Case 5: OBSTRUCTIVE JAUNDICE

Overview

• Causes of Obstructive Jaundice

• History Taking
• Abdominal Examination
• Investigations
• Algorithm in Management
• CBD stones
• Carcinoma Gall Bladder
• Bile Duct Cancers
• Bile Duct Injuries
• Pancreatic Cancers

Author’s note:

This is the most extensive case in exam. It deals in detail the whole of Hepato biliary and
Pancreatic system and discussion may go anywhere into any of the above. I’m trying my best to
cover the maximum area involved in discussion.

Causes of obstructive/ surgical jaundice.

• Congenital – Biliary atresia, Choledochal cyst
• Inflammatory- Ascending cholangitis, Primary Sclerosing cholangitis
• Obstructive Benign disorders- CBD stones , Biliary stricture, Parasitic infestation
• Obstructive Neoplastic disorders - Carcinoma of head of pancreas, periampullary
carcinoma, cholangiocarcinoma, Klatskin tumour
• Extrinsic compression- Compression by malignant metastatic pericholedochal and
Hilar nodes from, Malignancies directly compressing the Bile duct

Your Exam case will be mostly Obstructive Jaundice caused by

1. Malignancy obstructing the Bile duct or
2. Stone Obstructing the Bile duct

Presents with complaints of…

• Jaundice
• Fever
• Itching
• Weight loss/loss of appetite
• Vomiting
• Melena
• High Urine colouration
• Clay Coloured stools

H/O PRESENTING COMPLAINTS

1. JAUNDICE
• Duration
• Onset
 • Progression – gradual/ intermittent
• Associated with pain or not

Viva Stop

Painless intermittent Jaundice Periampullary cancer due to

sloughing of tumor
Painful Jaundice with Fever CBD stone ( Choledocholithiasis)
Painful Jaundice Progressive Hilar Cholangiocarcinoma
Jaundice with Back Pain Pancreatic Head cancer

2. FEVER
• Intermittent/ continuous
• Duration
• Associated with chills and rigors

Viva Stop:

What is CHARCOTS TRIAD?

Seen in ascending cholangitis
• Intermittent fever
• Intermittent pain
• Intermittent jaundice

What is Reynauld’s Pentad?

• Above 3 features added with
• Mental alteration
• Septic Shock

Past history:
• Diabetes, hypertension, heart disease, asthma
• H/o previous gall bladder surgery- may lead to bile strictures and jaundice

GENERAL EXAMINATION
• Jaundice:
Yellow discolouration of sclera, skin, nail bed, under surface of tongue, soft palate
Look in natural light
• Scratch marks- over chest and abdomen due to Itching Patient Scratches all over

Abdominal examination
Inspection
Look for fullness in right hypochondrium due to distended gall bladder
• Can be seen in very thin patients
• See for movement with respiration

Look for ascites

Look for Dilated veins over the abdomen.
Palpation
When distended it can be felt as tense globular swelling projecting downwards and forwards
from below the liver just lateral to the outer border of rectus muscle {Below the 9th rib tip}
• Moves with respiration
• Upper limit continuous with liver
• Can be moved slightly from side to side

Murphy’s sign
• Patient in sitting posture
• Place the right hand just below the right costal margin on the lateral border of
right rectus and moderate pressure is exerted with finger to palpate gall bladder
• Now ask the patient to take a deep breath in, the gall bladder descends and hurts
the examining finger, the patient will wince with catching pain if organ is
inflamed
Moynihan’s method ( Figure 5.1)
• Patient lies down instead of sitting with same steps as above.

Figure 5.1. Moynihan’s method ( in Murphy’s sign patient will be sitting)

Viva Stop:
Palpable gall bladder + Obstructive Jaundice:
1. Mucocele
2. Empyema
3. Obstructive jaundice due to carcinoma pancreas, Periampullary cancer, Distal CBD
cancer
4. Carcinoma of gall bladder

COURVOISIERS LAW:
In a patient with jaundice if there is a palpable gall bladder it is not due to stones

Explanation:
• In pathology of gall bladder like calculus cholecystitis there will be fibrosis of the
gall bladder and hence it cant enlarge if there is a distal obstruction.

• But if the pathology is there outside gallbladder due to CBD carcinoma,

pancreatic carcinoma you can palpate the gall bladder

Exceptions to this law

 • Double impaction of stone – one in CBD and other in cystic duct – Stone but GB
palpable**
• Hilar Cholangiocarcinoma- Malignancy but GB not palpable**

Other unusual exceptions which funny examiners may expect are:

- Previous Cholecystectomy in a distal malignancy
- Intrahepatic GB in a Distal malignancy
- Congenital Absence of GB
- Oriental Cholangiohepatitis cases

Figure 5.2. Courvoisier’s Law

DIAGNOSIS
• This is a case of obstructive jaundice ,
• The site of obstruction probably at…….. ,
• And the cause of obstruction due to ……………….

