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Surgical Obstructive Jaundice

What is Surgical Obstructive Jaundice

Obstruction of the bile flow into the duodenum lead to accumultion of bile pigments.As the cause of jaundice is obstruction it is called as obstructive jaundice and as it require surgical intervention it is called as surgical obstructive jaundice

Clinical Features of Surgical Obstructive Jaundice

The most prominent clinical feature which distinguish medical from surgical jaundice is pale stool in surgical jaundice. Because of obstruction bile pigments does not reach up to intestine and stools become pale. Patient complain of itching due to accumulation of bile salts in the blood

Surgical Obstructive Jaundice
Surgical Obstructive Jaundice
Liver Function Tests in Surgical Obstructive Jaundice

Total bilirubin level is raised. It is conjugated type of bilirubin which is raised in obstructive jaudice. Serum alkaline phosphatase level is raised, it indicates there is obstruction in bile passage


Ultrasound is the first investigation to be done as it is non-invasive, no radiation exposure and readily available. Dilatation of Biliary radicles is indicative of obstructive biliopathy. Level of biliary tract dilatation is suggestive of site of obstruction. The most common cause of surgical obstructive jaundice is Common Bile duct stones. In old age patients malignancy can be the cause of  jaundice. Small CBD stones may be missed on Ultrasound.
MRI/MRCP to detect small CBD stones missed on ultrasound. Biliary Anatomy is more defined on MRI.


Vitamin K is administered to correct coagulation profile before any intervention. If patient is in cholangitis proper antibiotic and I.V fluids are administered. Specific treatment depends on the cause of CBD obstruction. The first line of treatment for CBD stones is ERC stone clearance. Surgery is done for malignant cause of jaundice.

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Pseudocyst Pancreas

Pseudocyst Pancreas occur most commonly following acute pancreatitis. It occurs in chronic pancreatitis also. It is fluid collection around peri-pancreatic tissue. Following acute pancreatitis there is disruption in pancreatic duct which causes pancreatic juice to accumulate around pancreas and pseudocyst is formed. It is called as pseudocyst as there is no definitive lining of the cyst

Diagnosis of Pseudocyst Pancreas

Ultrasound is the fist investigation as it is non-invasive and readily available. Ultarsound will detect pseudocyst, its size and relation to surrounding structures. MRI is the investigation of choice to choose the management part. If MRI show that cyst contents are predominantly liquid that endoscopic drainage is done. If there is solid component in the cyst on MRI, then surgical drainage is best


When the pseudocyst compess over the surrounding structures it causes symptoms. Symptoms include pain when pseudocyst increases in size. It causes vomitting when it compress over the stomach and duodenum

Pseudocyst PancreasSurgical Management of Pseudocyst Pancreas

When the contents of the cyst are solid, Surgical management is the treatment of choice. Depending on the location of cyst either cysto-gastrostomy or cysto-jejunostomy is done. Cysto-duodenostomy is rarely done. These surgical procedures are now most commonly done by means of laparoscopy. Advantage of laparoscopy being minimal incision, less pain in the post-operative period and early recovery

Endoscopic Management of Pseudocyst Pancreas

When the cyst content is mainly in liquid form, Endoscopic management is treatment of choice. The most commonly endoscopic procedure performed is endoscopic cysto-gastrostomy

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Cancer Esophagus

Cancer Esophagus Risk Factors

Smoking, alcohol intake, obesity and GERD are common risk factors for cancer esophagus. Smoking and alcohol cause squamous cell carcinoma. Obesity and GERD are risk factors for adenocarcinoma. Healthy life style can prevent esophagus cancer

Cancer Esophagus Symptoms

The most common symptom is dysphagia. Initially it is for solid food and gradually to liquid also. Patient can have chest pain/regurgitation. Anorexia and weight loss are common. Advance cancer patients can have bony pain, abdomen distension due to ascites, respiratory distress due to pulmonary effusion

Cancer Esophagus
Cancer Esophagus
Cancer Esophagus Diagnosis
Upper GI Endoscopy is the investigation of choice. It will show growth or stricture in the esophagus. Biopsy will confirm the diagnosis

Esophagus Cancer Investigations

CECT Chest and upper abdomen is done.CECT will show the growth in the esophagus, its relation with surrounding structures, any associated lymph nodes, and metastases. It stage the tumor

