RESUMO
Abstract: Malignant Obstructive Jaundice can be due to proximal hilar obstruction [Cholangiocarcinoma] and carcinoma [CA]. gall bladder. Distal biliary obstruction can result from distal cholangiocarcinoma or tumors of pancreatic head, periampullary region, duodenum and rarely from tumors of stomach and retroperitoneum. The study was under taken to see prevalence of various malignant causes of biliary tract obstruction and evaluate the role of preoperative biliary drainage on post operative outcome
Patients and Methods: Retrospective study of 109 patients conducted between July, 2001 to July, 2008. Preoperative workup included history, physical examination and routine investigations. Ultrasound, computerized tomography [CT scan], Magnetic Resonance Cholangiopancreaticography [MRCP] were used to diagnose level of obstruction. Endoscopic retrograde cholangiopancreaticography [ERCP] was done to diagnose, take biopsies and to do therapeutic stenting to achieve biliary decompression after coagulation profile has been corrected by vitamin K and Fresh Frozen Plasma [FFP]. Treatment of proximal obstruction aimed at resection of tumor and CBD and gall bladder and internal drainage by Roux-en-Y hepaticojejunostomy if operable if not operable external drainage was done. Malignant distal obstruction was relieved by Kaush and Whipple's procedure, if operable, Bypass surgery was done if not operable
Results: There were 61 male patients and 48 female M:F ratio is 1.7: 1. and mean age 53 years. Main presenting symptoms were jaundice 100%, weight loss 58%, pruritis 53%, abdominal pain 41 %, fever 29% palpable mass 21 % respectively. Mean bilirubin was 18.1 mg/di. Mean Alkaline Phosphatase was 1119 IU/dl. The predominant pathology causing proximal malignant obstruction was hilar cholangiocarcinoma n=33 [30%], CA gall bladder n= l3 [12%] malignant distal obstruction was mainly caused by pancreatic head cancer in 44 patients [40%], pancreatic body tumor 2 [1.8%]. Periampullary tumors 13 patients [12%] and duodenal cancers 2 patients [1.8%] and retroperitoneal lymphoma in 2 patients [1.8%]. Preoperative biliary stenting was done in 24 patients 22% 18 by ERCP and six by percutaneous route. The main complications were wound infection 21 %, abdominal collection 21 % cholangitis 15% and respiratory complications 13%. 13 patients died due to various reasons. [12%]
Conclusions: Commonest malignancy causing proximal biliary obstruction is hilar cholangiocarcinoma. Pancreatic head cancer is the most common distal malignancy. Preoperative Biliary stenting endoscopic/percutaneous is associated with increased operative difficulty and post op. problems we don't recommend it, except in the very sick and inoperable patients