5/26/2018 Jordanian Surgical Society.ppt Last
1/166
Sameer Smadi MD.
5/26/2018 Jordanian Surgical Society.ppt Last
2/166
Cholangiocarcinoma
5/26/2018 Jordanian Surgical Society.ppt Last
3/166
Definition of Cholangiocarcinoma
Bile duct cancers arising from ductal
epithelial cells
Refers to cancers arising in the intrahepatic
(~5-15%), perihilar (~60-70%), or distal
(extrahepatic ~25%) biliary tree
Represents approx. 3% of all gastro-
intestinal malignancies
5/26/2018 Jordanian Surgical Society.ppt Last
4/166
Definition of CholangiocarcinomaBismuth-Corlette Classification subdivides
perihilar cholangiocarcinomas based on pattern
of involvement of hepatic ductsType I: tumors occurring below the confluence of the
left and right hepatic ductsType II : tumors reaching the confluenceTypes IIIA/IIIb: tumors occluding the common
hepatic duct and either the right or left hepatic ductType IV: tumors that are multicentric, or that involve
the confluence and both the right or left hepatic duct
Klatskin tumors occur at the bifurcation of the
proper hepatic duct
5/26/2018 Jordanian Surgical Society.ppt Last
5/166
(A) The anatomic location of cholangiocarcinoma can be described as intrahepatic, distal extrahepatic or hilar.Cholangiocarcinomas can be further described based on their macroscopic or cholangiographic appearance. (B) Nonhilarlesions can be described as mass-forming, periductal or intraductal, or as mixed mass-forming and periductal. Forextrahepatic lesions the terms periductal, mass-like and intraductal correspond to the alternative designations ofsclerosing, nodular and papillary. (C) Hilar lesions can be described using the Bismuth classification.70Type I tumors arefound below the confluence of the left and right hepatic ducts. Type II tumors reach the confluence of the left and righthepatic ducts. Type IIIa and IIIb tumors occlude the common hepatic duct and either the right or the left hepatic duct,respectively. Type IV tumors are multicentric or they involve the confluence and both the right and left hepatic ducts. Acombined anatomicmorphologic classification is useful for patient management and can provide consistency in clinical or
epidemiologic studies. Tumors are shown in (B) and (C) in yellow
http://www.nature.com/ncpgasthep/journal/v3/n1/full/ncpgasthep0389.htmlhttp://www.nature.com/ncpgasthep/journal/v3/n1/full/ncpgasthep0389.html5/26/2018 Jordanian Surgical Society.ppt Last
6/166
5/26/2018 Jordanian Surgical Society.ppt Last
7/166
5/26/2018 Jordanian Surgical Society.ppt Last
8/166
5/26/2018 Jordanian Surgical Society.ppt Last
9/166
5/26/2018 Jordanian Surgical Society.ppt Last
10/166
Incidence: 1.0 per 100,000 per year
Male to female ration of 1.3:1
Average age of presentation is 50-70
Etiology: Common features of risk factors include biliary stasis, bile
duct stones, and infection.
PSC, Choledocal cysts, hepatolithiasis, chlonorchis ortyphoid infections.
Other risk factors include liver flukes, nitrosoamines,dioxin exposure.
Presentation: Typically painless jaundice, may include pruritus, RUQ
pain, anorexia, fatigue, and weight loss.
5/26/2018 Jordanian Surgical Society.ppt Last
11/166
Work-up
Typically Alk phos will be elevated to 1.5 to 5 times normal, and transaminase levels will
be 1-2 times normal. CEA or CA 19-9 may also be elevated but these test are not
diagnostic.
5/26/2018 Jordanian Surgical Society.ppt Last
12/166
PathologyAdenocarcinoma (90%) Slow growing, locally invasive, mucin-producing Perineural spread, metastases uncommon
Three subtypes of adenocarcinoma Sclerosing
Majority of cholangiocarcinomas Characterized by an intense desmoplastic reaction Early ductal invasion leads to low resectability rates
Nodular Constricting annular lesion of the bile duct
Papillary Present as bulky masses occurring in the bile duct lumen Present early with biliary obstruction Highest resectability rates
5/26/2018 Jordanian Surgical Society.ppt Last
13/166
ClinicalTriad Cholestasis
Abdominal pain (30-50 %)
Weight loss (30-50 %)Pruritus (66 %)
Clay-colored stools, dark urine.