Esophagus Cancer Treatment

The recommended first line Esophagus Cancer Treatment is surgery if cancer is resectable. The standard surgery is radical esophagectomy. when done with thoracoscopic and laparoscopic approach it is called as minimally invasive esophagectomy. For locally advance tumor pre-operative chemotherapy is given.If patient respond to chemotherapy and tumor become resectable surgery is done. For metastatic disease endoscopic esophageal stent is placed for relief of dysphagia

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Gallbladder Cancer Risk Factors

All Cancers have some risk factors. Some can be changed such as alcohol,obesity and smoking. Some cannot be changed like family history and age. Most of the gallbladder cancer risk factors are non-modifiable. Having a risk factor does not indicate that definitely patient will get cancer and few patients develop cancer without any risk factor
But definetly presence of risk factors increases the chances of getting cancer. Various gallbladder cancer risk factors have been identified

Gallstones: Common Among various Gallbladder Cancer Risk Factors

Among many gallbladder cancer risk factors one is gallbladder stones. More than 70% of patients with gallbladder cancer have gallstones when they’re diagnosed.The incidence of gallbladder cancer is rare as compared to gallstones as most patients with gallbladder stones will never have gallbladder cancer

Porcelain gallbladder

It is a condition where gallbladder wall is covered with deposits of calcium.Can occur after chronic cholecystitis or long term inflammation of the gallbladder

Female gender

The incidence of gallbladder cancer is more in females as compared to men.It may be correlated with increased incidence of gallstones and inflammation in the gallbladder in females

Gallbladder Cancer Risk Factors
Gallbladder Cancer Risk Factors


It has been found that gallbladder cancer patients are obese or overweight. Gallstones are also more common in obese patients which may also explain the high risk for gallbladder cancer in these patients

Older age

As most cancer develop in old age same with gallbladder cancer.But incidence is increasing in young population also. In this age group it has been found that gallbladder cancer is more aggressive. Reason may be dietary and life style change

Ethnicity and geography

Worldwide, Incidence of gallbladder cancer is more in Central America, Pakistan and India. In India it is more common in North as compared to south

Choledochal cysts

These are cystic dilatation of biliary channels which are congenital

Gallbladder polyps

The incidence of Gallbladder cancer is more in gallbladder polyps which are more than 1cm in size, single polyp and sessile

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Gallbladder Surgery Complications

Most common abdominal surgery is Gallbladder Surgery. Mostly it is done laparoscopically called as laparoscopic cholecystectomy. Most common indications is symptomatic gallbladder stone disease. The incidence of complications of laparoscopic cholecystectomy has decreased. Following are the complications of gallbladder surgery


It occur due to injury to blood vessels during gallbladder surgery. Whenever there is bleeding intra-operatively dont be panic.First step should be applying pressure at the bleeding site. Small venous injury stops after packing only. Field should be cleared and after proper visualization bleeding point should be identified and either cauterized or clipped should be applied. Do not hesitate to convert to open surgery if bleeding is not controlled laparoscopically

gallbladder surgery complications
Gallbladder surgery complications
Bile duct Injury

The incidence of bile duct injury in gallbladder surgery has been decreased after the learning curve of laparoscopic surgery. It occur in difficult cases with dense adhesions at gallbladder fossa.In such cases it should be converted to open surgery. Dissection should be done close to the gallbladder.Intra-operatively whenever there is doubt of bile duct injury convert to open. If injury cannot be managed then put a drain and refer the patient to higher centre

Injury to Bowel

Bowel gets adhered to gallbladder fossa due to recurrent inflammation. Pylorus and duodenum are most commonly injured organs. Hepatic flexure is another common site of injury. In post-op period if recovery is not smooth and Common Bile duct is normal a high suspicious of bowel injury should be suspected and CECT abdomen should be done

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Treatment of Stomach Cancer

The treatment of stomach cancer is successfull if diagnosed and treated at early stage. However more than 50% of stomach cancer when proceed for surgery are found to be metastatic. Most of the early symptoms of stomach or gastric cancer are non-specific and are overlooked

