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Grand Rounds

Grand Rounds. Panel Discussion Moderator : Dr V Gandhi Panelists : Dr S Hegde Dr G Kanitkar Dr Sanjay MH

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Grand Rounds

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  1. Grand Rounds Panel Discussion Moderator : Dr V Gandhi Panelists : Dr S Hegde Dr G Kanitkar Dr Sanjay MH Dr Taheer C Dr NitinPai Dr Minish Jain

  2. CASE HISTORY • 48 year old gentleman • ECOG 1, No Co morbidities • Presented with • pain abdomen • jaundice • decreased appetite and weight loss

  3. INVESTIGATIONS AT PRESENTATION • Hemoglobin – 12 gm/dl • S. Bilirubin – 20 mg/dl • S. Albumin – 2.9 mg/dl, Sr creatinine – 0.9 • S. ALP- 557 IU/L • S.CA 19.9 – 14 .6 U/l • CXR – NAD • USG abdomen – dilated bile duct , IHBR dilated pancreas not visualised

  4. CECT Abdomen • Thickening with wall enhancement in the lower bile duct • Proximal duct dilated, GB distended • Enlarged lower bile duct node • Pancreatic duct is prominent • SMA/SMV free

  5. EUS • Lesion in the lower bile duct • Enlarged pericholedochal node • Vessels free ERC 10 FR stent placed for drainage

  6. Pre op biliary drainage – Surgical/Malignant jaundice • Cholangitis • Renal failure • Coagulation disorders • Malnutrition • Intractable pruritus • Neoadjuvant therapy • Bilirubin > 15 ? When to drain ?

  7. SEMS vs Plastic

  8. DURATION OF PBD • Level 1 studies :the range was 12 to 26 days , • Level 2 studies :10 to 32 days • The duration of biliary drainage should probably be at least 4 weeks. • Even if the bilirubin level has decreased to normal levels, hepatic function will be fully restored only after at least 4 weeks. Ann Surg. 2002

  9. PLAN Pylorus preserving pancreaticoduodenectomy

  10. Whipples Pancreaticoduodenectomy

  11. Whipple’s Pancreaticoduodenectomy Pancreatico jejunostomy Hepatico jejeunostomy Duodenojejunostomy

  12. HPR • Lower CBD cholangiocarcinoma 2 cm x1.5 cm • 1/10 node positive • All margins are negative • No lymphatic invasion • No vascular invasion • No perineural invasion

  13. Adjuvant Chemotherapy

  14. Case 2 • 60 yrs gentleman • Jaundice of one month duration • Weight loss, loss of appetite • No cholangitis • Lab : Bili – 15, congugated hyperbili CA 19-9 – 400

  15. CECT abdomen

  16. Resectable pancreatic cancer • Borderline resectable pancreatic cancer • Unresectable pancreatic cancer

  17. Resectable Borderline resectable Unresectable

  18. Biopsy – well differentiated adenocarcinoma • ERC and ductal drainage

  19. NACTRT • FOLFORINIX +/- subsequent chemo radiation • Gemcitabine +/- subsequent chemo radiation

  20. Whipples with venous resection

  21. Vascular Resections • Venous resections • Arterial resections

  22. Staging laparoscopy • Large primary tumors • Multiple enlarged nodes • Borderline resectable tumors • Very high CA 19-9

  23. Summary • Biopsy not required in resectable lesions • POBD – use stents judiciously • Venous resections acceptable • Arterial resections – No • Extended Lymphadenectomy – No • Adjuvant chemo – yes • BRPC – NACTRT !

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