Notes by dr Claudio Italiano
Neoplastic obstructive jaundice (see pancreatic cancer and papillary cancer of
Vater's cancer of the biliary tract) only rarely can be treated surgically with
intent of oncological radicality since the etiologic diagnosis of biliary
obstruction (see also biliary calculosis) comes almost always placed when the
disease is no longer localized but has spread, both locally and remotely.
In recent times, probably due to the improved diagnostic capacity of jaundice
imaging, the comparison of periampollar neoplasms has increased, recognizing the
most frequent tumor (80-85%) in the carcinoma of the pancreas head and a more
unfavorable prognosis.
The toxic-septic condition from cholestatic jaundice synergizes unfavorably with the frequent finding of expired general patient conditions due to neoplastic disease and any geriatric age. The duodenocefalopancreasectomy, a radical surgical operation common to all periampollar neoplasms, can be performed in a small number of patients (15-25% of pancreatic head tumors, 50% of the remaining locations.) Palliative therapy for endoscopic lesions is indicated in the reason that, in fact, only 10-30% of pancreatic cancer, diagnosed in the symptomatic phase, is resectable and the 5-year survival of resected patients does not exceed 0.4%, few cholangiocarcinomas of the proximal third of the Main Biliary Path (VBP) they can be attacked surgically, metastatic hepatic tumors are considered by definition to be unresectable It is also to be remembered that the demolition interventions are difficult to perform, are burdened by postoperative complications responsible for a mortality of 5-10% and 5 to 90 years after surgery, 80% to 90% of the neoplasms relapse.
Making a diagnosis of neoplastic diseases responsible for pre-icteric bile
stenosis is a purely incidental event. As a rule, the diagnostic suspicion
arises in the presence of a progressive cholestatic jaundice, almost always
painless, which frequently is associated with intense itching. In cases where
the stenosis is supported by a papillary neoplasm, the jaundice may be
intermittent and may be accompanied by fever; anemia or bleeding may occur due
to ulceration of the neoplastic mass.
A
moderate hepatomegaly is commonly seen on the physical examination and, in
patients in whom the neoplasm is located below the cystic outlet, the distended
gallbladder can be palpated. The biohumoral parameters are characterized by an
increase in bilirubinemia values, mainly of the conjugated one, of the alkaline
phosphatase, of the gamma-GT and to a lesser extent of the transaminases (see
cholestasis indices). If the anamnesis, the clinical examination and the
laboratory investigations, advance the hypothesis of a biliary obstruction, are
the instrumental diagnostic techniques that will allow to confirm or exclude the presence of the obstruction,
to establish its location and nature. At the same time, diagnostic imaging will
verify the resectability or not of the neoplasm. The choice of investigations to
be used depends on the presumed location of the obstruction and, as regards the
method, on the degree of invasiveness and diagnostic accuracy, on the percentage
of complications related to it and on the ability to simultaneously perform any
therapeutic treatment.
Trans-parietal ultrasound
It is the investigation commonly performed in the first instance in the presence
of a painless jaundice. The method highlights the dilatation of the VBP and the
site of the stenosis. It can hardly differentiate a neoplasm of the distal part
of the choledochus from a pancreatic neoplasm or to evaluate the neoplastic
involvement of the vessels and adjacent structures. The main advantages of
trans-parietal ultrasound are the non-invasiveness, the contained costs, the
possibility to transport the instrumentation. The disadvantages are related to
reduced accuracy, in the presence of fat or intestinal gas, and to the
difficulty in visualizing small pancreatic neoplasms; it is also an
operator-employee survey. Recent developments such as Color-Doppler, harmonic
tissue images, the use of contrast media, 3 D reconstruction have elevated the
diagnostic capabilities of the methodology in highly specialized centers.