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Advances in Hepatobiliary Surgery

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Advances in Hepatobiliary Surgery. Jack Matyas, MD, FACS & Keith Nichols, MD, FACS. Presenting Symptoms. Jaundice Weight Loss Pruritus Steatorrhea Clay-Colored Stool. Work-up 1980. Mass < 2cm No mass No stone “Double duct sign” No enlarged nodes No ascites No vessel involvement - PowerPoint PPT Presentation

Text of Advances in Hepatobiliary Surgery

  • Advances in Hepatobiliary SurgeryJack Matyas, MD, FACS&Keith Nichols, MD, FACS

  • Presenting SymptomsJaundice

    Weight Loss

    Pruritus

    Steatorrhea

    Clay-Colored Stool

  • Work-up 1980

  • CT Criterion for ResectabilityMass < 2cmNo massNo stoneDouble duct signNo enlarged nodesNo ascitesNo vessel involvementNo liver lesions

  • CT Criteria for UnresectabilityAbsoluteLiver mets Bx proven

    Portal vein thrombosis

    SMA or coeliac encasement

    Necrotic lymph nodes Bx proven

  • UnresectableBypass

    Biliary stent

    5 FU/XRT locally advanced

    Gemzar (Gemcitabine) - systemic

  • CT ScanRelative contraindicationsAscites

    Loss of portal vein fat plane

    Enlarged L. nodes

    Liver lesions not classic for metastasis

  • AscitesLaparoscopy with cytology and biopsy suspicious lesions

    Omentum - Liver

  • Liver LesionsCT guided biopsy

    MRI

    Laparoscopy

  • CT ScanRelative contraindicationsAscites

    Loss of portal vein fat plane

    Enlarged L. nodes

    Liver lesions not classic for metastasis

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  • SummaryAdenocarcinoma involving the distal bile duct continues to have an overall poor prognosis.Through aggressive high tech preoperative work-up, a select group of patients will enjoy surgical benefit.High volume institutions like Riverside maintain an acceptable
  • Summary (cont.)5FU/XRT provides reasonable palliation for locally advanced tumors avoiding unnecessary laparotomy.Gemcitibine has low toxicity and can provide short term palliation in cases of systemic metastasis.EVS has opened new doors for pre-op staging and better direction for cystic pancreatic neoplasms.

  • 2007History

    Physical

    Ultrasound dilated vs. non-dilated

    CT scan pancreatic protocol

    ~ 60% unresectable by CT scan

    40% further studies

  • Summary80% of distal bile duct obstructions are surgically incurable

    Technology & proper staging has significantly decreased unnecessary laparoscopy

    Almost all patients that are properly staged undergo definitive surgery

  • SummaryHigh volume institutions like Riverside have an acceptable morality such that even palliative whipple provides a good quality of life

    5 FU/XRT for locally advanced, Gemzar for systemic mets & wall stents are far superior to open biliary bypass.

  • Enlarged Lymph NodesEV5 endoscopic ultrasound with biopsy

  • Loss of Portal Vein Fat PlaneEV5

    MRI

    Angiogram with venous phase

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