Jaundice (~90 %)
Hepatomegaly
RUQ mass
Courvoisier's sign
Intrahepatic cholangioCA typically presents without
biliary obstruction
5/26/2018 Jordanian Surgical Society.ppt Last
14/166
LaboratoryElevations in: Total bilirubin (>10 mg/dL)
Direct bilirubin
Alkaline phosphatase (usually increased 2- to 10-fold) 5'-nucleotidase
Gamma glutamyltransferase
Transaminase levels initially normal With chronic biliary obstruction, liver dysfunction may
ensue with elevation in ALT/AST and PT
5/26/2018 Jordanian Surgical Society.ppt Last
15/166
Differential Diagnosis
Choledocholithiasis
Benign bile duct strictures (usually postoperative),
Sclerosing cholangitis
Compression of the CBD (secondary to chronic
pancreatitis or pancreatic cancer)
5/26/2018 Jordanian Surgical Society.ppt Last
16/166
Diagnosis
Tumor markers
Serum CEA >5.2 ng/mL(sensitivity 68%, specificity 82%) CA 19-9
Radiographic studies Transabdominal ultrasound- may reveal ductal dilatation
(intrahepatic >6mm)
CT/helical CT- can also detect vascular invasion Helical CT (esp. portal venous phase)- can delinieate nodal
basins
May be superior to MRI with respect to predicting
resectability
MRCP- may be coming the imaging modality of choice
5/26/2018 Jordanian Surgical Society.ppt Last
17/166
Diagnosis
Cholangiography
ERCP or PTC Useful if suspected level of obstruction is distal Preoperative drainage of the biliary tree Obtain diagnostic bile samples or brush cytology (low
sensitivity)Endoscopic ultrasound Useful for visualizing distal tumors and regional nodes Can be used for EUS-guided biopsy of tumors and
enlarged nodesPET High glucose uptake of biliary duct epithelium
Angiography (rarely used)Staging laparoscopy
5/26/2018 Jordanian Surgical Society.ppt Last
18/166
Diagnosis
Role of Staging laparoscopyTissue diagnosis important in the
setting of:
Strictures of unknown origin (e.g.bile duct stones, PSC)
Family/patient request for a
definitive diagnosis
Prior to chemotherapy or radiation
therapy
5/26/2018 Jordanian Surgical Society.ppt Last
19/166
5/26/2018 Jordanian Surgical Society.ppt Last
20/166
ManagementPoor prognosis- avg. 5-year survival ~5-10%
Resectability rate superior for distal tumors resectability rates for intrahepatic 60%, perihilar 56%, and
distal lesions 91% (Nakeeb A; Pitt HA, JHU 1996)
Negative margins achieved in 20-40% of proximal tumors
cases, 50% of distal tumor cases
5/26/2018 Jordanian Surgical Society.ppt Last
21/166
ManagementAccepted guidelines for resectability (accurately
determined at operative exploration) Absence of N2 nodal metastases or distant liver metastases
Absence of vascular (portal vein, hepatic artery) invasion
Absence of extrahepatic adjacent organ invasion
Absence of disseminated disease
5/26/2018 Jordanian Surgical Society.ppt Last
22/166
ManagementPre-operative biliary decompression
Liver dysfunction increases postoperativemorbidity and mortality
Arch Surg 2000 (Cherqui et. al.)Study demonstrated increased post-op morbidity injaundiced patients not undergoing pre-operativedrainage (vs. nonjaundiced patients)
Pre-operative portal vein embolization Induce liver hypertrophy to increase limits of safe
resection No demonstrated improvement in clincial outcome
5/26/2018 Jordanian Surgical Society.ppt Last
23/166
ManagementSurgical Procedures Distal lesions: pancreaticoduodenectomy (5-yr survival
rates 15-25%)
Intrahepatic cholangiocarcinoma: hepatic resection (3-yrsurvival rates 22- 66%)
Perihilar cholangiocarcinoma (5-yr survival rates 10-45%;
outcomes in PSC patients dismal)
Type I and II lesions: en bloc resection of extrahepatic
bile ducts and gallbladder with 5 to 10 mm bile duct
margins, regional lymphadenectomy with Roux-en-Y
hepaticojejunostomy.
