Grand Rounds Panel Discussion Moderator Dr V Gandhi

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

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

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

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

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

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

SEMS vs Plastic

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

PLAN Pylorus preserving pancreaticoduodenectomy

Whipples Pancreaticoduodenectomy

Whipple’s Pancreaticoduodenectomy Pancreatico jejunostomy Duodenojejunostomy Hepatico jejeunostomy

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

Adjuvant Chemotherapy

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

CECT abdomen

• Resectable pancreatic cancer • Borderline resectable pancreatic cancer • Unresectable pancreatic cancer

Resectable Borderline resectable Unresectable

• Biopsy – well differentiated adenocarcinoma • ERC and ductal drainage

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

Whipples with venous resection

Vascular Resections • Venous resections • Arterial resections

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

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 !