin
- Regional LN
- 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
Bypass for MBO
for Unresectable tumours
- Single bypass
- Choledochojejunostomy / Hepaticojejunostomy - Double bypass
- + Gastrojejunostomy —> prevent duodenal obstruction - Triple bypass (rare)
- + Pancreaticojejunostomy —> relief pancreatic duct obstruction
Why is malignant biliary obstruction so risky for operation?
- Cancer cachexia —> Malnutrition
-
**Liver function impairment
- impaired ability to synthesise clotting factors + Vit K malabsorption —> **Bleeding risk
- impaired protein synthesis —> ***Impaired healing -
**Superimposed biliary infection
- ∵ Biliary stasis ↑ bacterial colonisation —> **Septic complications
Pathophysiological effects of malignant biliary obstruction
- ***Impaired protein synthesis
- ***Impaired clotting factor synthesis
- Impaired gluconeogenesis
- Impaired ketogenesis
- ***Endotoxaemia (∵ Biliary tract infection + Impaired clearance of endotoxins)
- ***↓ Reticuloendothelial function
- ***↓ Cell-mediated immunity
Clinical manifestation of pathophysiological disturbance of MBO in relation to complications during surgery for MBO
- ***Bleeding tendency
- ***Poor wound healing (pancreatic head, liver hilum: important vessels + vascular branches)
- Poor anastomosis —> leakage
- Renal failure (***Hepatorenal syndrome)
- ***Infection
- Gastric erosion (∵ ***Stress gastritis)
Measures to reduce complications related to surgery for MBO
- Nutritional support
- ***IV Vit K (NOT oral Vit K ∵ impaired absorption)
- ***FFP (Fresh frozen plasma) during surgery if necessary
- ***Antibiotic cover
- Adequate hydration (prevent renal failure)
- H2 antagonist / PPI (reduce stress gastritis / ulcer)
Pre-operative relief of biliary obstruction
- ERCP + Endoprosthesis
- 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
Long term survival of pancreatic head cancer
Radical resection:
- 1-year survival: 65%
- 5-year survival: 25%
Palliative bypass:
- 1-year survival: 10%
- 5-year survival: 0%
SpC Interactive tutorial: Malignant biliary obstruction
Types of Jaundice
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