Type III and Type IV lesions: hepatectomy and portal
vein resection
5/26/2018 Jordanian Surgical Society.ppt Last
24/166
Role of liver transplantation
Bismuth-collette Type IV Recently, an extended bile duct
resection combined with totalhepatectomy,pancreatoduodenectomy, andorthotopic liver transplantation(HPLTx) was proposed to eradicate theentire biliary tract without cutting offthe hepatoduodenal ligament.
Liver transplantation may be atherapeutic option for the patientswith 1) unresectability confirmed atlaparotomy; 2) advanced tumor withinfiltration of the adjacent tissues thatan R0 resection is hardly to beachieved; 3) local intrahepatic
recurrence of the tumor; and 4)advanced hepatic cirrhosis andprimary sclerosing cholangitis withoutenough residual functional livertissues after resection.
5/26/2018 Jordanian Surgical Society.ppt Last
25/166
Hepatic Tumors
5/26/2018 Jordanian Surgical Society.ppt Last
26/166
Benign Solid liver tumors Hepatic Adenoma
Reproductive women
75% with abdominal pain onpresentation.
Chance of rupture issignificant (25% withhepatocellular adenoma)
Increased fat signal on MRI
Cold on Tc-MAA scan.
Resection remains thestandard of therapy for lesionslarger than 4 cm.
5/26/2018 Jordanian Surgical Society.ppt Last
27/166
Benign Solid liver tumors Focal Nodular Hyperplasia
Not associated withsymptoms.
No risk of rupture or
malignant degeneration Characteristic central scar,
hot on Tc-MAA scan.
Early embryologic vascularinjury.
If symptomatic, lesion may beresected.
Lesions are often peripheraland thus lap. Resection shouldbe advocated.
5/26/2018 Jordanian Surgical Society.ppt Last
28/166
Benign Solid liver tumors
Hemangiomas
Chronic RUQ pain CT or MRI diagnostic
Resection if symptomsare ascribed to the
hemangioma
5/26/2018 Jordanian Surgical Society.ppt Last
29/166
Malignant Liver Tumors HCC is one of the most common solid human
cancers, with an annual incidence estimated to beapproximately 1 million new patients.
In addition the liver is second only to lymph nodesas a common site of mets from other solid tumors. It is not uncommon, particularly with colorectal
cancer for the liver to be the only site of metastasis.
Resection of both primary disease and isolatedmetastatic disease may result is significant longterm survival benefits in 20-45% of patients.
5/26/2018 Jordanian Surgical Society.ppt Last
30/166
Presentation:
Mostly diagnosed through imaging performed for someother indication, as part of a screening protocol, or during
follow-up for a known primary malignancy of anotherorgan site.
Symptoms may include dull right upper quadrant pain,fullness or bloating, and in some instances nausea or
vomiting, or systemic complaints. History: high-risk behaviors or known hepatitis virus
infection, travel to areas where hepatitis B or C is endemic,alcohol use, exposure to hepatotoxins, use of oral
contraceptives or hormone replacement therapy, or ahistory of hereditary liver diseases
5/26/2018 Jordanian Surgical Society.ppt Last
31/166
Imaging for suspected liver neoplasm
CT scan: highly sensitive at spatial discrimination andquantification of lesions in the liver, good for pre-opplanning.
MRI: better for detecting early HCC, and distinguishingbetween HCC and macroregenerative nodules.
U/S: Useful for guiding biopsy, determining tumorvascularity, and intraoperatively to guide resections.