INVESTIGATIONS
1. Basic blood investigations:
• Serum bilirubin- Total and Direct Bilirubin more increased( Increased direct bilirubin
suggests obstructive type)
• Elevated alkaline phosphatase > 10 times normal is strongly suggestive of obstruction
• Simultaneous elevation of gamma glutamyl transferase confirms obstruction.
• Coagulation profile: Prothrombin time and INR- international normalised ratio are
increased
 Viva Stop:
Why Prothrombin Time is elevated in Obstructive Jaundice?
• Liver is the main site for synthesis of all coagulation proteins. Abnormalities of
these factors can be determined by measuring prothrombin time[PT]- which
measures the rate of conversion of prothrombin to thrombin, which requires
vitamin K Dependent clotting factors { factor 2, 7, 9, 10}
vitamin k is fat soluble vitamin , absorption of which requires presence of bile
salts in intestine which is absent in patients with obstructive jaundice.
• So PT is prolonged- hence injection of vitamin k should normalise the
prothrombin time in obstructive jaundice.

LFT Normal Values:

• Serum Total Bilirubin- 5-17 Micromol/litre
• Alkaline phosphatase- 35-130 IU/litre
• Aspartate Transaminase- 5-40 IU/litre
• Alanine Transaminase- 5-40 IU/litre
• GGT- 10-48 IU/litre
• Prothrombin Time- 12-16 Seconds
• INR- Less than 1.1
• Albumin- 35-50 gm/litre

2. Radiological investigations

• USG- First investigation for GB and bile duct.

• HIDA SCAN (TC 99 m labelled iminodiacetic acid)- Gold Standard** to diagnose Acute
cholecystitis. ( There will be non- visualisation of Gall bladder)
• CT scan- Only in ca gallbladder and bile duct
• ERCP- gold standard to diagnose CBD stones. ( Fig 5.3 a and b)
• MRCP- Most accurate non invasive ** and now has replaced ERCP in most places (
Figure 5.4 a and b)

Figure 5.3.a. Normal ERCP

 Figure 5.3 .b .CBD stone/ Gall stones in ERCP

Figure 5.4 a. MRCP- showing gall stone/ CBD stone

Figure 5.4 b. MRCP- showing Hilar cholangiocarcinoma

Viva Stop:
ERCP:
The diagnostic use of ERCP is no more and nowadays MRCP has replaced it in diagnostic
use.

Therapeutic uses:
 • Gold standard for CBD stone removal
• Stenting for inoperable tumours
• Endoscopic Stenting into Bile duct
• Biopsy
• Preoperative bile drainage
• Sphincter of oddi dysfunction- sphincterotomy.

Complications of ERCP:
1. Acute pancreatitis [5%]- Most common complication
2. Duodenal perforation
3. Haemorrhage
4. Infection
5. Stent migration

3. Other Investigations:

PTC[ PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM]- Figure 5.5

1. To diagnose pathologies in higher level above cystic duct
2. Preoperative bile drainage

DIAGNOSTIC LAPAROSCOPY
• Diagnostic lap- It will detect micromets in liver surface and pelvic
deposits. Thus prevents unnecessary laparotomy.
• Always done before operating a cancer Gall bladder.

Figure 5.5. Percutaneous Cholangiogram(PTC)- shows Caroli’s disease

Common Diagnosis
Undergraduate level
CBD stone causing Jaundice
(or)
Post Cholecystectomy Biliary Stricture
Distal CBD cancer, Periampullary
cancer, Head of Pancreas cancers
causing Obstructive Jaundice if
operable
Cholangiocarcinoma if operable
( CBD Cancer)
Cancer GB causing Jaundice if operable
Management that should be mentioned in Exam at
• ERCP and CBD stone removal followed by
Laparoscopic Cholecystectomy as Two
procedures.
• Choledocholithotomy with Cholecystectomy
in single sitting. ( Laparoscopic or Open
method)
• Hepatico-Jejunostomy using a Roux loop
Jejunum
• Whipple’s Operation- Pancreatico
Duodenectomy
• Resection of Bile duct if margin clearance
possible for 1 cm with Hepatico jejunostomy .
Even Extended Hepatectomy done for selected
cases of Hilar cholangiocarcinoma
• Radical Cholecystectomy with Excision of
Segment 4b, 5 of Liver
DISCUSSION OF EACH TOPIC:

Author’s Excuse:
• I am going to discuss the following important etiologies which can be asked by Examiners-
Though my discussion is like a Post graduate level, UG’s please excuse me- this will help you
in PG entrance time.

