Pathology causing malignant biliary obstruction

1
Pathology causing malignant biliary obstruction

• Carcinoma of duodenum
• Periampullary carcinoma
• Carcinoma of pancreas
• Lymphoma
• Carcinoma of gallbladder
• cystic duct LN, direct infiltration of CBD,
  tumour fragments
• Cholangiocarcinoma at hilum, Klatskin tumour
• HCC
• direct infiltration, compression, tumour
  fragments in CBD

2
Causes of mortality of MBO

• Cancer cachexia
• Liver failure
• Biliary sepsis

3
Biliary obstructionPathophysiology

• Disruption of endoplasmic reticulum and
  canalicular membrane
• Destruction of hepatocytes
• ? reticulin ? collagen
• portal hypertension

4
Biliary obstructionPathophysiology

• ? protein synthesis
• ? clotting factor synthesis
• Impaired gluconeogenesis
• Impaired ketogenesis
• ? endotoxaemia
• ? cell-mediated immunity
• ? reticulo-endothelial function

5
Clinical manifestation of pathophysiological
effects of MBO

• Wound dehiscence
• Anastomotic dehiscence
• Bleeding tendency
• Malnutrition
• Sepsis
• in bile duct
• in other parts of body
• Renal failure
• Bleeding gastric erosions

6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
Selection of patients with MBO for surgeryWhy
surgery?

• Remove tumour
• Relieve obstruction

13
Selection of patients with MBO for surgery

• Assessment of general status
• Assessment of tumour status

14
Assessment of general status

• 1. Age
• 2. Concomitant medical diseases
• 3. Hidden medical illness
• ECG
• spirometry
• blood sugar
• renal function
• (Aim to define whether the patient is fit for
  surgery)

15
Assessment of tumour status

• Clinical examination
• US
• HAG
• CT scan
• MRI
• (Aim to define whether the tumour is still
  confined to the organ of origin)

16
Clinical examinationSigns of inoperability
Left supraclavicular lymph node Irregular surface
hepatomegaly Umbilical nodule Ascites Rectal-vesic
al pouch deposit
17
Radiological examinationSigns of inoperability
Liver secondaries Lymph node metastases SMV/PV/SMA
encasement
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
Laparotomy if

• 1. General condition is fit
• 2. Tumour is confined
• No promise of resection until laparotomy finding
  shows no spread

23
General status
Tumour status
bad
good
confined
spread
PTBD or endoprosthesis
PTBD or endoprosthesis
laparotomy
bypass if spread
radical resection if confined
24
Radical resection of tumour causing MBOExamples
Whipple operation for carcinoma of pancreas,
ampulla, lower part of CBD or duodenum Right or
left hepatectomy together with confluence of
hepatic ducts for Klatskin tumour
25
Bypass for MBO

• Single bypass
• choledochojejunostomy or hepaticojejunostomy
• Double bypass
• gastrojejunostomy
• Triple bypass
• pancreaticojejunostomy

26
(No Transcript)
27
Single bypass
28
Double bypass
29
Malignant biliary obstructionPostoperative
mortality
30
Measures to reduce complications related to
surgery for MBO

• 1. Nutritional support
• 2. Vit K
• 3. FFP during surgery
• 4. Antibiotic cover
• 5. Mannitol, dopamine to prevent renal failure
• 6. H2 antagonist

31
Measures to reduce postoperative complications
related to surgery for MBO

• 1. Preoperative PTBD
• 2. Preoperative endoscopic drainage

32
Percutaneous transhepatic biliary drainage
33
Endoprosthesis