1. Advances in Hepatobiliary Surgery Jack Matyas, MD, FACS & Keith Nichols, MD, FACS

5. Presenting Symptoms Jaundice Weight Loss Pruritus Steatorrhea Clay-Colored Stool

6. Work-up 1980

7. CT Criterion for Resectability Mass < 2cm No mass No stone “Double duct sign” No enlarged nodes No ascites No vessel involvement No liver lesions

9. CT Criteria for Unresectability Absolute –Liver mets – Bx proven –Portal vein thrombosis –SMA or coeliac encasement –Necrotic lymph nodes – Bx proven

10. Unresectable Bypass Biliary stent 5 FU/XRT– locally advanced Gemzar (Gemcitabine) - systemic

11. CT Scan Relative contraindications –Ascites –Loss of portal vein fat plane –Enlarged L. nodes –Liver lesions not classic for metastasis

12. Ascites Laparoscopy with cytology and biopsy suspicious lesions Omentum - Liver

13. Liver Lesions CT guided biopsy MRI Laparoscopy

14. CT Scan Relative contraindications –Ascites –Loss of portal vein fat plane –Enlarged L. nodes –Liver lesions not classic for metastasis

19. Summary 1.Adenocarcinoma involving the distal bile duct continues to have an overall poor prognosis. 2.Through aggressive “high tech” preoperative work-up, a select group of patients will enjoy surgical benefit. 3.High volume institutions like Riverside maintain an acceptable <5% mortality. Low volume institutions have 5-6x greater morbidity and mortality. 4.Transduodenal/Transhepatic wall stents have replaced cumbersome unsatisfactory internal bypass.

20. Summary (cont.) 5.5FU/XRT provides reasonable palliation for locally advanced tumors avoiding unnecessary laparotomy. 6.Gemcitibine has low toxicity and can provide short term palliation in cases of systemic metastasis. 7.EVS has opened new doors for pre-op staging and better direction for cystic pancreatic neoplasms.

22. 2007 History Physical Ultrasound – dilated vs. non-dilated CT scan – pancreatic protocol ~ 60% unresectable by CT scan 40% further studies

23. Summary 80% 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

24. Summary High 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.

25. Enlarged Lymph Nodes EV5 endoscopic ultrasound with biopsy

26. Loss of Portal Vein Fat Plane EV5 MRI Angiogram with venous phase