1. Gall stone obstructing CBD

2. Cancer GB causing jaundice
3. Bile duct cancers
4. Post cholecystectomy Biliary Stricture
5. Pancreatic cancers causing Jaundice

Etiology 1: Gall stones Obstructing at CBD and causing jaundice

❖ M/c type of stone – Mixed stone
❖ MC stone in US- Mixed
❖ MC stone in Asia- Pigment Stone
❖ 90% gall stones are radiolucent ( 90% kidney stones are radio opaque)

TYPES OF STONES
• Cholesterol stones( Fig 5.6)
• Brown pigment stones ( Fig 5.7)
• Black pigment stones
• Mixed ( Fig 5.8)

Fig 5. 6 Cholesterol Gall stones

Fig 5.7. A huge Brown Pigment stone removed by Dr. RRM

Fig 5.8. Mixed Gall stone operated by Dr. RRM

Important risk factors for Gallstones:

• Obesity ( BMI>30)**
• Rapid weight loss ( After Bariatric Surgery etc.,)
 • Child bearing
• Multi parity
• Female sex
• 1st degree relatives
• Drugs ( TPN, Estrogens, Ceftriaxone)
• Ileal resection/ Bypass ( decreased Entero hepatic circulation of Bile salts)
• Ethnicity ( Native Americans- PIMA INDIANS), Scandinavia*

Pathogenesis of Gall stone Formation**

• Lithogenic Bile
• Nucleation
• Stasis or GB hypo motility*

Extra mile in Gall stone:

Lithogenic bile**
• Bile salts and phospholipids in bile keep cholesterol in solution by forming micelles.
• Cholesterol is insoluble in water which is made soluble by bile salts and phospholipids.
• An excess of Cholesterol relative to bile acids and Phospholipids allows Cholesterol
Crystals to form and such bile is called as Supersaturated or Lithogenic Bile**

Normal ratio
• Bile acids : cholesterol=20:1*
• Critical ratio= <13:1 at which crystallization occurs.

Causes of Cholesterol Stones:

Increased Biliary Cholesterol:
• Obesity
• Cholesterol Rich Diet
• Clofibrates therapy

Decreased Bile Acids:

• Primary Biliary Cirrhosis
• Mutation in CYP7A1 Gene( Deficiency of 7 Alpha Hydroxylase- Rate limiting enzyme in
the Bile acid Synthesis from Cholesterol.
• MDR 3 Gene Mutation leading to defective Lecithin in Bile**

Nucleation:
• Cholesterol Monohydrate crystals aggregates to forms Macroscopic crystal.
• Excess of Pronucleating factors ( Mucin, Non Mucin Glyco protein, Infection) and
decrease of Anti nucleating factor ( Apo lipo protein A-1 and A-II )

Stasis:
• TPN
• Fasting
• Pregnancy
• Octreotide
• OCP
• Massive Burns
PIGMENT STONES
❖ Name given when contains cholesterol <30 % **

BLACK PIGMENT BROWN PIGMENT

( Insoluble Bilirubin Pigment polymer+
Calcium Phosphate + Calcium Carbonate)
M/c in hemolytic states
• Hereditary spherocytosis, sickle cell
disease
• Heart valves [mechanical]
• Liver cirrhosis
• Gilbert’s syndrome
• Cystic fibrosis
• Ileal resection
( Calcium Bilirubinate+ Calcium Palmitate+
Calcium Stearate+ Cholesterol)
• Rare in gall bladder
• Common in Asia*
• Primary bile duct stone formation** (
Formed in Bile duct itself)
• Due to bile stasis and infection**
• M/C – E.COLI*
• M/C IN presence of FB, stents,
parasites**
• MC recurrent type of recurrent stone
• MC type of stone seen in
Hepatolithiasis ( Oriental
Cholangiohepatitis)

Treatment:
• Laparoscopic cholecystectomy is the gold standard surgery for Gall stones.
• Done by using Four Port technique as shown in figure below.( Fig 5.9)

Fig 5.9. Lap Port sites:

Extra mile
Indications for Cholecystectomy
• All Symptomatic Stones are operated.
• Prophylactic Cholecystectomy ( Asymptomatic cases where cholecystectomy is
done)
 Stone associations:
• Size Based: > 2.5 cm Size stones
• Stone+ Polyp associated
• Stone+ Anomalies in Gall bladder
• Family H/o GB Cancer+ Stones
• Acalculous cholecystitis
• Gallstone pancreatitis

Surgery associations:
• Transplant surgeries ( Lung and Heart)- as they receive cyclo sporine drug
which can cause stones.
• During some other Elective Surgeries if there are stones.
• After Bilio pancreatic Surgeries ( Obesity Surgeries)

For Some other Pathologies:

• Children with hemoglobinopathies like sickle cell anemia
• Chronic TPN need
• Chronic immunosuppression
• Porcelain GB
• Typhoid Carriers with Bile Culture+

Author’s Note: Old books mention Diabetes and Multiple Small stones are
Indications for surgery. This concept is no more..