Curative Surgical Treatment of Stomach Cancer

The standard curative treatment of stomach cancer is surgery if patient if fit for surgery and cancer is resectable. Patients factors which are responsible for good recovery in the post-op period include nutrition and ambulatory level. Patient nutrition and chest functions are good recovery is easy.
Staging laparoscopy is the first step in the surgery before definitive curative surgery is planned in case of open surgery. Staging laparoscopy helps in identification of metastases which are missed on CT Scan and PET Scan. No resection is done in case of metastatic disease unless tumor is bleeding. Radical gastrectomy is done. Depending on the location of tumor radical distal gastrectomy or radical sub-total gastrectomy or radical total gastrectomy is done. At least 12 lymph nodes should be dissected in the resected specimen for completeness of lymphadenectomy
Radical gastrectomy can be done laparoscopically. Today we have enough evidence in the literature which support laparoscopic surgery in the abdominal malignancy. Laparoscopy surgery has the advantage of less pain and early recovery

Treatment of Stomach CancerPalliative Surgical Treatment of Stomach Cancer

If the stomach cancer is unresectable because either it is locally advance involving major blood vessels or it is metastatic then patient require some definitive therapy for palliation of there symptoms. If the tumor is bleeding and not controlled endoscopically or radiologically then palliative resection is done

Palliative Endoscopic Treatment of Stomach Cancer

If the stomach cancer is metastatic best method for palliation of symptoms is by means of endoscopy. The most common symptom that require palliation is vomitting, Endoscopically metallic stent is placed across the site of obstruction

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Treatment of Colon Cancer

The recommended treatment of colon cancer is surgery. Colon cancer is one of the gastrointestinal cancer in which surgery carries a very good prognosis. Patient should be fit for surgery and cancer should be resectable. Recent studies suggest that no bowel preparation is required before surgery.Patient should be on clear liquid diet one day prior to surgery

Curative Surgical Treatment of Colon Cancer

The standard surgical treatment of colon cancer is radical colectomy. Colon is divided into four parts, ascending or right colon, transverse colon, descending or left colon and sigmoid colon. Depending on location of cancer respective colectomy is done. After colonic resection depending on patient nutrition status and tumor burden either anastomosis is done or stoma is created. Minimal 12 lymph nodes is the criteria for adequate lymadenectomy for colon canecr has been recommended. If the number of lymph nodes resected is less than 12 then the patient need adjuvant chemotherapy irrespective of staging on histopathology report
Colon cancers are being operated more frequently laparoscopically by Laparoscopic colo-rectal surgeon. The length of incision in laparoscopic surgery is very minimum as compared to open surgery. Minimal incision cause less pain in the post-op period, allow early mobilization of patient and early recovery

Treatment of Colon Cancer
Treatment of Colon Cancer

Palliative Surgical Treatment of Colon Cancer

Palliative surgery is done for multiple site metastatic disease.The two most common symptoms for which palliation is required is large bowel obstruction and bleeding. Right or ascending colon have a tendency to bleed. Left or descending colon because diameter is less compared to right colon causes obstruction. For patients who present with large bowel obstruction depending on tumor burden and patient nutrition status either bypass is done or stoma is created. For bleeding tumors resection is done and attendants are counselled for high risk surgery

Role of Chemo-Radiotherapy in Treatment of Colon Cancer

Colon cancer are less sensitive to chemo-radiotherapy thats why its role is minimal in the management of colon cancer

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Stomach Cancer Symptoms Diagnosis

Stomach cancer or gastric cancer is the fifth most common cancer worldwide but it is the third leading cause of cancer-related deaths. Most stomach cancer are diagnosed at advanced or metastatic stage as most patient do not seek medical advice at initial symptoms

Symptoms of stomach cancer

Most common early symptoms are non-specific and includes dyspepsia, bloating,fullness, pain abdomen. Stomach cancer have a tendency for bleed, bleed is generally slow and patient passes black colored stool and develop anemia. Because of this slow bleed patient may have symptoms of anemia like tiredeness, weakness, Anorexia and weight loss are common as in other cancer
When the cancer is located at antro-pyloric region it will cause vomitting

