PREOPERATIVE

MANAGEMENT IN
PATIENTS WITH
SURGICAL OBSTRUCTIVE
JAUNDICE
DR. JAY MEHTA ( JUNIOR RESIDENT, DEPARTMENT OF GENERAL SURGERY,
PGIMER CHANDIGARH)
DEFINITION

• FAILURE OF NORMAL AMOUNT OF BILE TO REACH INTESTINES DUE TO

MECHANICAL OBSTRUCTION OF BILIARY TREE.
CLINICAL CLASSIFICATION (BENJAMIN)

• TYPE 1- COMPLETE OBSTRUCTION ( CLASSICAL SYMPTOMS WITH

BIOCHEMICHAL CHANGES)
1. CA HEAD OF PANCREAS
2. CHOLANGIOCARCINOMA
• TYPE 2- INTERMITTENT OBSTRUCTION- ( SYMPTOMS WITH BIOCHEMICAL
CHANGES BUT JAUNDICE +/-)
1. CHOLEDOCOLITHIASIS
2. CHOLEDOCHAL CYST
3. DUODENAL DIVERTICULA
4. BILIARY INFECTIONS( WORM INFESTATIONS)
5. PERIAMPULLARY CANCER
• TYPE 3- CHRONIC INCOMPLETE OBSTRUCTION- (WITH OR WITHOUT
CLASSICAL SYMPTOMS BUT PATHOLOGICAL CHANGES PRESENT)
1. CBD STRICTURES
2. STENOSED BILIARY ENTERIC ANASTAMOSES
3. CHRONIC PANCREATITIS
• TYPE 4- SEGMENTAL OBSRUCTION
1. TRAUMATIC
2. CHOLANGIOCARCINOMA
3. HEPATOLITHIASIS
PATHOPHYSIOLOGY OF OBSTRUCTIVE
JAUNDICE
1. HEPATIC FUNCTIONS- PROTEIN SYNTHESIS, RETICULO-ENDOTHELIAL
FUNCTION, CLOTTING FACTORS
2. RENAL FUNCTIONS- TUBULAR DAMAGE ( INFLAMMATORY MEDIATORS
AND BILIRUBIN)
3. CARDIOVASCULAR EFFECTS- BRADYCARDIA , DECREASED CARDIAC
CONTRACTILITY
4. DECREASED PLATELET FUNCTION AND COLLAGEN SYNTHESIS
PREOP MANAGEMENT
NUTRITIONAL THERAPY

• 45-70% PATIENTS- 10% WEIGHT LOSS, ALBUMIN <3, DECREASED TRICEPS

SKIN FOLD, IMPAIRED DELAYED TYPE HYPERSENSITIVITY REACTION
• DUE TO FAT AND FAT SOLUBLE VITAMIN MALABSORPTION
• BILIARY SEPSIS- SHIFTING PATTERN OF PROTEIN SYNTHESIS (FROM
ANABOLIC TO ACUTE PHASE PROTEIN SYNTHESIS)
• TO REVERSE CATABOLIC EFFECT, BILIARY DECOMPRESSION (ENTERAL
DRAINAGE OVER PERCUTANEOUS) AT LEAST 4 WEEKS PRIOR TO MAJOR
HPB SURGERY
INDICATIONS FOR PTBD RELATIVE TO ERCP

1. FAILED ERCP STENTING

2. SEVERE CHOLANGITIS
3. INTRAHEPATIC OBSTRUCTION
4. PRIMARY CONFLUENCE NOT PATENT
5. SEGMENTAL HEPATIC DECOMPRESSION ( HILAR CHOLANGIOCA)
ORAL NUTRITION REPLETION

• ORAL BILE SALTS- URSODEOXYCHOLIC ACID ( 300 MG QID)

• BILE REFEED THROUGH FJ OR GJ TUBE.
• DIET RICH IN MEDIUM CHAIN TRIGLYCERIDE (MCT)
• VITAMIN A, D , E AND K SUPPLEMENTATION (WATER SOLUBLE FORMS)
• AT LEAST 7 DAYS OF ORAL NUTRITION REPLETION (PROTEIN AND
CARBOHYDRATE RICH DIET) OR TILL SERUM ALBUMIN RISES TO >3 MG/DL.
HYDRATION

• LOSS OF BILE SALTS LEADS TO DEHYDARTION , METABOLIC ACIDOSIS ,

MALABSORPTION
• BILE LOST THROUGH PERCUTANEOUS DRAINAGE SHOULD BE REPLACE BY
ORS OR RINGER LACTATE.
• URETHRAL CATHETERISATION FOR MONITORING OF URINE OUTPUT (>0.5
ML/KG/HR)
• CORRECTION OF DYSELECTROLEMIA( HYPONATREMIA, HYPOKALEMIA)
COAGULOPATHY

• PRE-OP A 3-DAY TRIAL OF IV ADMINSTRATION OF VITAMIN K IN CASE OF

SUSPECTED VIT K DEFICIENCY
• ACTIVE BLEEDING-
• 1) FFP/ PROTHROMBIN COMPLEX CONCENTRATE
• 2)CRYOPRECIPITATE ( FIBRINOGEN<100 MG/DL)
• 3)PLATELET TRANSFUSION( <50,000)
ANTIBIOTIC PROPHYLAXIS

• BROAD SPECTRUM IV ANTIBIOTIC PROPHYLAXIS

• 3RD GENEARTION CEPHALOSPORIN, EXTENDED SPECTRUM PENICILLINS ,
AMINOGLYCOSIDES
RECENT ADVANCES- IMMUNE MODULATING
NUTRITION
• OMEGA-3-FATTY ACIDS, ARGININE, GLUTAMINE ORALLY 7-14 DAYS
REDUCES RISK OF POST OP INFECTIONS
• ALSO SHOWN TO REDUCE INFLAMMATORY MEDIATORS( IL 6 AND TNF) AND
HENCE A BETTER LIVER FUNCTION IN POST OP PERIOD
THANK YOU