Ref. Table Blumgart Page 514/5th edition

COMPLICATIONS of Gall stones:

• Silent
 • Acute cholecystitis
• Chronic cholecystitis
• Mucocele
• Empyema
• Gangrene
• Carcinoma
• Fistula
• Gall stone Ileus
• Mirizzi Syndrome
• Cholangitis
• Pancreatitis
• CBD stones

Extra mile:
• Murphy’s Sign- Inspiratory arrest with deep palpation in the RUQ pain in Acute
Cholecystitis.
• Boas Sign- Hyperaesthesia below Right Scapula in Acute Cholecystitis

Latest Update from Bailey and Love 27th edition :

Acute calculus Cholecystitis: An overview:

• 90% of Acute Cholecystitis subsides with Conservative measures.

• Non operative treatment is based on 4 principles:
- Nil Oral and IV fluids until Pain resolves
- Analgesics
- Antibiotics ( as the Cystic duct is blocked we have to give antibiotics
which will concentrate in serum rather than in Bile Eg. Cefazolin,
cefuroxime and Ciplox)
- Once the temperature and physical signs subside , oral fluids started
and investigations done like USG, and MRCP if jaundice is there and CT
scan if perforation suspected.
• Cholecystectomy is done in next available list or patient sent home to return after
inflammation is completely subsided.

Latest Updates:
• Acute Cholecystitis is taken for Early Cholecystectomy (within 72 hours) is the latest
concept. ( Old Concept is to do only conservative management for Acute Cholecystitis is
gone )
• Laparoscopic cholecystectomy is the treatment of choice for Acute Cholecystitis, but the
rate of conversion is high.

• Bailey 27th edition Says- Early Cholecystectomy is done in 5-7 days,

• Bailey 27th Edition Says - Delayed Interval Cholecystectomy operation is done in
around 6 weeks
MUCOCELE
• Obstruction of stone at neck of gall bladder*
• Treatment-Early cholecystectomy*

MIRIZZI SYNDROME ( Fig 5.10)

• It refers to the obstruction or stricture of the common hepatic duct as result of extrinsic
compression by a gall stone in the cystic duct or Hartman’s Pouch in Gallbladder.

Fig 5.10. Mirizzi Syndrome: Csendes Classification.

FISTULAS FROM GALL BLADDER:

• M/C site duodenum [CHOLECYSTOENTERIC FISTULA]
• Diagnosis suspicious by presence of air in bile duct
• Complication- Gall stone ileus**
• Other sites of fistula- colon.

Gallstone Ileus:
• Characterised by Tumbling Intermittent Small intestine obstruction by the Gall stone
which has passed via the Choledocho Duodenal Fistula
• RIGLER’S TRIAD: Pneumobilia, Intestinal obstruction and Cholecystoenteric fistula
• Duodenal obstruction due to gall stones usually in the bulb is known as Bouveret’s
syndrome*
• MC in Old age- > 70 years.
• MC site of Obstruction is terminal ileum**
• Management:
- Stable cases: Enterotomy and Stone removal+ Closure of Fistula+
Cholecystectomy
- Unstable cases: Only Stone removal and obstruction relief

Saints triad**
o Gall stones
o Diverticulosis of colon
o Hiatus hernia

Extra mile:
 MEDICAL TREATMENT
• Useful only for cholesterol gall stones not for pigment stones*
• Mechanism is by inhibiting HMG CO –A reductase in cholesterol synthesis, thus
decrease cholesterol Super saturation.

Useful only in**

o Radiolucent
o Size <10 mm
o Functioning gall bladder
o Non acute symptoms

COMMON BILE DUCT STONES

❖ Incidence- 6-12% of GB stones*

Primary CBD stone Secondary CBD stone

• Formed in bile duct itself • Formed in gall bladder and enters
• Usually they are brown CBD by migration
pigment**stones ( Soft and • MC in Western Countries.
earthy) • Cholesterol stones
• MC in Asian Population*
• Usually due to Foreign bodies,
Stasis and Infection.

Extra Edge:
• ERCP is the diagnostic and therapeutic treatment of choice*
• A dilated CBD >8mm strongly suggests Gall stones*
• Increased Serum Bilirubin, SGOT/SGPT and Alkaline Phosphatase implies presence of
CBD obstruction.