Other studies: PET, Angiography, Dx laporoscopy.
5/26/2018 Jordanian Surgical Society.ppt Last
32/166
Treatment
5/26/2018 Jordanian Surgical Society.ppt Last
33/166
HCC Treatment Options
Curative
Transplantation
Surgical Resection
Ablative Therapy
RadioFrequency Ablation (RFA)
Cryoablation
Percutaneous ETOH ablation
Non-Curative
Trans-Arterial Chemo-Embolization (TACE)
Sorafenib
5/26/2018 Jordanian Surgical Society.ppt Last
34/166
Treatment Surgery Ultimately complete resection of the liver mass remains
the optimal choice for treatment.
Newer techniques continue to decrease the morbidityassociated with hepatic resection including staplingtechniques and laparoscopic approaches.
For patients with a single lesion and preserved liverfunction, resection is curative, with 5-year survival rates of
50% to 70% Recurrent HCC occurs in 50% to 80% of patients at 5 years
after resection, with the majority occurring within 2 years
5/26/2018 Jordanian Surgical Society.ppt Last
35/166
Treatment Radiofrequency ablation thermal necrosis to tumors by
delivering electromagnetic energythrough needle electrodes.
RFA versus resection for patients withsingle small lesions show comparable
1- and 3-year overall survival results(100% and 72.7% versus 97.9% and83.9%, respectively.
higher 1- and 3-year local recurrencerates (16.3% and 18.2% versus 1.1% and2.2%, respectively).
May also be considered as a bridge to
transplantation.
5/26/2018 Jordanian Surgical Society.ppt Last
36/166
Treatment
Transplantation Choosing the patient who can maximize each organ is of
paramount importance and is dictated by the Milancriteria.
The consensus is that liver transplantation is indicated inpatients with HCC with at least a 50% chance of survival at5 years
Most series demonstrate a survival advantage for HCCpatients from transplantation over all other modalities.
In an ideal world without an organ shortage, timely livertransplantation would offer better survival rates thanresection by offering both decreased tumor recurrence anda treatment of the underlying liver disease.
Mil it i f HCC i li
5/26/2018 Jordanian Surgical Society.ppt Last
37/166
Milan criteria for HCC in liver
cirrhosis
Cha, et al: Ann Surg, Volume 238(3).September 2003.315-323
5/26/2018 Jordanian Surgical Society.ppt Last
38/166
Colorectal neuroendocrine
Non Colorectal neuroendocrine
5/26/2018 Jordanian Surgical Society.ppt Last
39/166
Surgical resection is currently acceptedas a safe, and also the only potentiallycurative treatment available for patients
with colorectal liver metastases.
Chance of long-term survival with
rates ranging from 25% to 50% at 5years
5/26/2018 Jordanian Surgical Society.ppt Last
40/166
During the last decade, significanttechnical advances have beenaccomplished in liver surgery.
They allow bilobar resections with verylow mortality (around 1%) and lowmorbidity
5/26/2018 Jordanian Surgical Society.ppt Last
41/166
5/26/2018 Jordanian Surgical Society.ppt Last
42/166
5/26/2018 Jordanian Surgical Society.ppt Last
43/166
5/26/2018 Jordanian Surgical Society.ppt Last
44/166
HV Analysis labeled
5/26/2018 Jordanian Surgical Society.ppt Last
45/166
5/26/2018 Jordanian Surgical Society.ppt Last
46/166
5/26/2018 Jordanian Surgical Society.ppt Last
47/166
5/26/2018 Jordanian Surgical Society.ppt Last
48/166
5/26/2018 Jordanian Surgical Society.ppt Last
49/166
5/26/2018 Jordanian Surgical Society.ppt Last
50/166
Colon cancer with liver metastasis
Unless there is an absolute prohibitivemedical risk, all patients with
potentially liver mets.should havecareful evaluation todetermine whether they havepotentially resectable disease .