Stomach Cancer
Stomach Cancer

Diagnosis of Stomach Cancer

When patient present with non-specific upper GI symptoms at old age associated with anorexia and weight loss first investigation to be done is upper GI endoscopy. It will detect any mass lesion or ulcer in the stomach. Biopsy should be taken from any suspicious lesion. Biopsy confirms the diagnosis. Most common stomach cancer is adenocarcinoma


Once diagnosis is confirmed and patient is fit for surgery further investigations should be done for resectability of cancer, CECT abdomen is the ideal for staging the disease. It will detect distant metastases and relation of cancer to surrounding structures. PET scan should be done in patients who are high risk for surgery as it detect some occult metastases which are missed on CT Scan

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Treatment of Gallbladder Cancer

The main stay of treatment of gallbladder cancer is surgery. In Northern part of India the incidence of gallbladder cancer is more as compared to southern part. Because of non-specific symptoms and signs of gallbladder cancer it is diagnosed at very late stage. Because of such high incidence of late diagnosis it carries a very bad prognosis

Curative Surgical Treatment of GallBladder Cancer

On Investigations when gallbladder cancer is found to be resectable and patient being fit for surgery, standard gallbladder cancer surgery is planned. Surgery for gallbladder cancer is radical cholecystectomy. In radical cholecystectomy gallbladder is removed along with the gallbladder liver wedge along with lymph nodes.
Staging laparoscopy is the first step before opening the abdomen. The chances to identify metastases which are missed on CECT abdomen or PET scan is high in case of gallbladder cancer. If any suspicious lesion is identified on staging laparoscopy it is sent for frozen biopsy and if found to be mets then there is no need to proceed for defintive surgery and morbidity of long length incision is avoided

Treatment of Gallbladder Cancer
Treatment of Gallbladder Cancer

Palliative Surgical Treatment of Gallbladder Cancer

Gallbladder cancer can involve gastric antrum or duodenum and cause vomitting. In such cases palliative gastro-jejunostomy is done. It can also involve hepatic flexure of colon and cause large bowel obstruction. Some patient present in emergency with features of large bowel obstruction. In such cases either ileo-colic bypass is done or stoma is created depending on patient nutrition status.

Palliative Endoscopic Treatment of Gallbladder Cancer

The gallbladder cancer patients which are found to be metastatic before surgery and are locally advanced in which resection is not possible are candidates for endoscopic palliation of there symptoms. Most commonly these symptoms include jaundice and vomitting. Jaundice can be relieved by endoscopic biliary stent placement. If there is complete biliary obstruction then percutaneous transhepatic biliary drainage is done

Consult Dr Amit Jain MS MCh Best Surgical Oncologist in Delhi Noida Ghaziabad NCR who is trained in Laparoscopic GI Oncosurgery at GB Pant Hospital Delhi. Fellowship in Advance Laparoscopic Surgery

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Laparoscopic Cholecystectomy

Indication for Laparoscopic Cholecystectomy

The most common indication for laparoscopic cholecystectomy is gallbladder stone disease or gallstone. Not all gallstone disease require surgery. It is only symptomatic one which require surgery. Gallstone disease may lead to biliary colic, acute cholecystitis or chronic cholecystitis. Porcelain gallbladder which is a risk factor for gallbladder cancer is also an indication for laparoscopic cholecystectomy

Patient Preparation

As it is an elective procedure all routine lab investigations are done. Pt require Chest-X ray and ECG. Pre-Anesthetic check up is done. Patient require fasting for 6hr before surgery. Avoid hypogylcemic drug on day of surgery. Continue anti-hypertensive drug and thyroxine tablet on day of surgery with sips of water

Laparoscopic Cholecystectomy
Gallbladder stone treatment

Surgical Procedure

Done mostly through four ports, but if there are no so much adhesions it can be done through four ports.Camera port is inserted. Under vision other ports are placed. Adhesionolysis is done if present. Cystic duct and artery dissected, clipped and divided.Gallbladder is dissected out. Gallbladder is extracted. Bile and stone spillage is avoided

Post-op Recovery after Laparoscopic cholecystectomy

Patient is allowed orally four hrs after surgery, starting from liquids and gradually increased to normal diet. Patient is encouraged to walk

Diet after Laparoscopic Cholecystectomy

Generally it is advised to avoid excessive fat in the dist for 2-3 months post surgery. After that patient can have normal diet

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