CHOLANGITIS
Etiological factors:
• CBD stone ( MC cause)
• ERCP
• Benign and malignant strictures
• Parasites

M/C ORGANISMS- E.COLI**, Klebsiella, Streptococcal Faecalis , Bacteroides

CLINICAL FEATURES
• MC presentation – Fever with Chills and Rigors*

CHARCOT’S TRIAD*
CBD stone causing cholangitis
❖ Pain
❖ Jaundice
❖ Rigors

REYNAULDS PENTAD*
Includes Charcots triad + Septic shock+ Mental status changes

Treatment of Cholangitis:
 ❖ Immediately start IV Fluids and Broad spectrum Antibiotics.
❖ Urgent Biliary Decompression is the priority in management of Cholangitis if they do not
respond to antibiotics

Management of CBD Stones- Protocol:

Management of CBD Stone:

IN PRESENCE OF CHOLANGITIS
• ERCP with sphincterotomy and stone extraction [Treatment of choice]**
• PTC drainage- ERCP failed cases
• Surgery- Only when above two procedures not possible - Decompression of CBD by
Choledochotomy with T tube insertion is done ( Figure 5.12 a and b)

IN ABSENCE OF CHOLANGITIS
• Lap cholecystectomy with Lap CBD exploration ( or)
• Lap cholecystectomy with ERCP stone removal

CBD EXPLORATION AND T TUBE REMOVAL

• A T-tube cholangiogram is taken around 7 days after the operation. ( Fig 5.11)
• If it appears normal, the tube is removed on day 7 or 8 by gentle traction**

Author’s Preference:
• Me and most Gastro surgeons prefer to remove the T tube after 14 days***
Fig 5.11. T Tube Cholangiogram

Figure 5.12 a. Open Cholecystectomy with CBD Stone removal and T tube Insertion
Figure 5.12 b. T Tube insertion

Rare Scenarios in CBD Stone management:

MISSED/ RETAINED/ RESIDUAL STONES[ < 2 YEARS]

IF T TUBE PRESENT ;
• Flushing with heparinized saline
• Dissolution with MTBE ( Methyl Ter Butyl Ether)
• Percutaneous stone extraction via T tube tract after 4-6 weeks [BURHENNE
TECHNIQUE]*

IF T TUBE ABSENT;
• ERCP stone removal

RECURRENT STONES [> 2YEARS]

• M/C due to non absorbable suture materials, clips, ;;
• They get internalized and get covered with calcium bilirubinate to form brown*
pigment stones
• ERCP- first approach
• If duct dilated > 2cm – choledocho duodenostomy or trans duodenal sphincteroplasty

Extra Mile:
Courvoisier Law: ( Figure 5.13)

In patients with Obstructive Jaundice- Courvoisier gave a law based on Palpatory finding.
If the obstruction is due to stone in CBD- Gall Bladder will not be palpable (Figure a)
• Reason- The stone in bile duct would have come from a cholecystitis GB- so its wall
would be so thick to get further distended.
If the Obstruction is due to malignancy in CBD- Gall bladder will be palpable. (Figure b)
• Reason- The gall bladder here is a normal GB so it will get distended to the maximum
 size once the Bile duct gets obstructed.

Figure 5.13. Courvoisier’s law

Exceptions to Courvoisier’s Law:

• Double Impacted stone (One in CBD and One in cystic duct)- Gall bladder gets distended.
• Pancreatic stone obstructing the ampulla of Vater*
• Oriental Cholangio hepatitis

Etiology 2: CARCINOMA GALL BLADDER – Presenting with Obstructive Jaundice

• M/c malignancy of biliary tract*

• M/c female elderly
• 70 to 80% cases are gallstones associated*.
• MC site of cancer in GB- Fundus and Body.

Risk factors
• Gallstones
• Polyps[ >10 mm]
• Porcelain GB
• Choledochal cyst
• Anomalous pancreato bile duct junction
• Typhoid carriers*
• Sclerosing cholangitis
• Ulcerative colitis
• Cholecysto enteric fistula
• Drugs- estrogens[ not OCP]*
• Carcinogens[ nitrosamines, azo dyes, rubber industry chemicals]
Recent Updates:
• 95% have associated Gall stones
• Risk of developing Ca. GB in Gall stone disease in 20 years is 0.5% in General population
and 1.5% in High risk cases.
• Risk is more with Symptomatic Gall stones and less with Asymptomatic stones
• Larger stones>3 cm have 10 fold risk

Clinical features
• Pain[ 73%}
• Anorexia and weight loss{63%}
• Jaundice[54%]- poor prognostic sign*
• Fever
 • Vomiting [ mechanical obstruction or malignant gastro paresis]
• O/E- mass palpable [50%], hepatomegaly, ascites
Pathology-Adeno carcinoma(90%),undifferentiated, squamous cell carcinoma.