5/26/2018 Jordanian Surgical Society.ppt Last
51/166
SYNCHRONOUS COLORECT L LIVERMET ST SESLiver mets is detected in 15-25% of
colorectal cancer cases
Have been presumed to representmore aggressive tumour
No evidence that these patients do
worse after liver resection
5/26/2018 Jordanian Surgical Society.ppt Last
52/166
Should these patients have
concurrent or staged liver
resection?
5/26/2018 Jordanian Surgical Society.ppt Last
53/166
YOKOH M EXPERIENCE
39 consecutive patients 39 concurrent multivariate analysis for safety and
success rate
Poor overall survival with poorly differentiated and
mucinous adenocarcinomas (p
5/26/2018 Jordanian Surgical Society.ppt Last
54/166
TOKYO EXPERIENCE
187 consecutive patients, 1980-2002 142 concurrent, 27 staged resections
Prognosis affected by
multiple liver metastases
4 or more lymph node metastases around the primary
tumour
Conclusion: Simultaneous resection inpatients with 3 or less colorectal lymph node
metastases only
Minigawa M et al (Makuuchi). Arch Surg 2006; 141: 1006-12.
5/26/2018 Jordanian Surgical Society.ppt Last
55/166
STR SBOURG EXPERIENCE 97 consecutive patients (1987-2000)
35 concurrent vs 62 staged Concurrent resection if
5/26/2018 Jordanian Surgical Society.ppt Last
56/166
BERLIN EXPERIENCE
219 consecutive patients (1988-2005) 40 concurrent vs 179 staged
Morbidity similar
Mortality higher in concurrent group (p=0.012)
Mortality in concurrent group (n=4) after majorhepatectomy and age >70 yrs
No significant difference in long-term survival
Conclusion: decision should be based onage and extent of liver resection
Thelen A et al. (Neuhaus) Int J Colorectal Dis 2007; Feb 21 (Epub ahead of print).
5/26/2018 Jordanian Surgical Society.ppt Last
57/166
MSKCC EXPERIENCE 240 consecutive patients (1984-2001)
134 concurrent vs 106 staged Concurrent resection: more right colon primaries (p
5/26/2018 Jordanian Surgical Society.ppt Last
58/166
Clinical score for predicting recurrence after hepatic resection for
metastatic colorectal cancer - analysis of 1001 consecutive cases
Fong et al, Annals of Surgery 1999; 230: 309
Nodal status of primary
Disease-free interval from primary to discovery of the livermetastases of < 12 months
Number of tumours > 1
Preoperative CEA level > 200 ng/ml
Size of largest tumour > 5 cm
Overall actuarial survival 37% at 5 years, 22% at 10 years
Clinical Risk Score (CRS) predictive of long term outcome
(p
5/26/2018 Jordanian Surgical Society.ppt Last
59/166
Case No. 155 years old femalemedically freeLeft hemicolectomy 2.5 years ago
-ve nodal status of primary colonic tumourNo chemotherapyLost follow up for two years then came withCEA 150
CT scan
5/26/2018 Jordanian Surgical Society.ppt Last
60/166
5/26/2018 Jordanian Surgical Society.ppt Last
61/166
5/26/2018 Jordanian Surgical Society.ppt Last
62/166
5/26/2018 Jordanian Surgical Society.ppt Last
63/166
5/26/2018 Jordanian Surgical Society.ppt Last
64/166
5/26/2018 Jordanian Surgical Society.ppt Last
65/166
5/26/2018 Jordanian Surgical Society.ppt Last
66/166
5/26/2018 Jordanian Surgical Society.ppt Last
67/166
5/26/2018 Jordanian Surgical Society.ppt Last
68/166
5/26/2018 Jordanian Surgical Society.ppt Last
69/166
5/26/2018 Jordanian Surgical Society.ppt Last