INVESTIGATIONS
• USG- Localized excessive thickening of gall bladder [ normal GB thickness is < 3mm]
• CT contrast[CECT]- lymph nodes >10 mm visible
• MRI+MRCP+MRA- is most useful than all above- helps in planning management
• FNAC- contraindicated in operable tumors[ risk of dissemination via tract]
FNAC is indicated only in inoperable tumours
• Diagnostic laparoscopy is must: 38% cases found inoperable among those cases
planned for curative resection after all the investigations.
• Tumor markers CEA, CA 19-9

Contraindications for surgery

• Poor general condition
• Liver mets
• Extra hepatic mets
• Peritoneal spread
• Distant nodes[coeliac, Superior mesentric, para aortic]
• Portal vein or hepatic artery involved
• Bilateral involvement of secondary biliary radicles
• Extensive duodenal involvement

Treatment

Gall bladder cancer is treated according to the stage.

Hence a few points must be known regarding Staging.
• T1a- Tumor into Lamina Propria
• T1b- Tumor into Muscle layer
• T2- Tumor into muscle layer and serosa but not beyond
• T3- Visceral peritoneum involved, Liver or one Organ like -Stomach, Duodenum,
Colon, Pancreas, Bile ducts, Omentum
• T4- Invades main PV or HA or two or more extrahepatic organs.
• N1- Nodes in cystic duct, CBD, HA, PV
• N2- Periaortic, Pericaval, SMA, Coeliac nodes

So in cases found to have cancer incidentally: we will wait for specimen report.
If specimen says
• T1a- Already done cholecystectomy is enough
• T1b- Cholecystectomy is enough if margins are negative
• T1b ( if has Perineural, vascular invasions) – risk of nodal involvement is
more – hence Extended Cholecystectomy is done.
• In extended cholecystectomy 2 cm of normal hepatic parenchyma is to be
removed, CBD should be removed if cystic duct margin is positive and all the
nodes Pericholedochal, periportal, Hepatoduodenal. Coeliac and posterior
pancreatico duodenal nodes are removed.

• T2 – Cases Radical cholecystectomy involving removal of segment 4b and 5 along with

nodes. ( Figure 5.14)
• T3- Radical cholecystectomy or Extended Right Hepatectomy is done
• If only segment 5 was involving removal of Segment 4b and 5 would have been done*
 • Some cases will also require a central hepatectomy- Removal of segments 4,5 and 8
• Some cases will also need Right Trisegmentectomy- Removal of segments 5,6,7,8 and
segment 4**

Cancers diagnosed in cholecystectomy specimens

• Except for tumors confined to mucosa re do laparotomy is advised with resection as per
staging along with lap port sites excision.

Figure:5.14 Extended Cholecystectomy for cancer GB

Extra Mile
• Median Survival of Unresectable cases- 2-4 months only*
• Gemcitabine+ Cisplatin is used for Unresectable cases.

Latest updates:
• Port Site Excision is not having any potential therapeutic benefit and not done
nowadays.
• It is rare for port site alone to have recurrence. If there is a recurrence it will be
generalised.
• So now it is not recommended to excise the port sites during re resection.

Sabiston says- Port sites to be excised ( But Blumgart says no need to do port site excision)
Bailey says- Routine port site excision is not performed ( Page 1117)
Author’s vote is for non excision of port*

Etiology 3: BILE DUCT CANCERS

• MC site of Cholangiocarcinoma- Hilum of Bile duct ( Klatskin tumor)

RISK FACTORS
Inflammatory Causes:
- Primary Sclerosing Cholangitis ( MC risk Factor in Western- 20
 fold increased risk)
- Ulcerative Colitis Leading to PSC
- Hepatitis C infection
- Oriental Cholangio hepatitis

Parasitic Infections:
- Opisthorcis Vivernii
- Clonorchis Sinensis

Chemicals:
- Thorium Dioxide
- Vinyl chloride
- Dioxin
- Asbestos

Congenital:
- Caroli disease
- Choledochal Cyst

Post Surgical :
- Post Biliary Enteric Anastomosis

PATHOLOGY TYPES
• Sclerosing variety [m/c]- Worst prognosis**
• Nodular
• Papillary [better prognosis] type of Adeno carcinomas

CLINICAL FEATURES
o MC site : KLATSKIN TUMORS- tumors at bifurcation- Hilar tumors – 65%
o MC symptom: Painless Jaundice* followed by Pruritus
o MC elevated Tumor marker- CA- 19-9 ( poor prognostic factor)

Criteria for Unresectability of Hilar Cholangiocarcinomas:

o Bilateral hepatic ducts upto secondary radicles involved ( Type 4)
o Main PV Involvement
o Atrophy of one lobe with Contralateral PV
o Atrophy of One lobe with Contralateral Secondary Radicles involvement
o Distant Mets

BISMUTH- CORELETTE CLASSIFICATION; ( Fig 5.15)

• TYPE 1- At common hepatic duct only.
• TYPE 2- Involving confluence without involvement of secondary ducts
• Type 3-a- Involving right secondary intra hepatic ducts
• Type 3 b- involving left secondary intra hepatic ducts
• TYPE 4 – Involves secondary ducts on both sides
 Fig 5.15. Bismuth Corelette classification of Hilar cancers
Recent Advance:
• Rebeccamycin analogue*- Novel antibiotic with Topoisomerase activity I and II
and DNA intercalating property is used for Cholangiocarcinoma and found to
increase survival for 10 months.