70/166
Ist Right portal vein ligation
5/26/2018 Jordanian Surgical Society.ppt Last
71/166
5/26/2018 Jordanian Surgical Society.ppt Last
72/166
5/26/2018 Jordanian Surgical Society.ppt Last
73/166
5/26/2018 Jordanian Surgical Society.ppt Last
74/166
5/26/2018 Jordanian Surgical Society.ppt Last
75/166
5/26/2018 Jordanian Surgical Society.ppt Last
76/166
5/26/2018 Jordanian Surgical Society.ppt Last
77/166
5/26/2018 Jordanian Surgical Society.ppt Last
78/166
5/26/2018 Jordanian Surgical Society.ppt Last
79/166
5/26/2018 Jordanian Surgical Society.ppt Last
80/166
5/26/2018 Jordanian Surgical Society.ppt Last
81/166
5/26/2018 Jordanian Surgical Society.ppt Last
82/166
5/26/2018 Jordanian Surgical Society.ppt Last
83/166
5/26/2018 Jordanian Surgical Society.ppt Last
84/166
Extended Rt hepatectomy
5/26/2018 Jordanian Surgical Society.ppt Last
85/166
Extended Rt. hepatectomy
5/26/2018 Jordanian Surgical Society.ppt Last
86/166
5/26/2018 Jordanian Surgical Society.ppt Last
87/166
5/26/2018 Jordanian Surgical Society.ppt Last
88/166
5/26/2018 Jordanian Surgical Society.ppt Last
89/166
5/26/2018 Jordanian Surgical Society.ppt Last
90/166
5/26/2018 Jordanian Surgical Society.ppt Last
91/166
5/26/2018 Jordanian Surgical Society.ppt Last
92/166
5/26/2018 Jordanian Surgical Society.ppt Last
93/166
5/26/2018 Jordanian Surgical Society.ppt Last
94/166
5/26/2018 Jordanian Surgical Society.ppt Last
95/166
5/26/2018 Jordanian Surgical Society.ppt Last
96/166
5/26/2018 Jordanian Surgical Society.ppt Last
97/166
5/26/2018 Jordanian Surgical Society.ppt Last
98/166
5/26/2018 Jordanian Surgical Society.ppt Last
99/166
5/26/2018 Jordanian Surgical Society.ppt Last
100/166
5/26/2018 Jordanian Surgical Society.ppt Last
101/166
5/26/2018 Jordanian Surgical Society.ppt Last
102/166
5/26/2018 Jordanian Surgical Society.ppt Last
103/166
Extended Rt. hepatectomy
5/26/2018 Jordanian Surgical Society.ppt Last
104/166
60 years old female, diabetic
Left hemicolectomy one year ago for recto-sigmoidtumour
3 Lymph nodes +veReceived chemotherapy
CEA = 25
CT Scan
5/26/2018 Jordanian Surgical Society.ppt Last
105/166
5/26/2018 Jordanian Surgical Society.ppt Last
106/166
5/26/2018 Jordanian Surgical Society.ppt Last
107/166
5/26/2018 Jordanian Surgical Society.ppt Last
108/166
5/26/2018 Jordanian Surgical Society.ppt Last
109/166
5/26/2018 Jordanian Surgical Society.ppt Last
110/166
5/26/2018 Jordanian Surgical Society.ppt Last
111/166
5/26/2018 Jordanian Surgical Society.ppt Last
112/166
2nd case
5/26/2018 Jordanian Surgical Society.ppt Last
113/166
2 caseExtended Lt. Hepatectomy
LEFT TRISECTIONECTOMY
5/26/2018 Jordanian Surgical Society.ppt Last
114/166
S C O C O
One of the most difficult of the major hepatectomies
Technically hazardous because: Absence of landmarks for the right fissure
Anatomic variations of the right portal structures
Remains a useful technique for: Centrally located tumours
Hilar cholangiocarcinomas with predominant left ductinvolvement
Experience with this technique is rarely reported
5/26/2018 Jordanian Surgical Society.ppt Last
115/166
5/26/2018 Jordanian Surgical Society.ppt Last
116/166
5/26/2018 Jordanian Surgical Society.ppt Last
117/166
5/26/2018 Jordanian Surgical Society.ppt Last
118/166
5/26/2018 Jordanian Surgical Society.ppt Last
119/166
5/26/2018 Jordanian Surgical Society.ppt Last
120/166
5/26/2018 Jordanian Surgical Society.ppt Last
121/166
5/26/2018 Jordanian Surgical Society.ppt Last
122/166
5/26/2018 Jordanian Surgical Society.ppt Last
123/166
Extended Lt. Hepatectomy
5/26/2018 Jordanian Surgical Society.ppt Last
124/166
62 years old male , diabetic , hypertensive
Rt. Hemicolectomy 6 months ago
He received chemotherapy
CEA 14
CT scan
5/26/2018 Jordanian Surgical Society.ppt Last
125/166
5/26/2018 Jordanian Surgical Society.ppt Last
126/166
5/26/2018 Jordanian Surgical Society.ppt Last
127/166
5/26/2018 Jordanian Surgical Society.ppt Last
128/166
5/26/2018 Jordanian Surgical Society.ppt Last
129/166
5/26/2018 Jordanian Surgical Society.ppt Last
130/166
5/26/2018 Jordanian Surgical Society.ppt Last
131/166
3rdCase Resection of
5/26/2018 Jordanian Surgical Society.ppt Last
132/166
Posterior Sector (Seg VI + VII)
5/26/2018 Jordanian Surgical Society.ppt Last
133/166
3rdcase
Posterior Sector (Seg VI and VII)
Resection
5/26/2018 Jordanian Surgical Society.ppt Last
134/166
5/26/2018 Jordanian Surgical Society.ppt Last
135/166
5/26/2018 Jordanian Surgical Society.ppt Last
136/166
5/26/2018 Jordanian Surgical Society.ppt Last
137/166
5/26/2018 Jordanian Surgical Society.ppt Last
138/166
5/26/2018 Jordanian Surgical Society.ppt Last
139/166
5/26/2018 Jordanian Surgical Society.ppt Last
140/166
5/26/2018 Jordanian Surgical Society.ppt Last
141/166
5/26/2018 Jordanian Surgical Society.ppt Last
142/166
Segmental Resection
5/26/2018 Jordanian Surgical Society.ppt Last
143/166
Posterior sector (Seg. VI+VII)
5/26/2018 Jordanian Surgical Society.ppt Last
144/166
58 years old female , diabeticLeft hemicolectomy 8 months ago inPalastine
Developed reco-vaginal fistulaTreated by diversion ileostomy
Referred from west bank for
chemotherapyCEA 25
5/26/2018 Jordanian Surgical Society.ppt Last
145/166
5/26/2018 Jordanian Surgical Society.ppt Last
146/166
5/26/2018 Jordanian Surgical Society.ppt Last
147/166
5/26/2018 Jordanian Surgical Society.ppt Last
148/166
5/26/2018 Jordanian Surgical Society.ppt Last
149/166
5/26/2018 Jordanian Surgical Society.ppt Last
150/166
5/26/2018 Jordanian Surgical Society.ppt Last
151/166
5/26/2018 Jordanian Surgical Society.ppt Last
152/166
5/26/2018 Jordanian Surgical Society.ppt Last
153/166
5/26/2018 Jordanian Surgical Society.ppt Last
154/166
5/26/2018 Jordanian Surgical Society.ppt Last
155/166
5/26/2018 Jordanian Surgical Society.ppt Last
156/166
5/26/2018 Jordanian Surgical Society.ppt Last
157/166
SegmentalResection
(Seg. Vand Seg VI
5/26/2018 Jordanian Surgical Society.ppt Last
158/166
5/26/2018 Jordanian Surgical Society.ppt Last
159/166
5/26/2018 Jordanian Surgical Society.ppt Last
160/166
5/26/2018 Jordanian Surgical Society.ppt Last
161/166
5/26/2018 Jordanian Surgical Society.ppt Last
162/166
5/26/2018 Jordanian Surgical Society.ppt Last
163/166
5/26/2018 Jordanian Surgical Society.ppt Last
164/166
Segmental resection
5/26/2018 Jordanian Surgical Society.ppt Last
165/166
Segmental resection
The best is yet tocome.
5/26/2018 Jordanian Surgical Society.ppt Last
166/166