Treatment for Cholangiocarcinomas:

• Proximal CBD cancers- CBD resection + lymph node dissection+ Hepatic resection.
• Intrahepatic Cholangiocarcinomas- hepatic resections
• Distal CBD growth- Whipple procedure.

Etiology 4: Bile duct Injuries

• Lap cholecystectomy associated with higher percentage of injuries [0.3 to

0.85%] compared to open surgeries[0.1 to 0.2%]*

CLASSIFICATIONS
Bismuth Classification STRASBERG CLASSIFICATION ( Fig 5.16)
Based on Location (Depending on patterns of injury)

TYPE 1- Low common hepatic duct stricture.
stump>2cm
TYPE 2- Proximal stricture. Stump< 2 cm
TYPE 3- Hilar stricture. Confluence intact
TYPE 4- Destructed confluence. Right and left
ducts separated
TYPE 5- Involvement of right aberrant sectoral
duct alone or along with stricture at CHD
TYPE A- minor hepatic duct or cystic duct
leaks
TYPE B- aberrant right hepatic duct or
sectoral duct divided and LIGATED
TYPE C- same as B but BILE LEAK
TYPE D- lateral injury to CBD or CHD
TYPE E- circumferential injury to main ducts

Extra Mile:
• Type B – Strasberg will have no Bile leak.
• Type A- Strasberg can be managed by only Percutaneous drainage
• Type B- Strasberg cannot be diagnosed by ERCP as it doesn’t show leak.
Fig 5.16. Strasberg Classification of Bile Duct Injuries

Protocol for Bile duct Injury management:

MANAGEMENT;
• Early repair not attempted. Only drainage procedures carried out
 • Ideal time of repair is 8 to 12 weeks to allow inflammation to subside**
• ROUX EN Y HEPATICO JEJUNOSTOMY is ideal repair ( Figure 5.17)

Figure 5.17

Extra mile in Bile duct injury repairs:

Injury recognised immediately after injury
• Transected Ducts smaller than 3 mm – Usually drain only single segment or
subsegment of liver hence ligate it.
• Transected Ducts larger than 3mm – May drain more than a single segment hence
reimplanted into biliary system
• Injury involving circumference less than 50% of Bile duct is repaired on a T tube*
• Injury involving circumference more than 50% or Cautery injury requires Biliary enteric
anastomosis.
• If no expert surgeon available to reconstruct the immediate injury – appropriate
treatment is to keep a drain and refer the patient to Expertise centre.**

Must know Table:

• Pancreatic duct anastomosis must be done with Polypropylene ( non-absorbable
material)
• Bile Duct Anastomosis done with Polyglycolic acid(Vicryl)

Etiology 5: Pancreatic Cancers

o M/c type- Adeno carcinoma

o M/c site- Head of pancreas**
o Other sites are- Periampullary, Body and Tail.
o Most best prognosis- Periampullary cancer
o Most worst prognosis- Cancer in Body and Tail
Risk factors of Pancreatic cancers:
• Tobacco
• Genetic
• Chronic pancreatitis
• Diabetes mellitus type 2
• Obesity
• High carbohydrate diet

Extra mile:
Hereditary risk factors:
• PRSS1 and SPINK 1 gene mutation- Familial pancreatitis
• STK11- Peutz jeughers – 100 fold increased risk ( Highest risk of all)
• Familial Atypical Mole and Malignant melanoma Syndrome
• CFTR mutation
• BRCA-2 mutation
• MLH- 1 mutation - Lynch syndrome
• FAP- Familial adenomatous polyposis

Genetic mutations:
- K-ras is the most common and the earliest mutation to occur in pancreatic cancers**
and is associated with 95% of pancreatic cancers*
- P16 mutation is seen in 90% cases
- P53 mutation is seen in 79% cases
- DPC4 mutation is seen in 78% cases
-
( Controversial question- Pathology books say P16 mutation is MC, but I always stick with
my friend Sabiston 20th edition Page 1543**)

PERIAMPULLARY CANCER*:
• Tumors in region of ampulla, lower CBD, duodenum
• M/c presentation is painless jaundice- 70% cases
• Good prognosis than pancreatic head cancers

Must know points in Cancer pancreas:

• Courvoisier’s Law- In cases of obstructive jaundice due to CBD stones- Gall bladder will
not be palpable. At the same time if it is due to malignancy GB will be palpable. So as per
law GB will be palpable in Periampullary cancers ( But only in 1/3rd cases) ( See Figure
5.18 )
Figure: 5.18. Periampullary cancer with GB distension

• Best tumor marker- CA-19-9*

• CA 19-9 will not be elevated in blood Lewis Antigen negative status ( 10-15% cases)
• Investigation of choice- Triple phase CECT scan with Pancreatic protocol ( where 3
mm cuts are made near pancreas)

Fascinating Signs in Pancreas:

Double Duct Sign: ( Figure 5.19)

• Simultaneously Dilated CBD and Pancreatic duct due to compression by Cancer Head of
Pancreas or Periampullary Tumors.
• Can be seen rarely in Benign cases like Distal Bile duct stone with edema causing
obstruction in Pancreatic duct.
• This finding is classically an ERCP finding -but can be seen in MRCP, CECT and even USG
also.
Figure 5.19. Double Duct Sign.

Inverted 3 sign: ( Epsilon/ Frostberg Sign) Figure 5.20

• Barium meal finding
• Distortion of the mucosal pattern on the medial wall of the second part of the
duodenum due to focal mass and local oedema.
• Mc seen in carcinoma of the head of the pancreas rarely in duodenal carcinoma and
chronic pancreatitis.

Figure 5.20. Frostberg Sign

Extra Edge : Resectability of Pancreatic Tumors Based on CECT abdomen:

On CT scan the tumors are divided into resectable, Borderline resectable and Unresctable
tumors:

Resectable tumors:
• Tumors localized to pancreas
• No Evidence of SMV or PV involvement
 • Preserved fat plane between tumor and SMA, Hepatic artery and coeliac artery

Borderline resectable tumors:

• Tumor involving SMV – Portal vein involvement
• Abutment or encasement of hepatic artery < 180 degrees
• SMV occlusion short segment- reconstructible

Unresectable tumors:
• Arterial involvement more than 180 degrees
• Ascites
• Peritoneal mets
• Lymphnode mets outside the operation areas
• Liver mets.

WHIPPLES PROCEDURE
• Radical pancreatico duodenectomy
• Done for cancer of the pancreas head/ Periampullary cancer/ distal CBD and Duodenal
cancers*

During Whipple’s procedure,

- Gastroduodenal artery originating from Common hepatic artery is to be
ligated .
Before ligating GDA- it’s very important the following manuever is done:
- Occlude the GDA temporarily and ensure distal hepatic artery flow is normal,
because some cases atherosclerosis of coeliac artery will cause retrograde arterial
flow from SMA through GDA.
- Once the Proper hepatic artery flow is confirmed via duplex scan we must ligate the
GDA.
- If there is retrograde flow via GDA we must not ligate and we must do GDA
preservation or resection with Bypass as aortic hepatic conduit.

Removal of: ( Figure 5.21 a,b, c)

• Pancreas head
• Duodenum
• Distal Stomach
• Portion of jejunum
• Gallbladder
• Distal CBD
Triple anastomosis done during reconstruction: choledocho jejunostomy, pancreato
jejunostomy, gastro jejunostomy.
 Figure 5.21 a: Whipple procedure

• Pylorus Preserving Pancreatico duodenectomy is known as LONGMIRE AND

TRAVERSO procedure*
• Survival of stage 4 pancreatic cancers- 3-6 months*

Fig 5.21 b. Resected Bed

 Fig 5.21 c. Whipple specimen

Post operative complications of Whipple Procedure:

• Delayed Gastric Emptying ( 18%)
• Pancreatic leak ( Fistula)- 12%- defined by Drain amylase level 3 times higher than
Serum amylase level after 3rd POD. Most significant predictor of leak is soft gland has
high risk.
• Wound infection- 7%
• Bile leaks
• Intra abdominal abscess
• Cardiac events
• Pancreatic endocrine and exocrine deficiency
• Mortality

Definition of Pancreatic leak/Fistula:

• On or after 3rd Post operative day,
• Output coming via the drain shows- Fluid Amylase level > 3 times of serum amylase
level**
• European studies has shown the risk of Pancreatic fistula is reduced by giving-
Octreotide*

Recent advance:
• Gemcitabine* is the Chemotherapy of choice in pancreatic cancers.

Palliative treatments of Pancreatic cancer:

Symptom Palliative Treatment

Jaundice and Biliary Sepsis
Delayed Gastric Emptying
Pain relief
Surgical Biliary Bypass
ERCP stenting
Percutaneous Transhepatic Cholangiography
Surgical Gastro Jejunostomy
Duodenal Stent
Analgesics
Coeliac plexus Block
Transthoracic Splanchinectomy
Quality of Life Motivation
Enzyme substitutes
Treat Diabetes
Chemotherapy
- 5FU or Gemcitabine for Adeno cancers