HPB Surgery by -Dr Harshal RajekarDr.Harshal Rajekar
- Prometheus enraged the Gods after climbing the Mount Olympus and stealing the torch in order to give fire to the humans.
- He was punished by Zeus and chained to a rock in the Kaukasus Mountains. Every couple of days, an eagle came and ate part of his liver.
- As the liver regenerated every time, the eagle returned, again and again, to eat the liver and thereby torture poor Prometheus.
Longmire, called it a “hostile” organ because it welcomes malignant cells and sepsis so warmly, bleeds so copiously, and is often the 1st organ to be injured in blunt abdominal trauma.
Yet, the liver is able to regenerate after massiveloss of substance, and is able, in many ways, to forgive the insult.
Liver surgery started in the early 1900s. In the beginning, however, blood loss and mortality were considerable.
A multicentre analysis in 1977 of more than 600 hepatic resections for various indications showed an operative mortality of 13%, which rose to 20% for major resections
What is HPB and why is it special?
HPB – separate specialty.
Blood loss, vascularity and portal hemodynamics.
Difficult to access.
So… what’s new?
Many advances in the last 2 decades.
Liver surgery, Liver failure, and liver transplantation, Portal hypertension, Surgery for Cholangiocarcinoma.
Pancreatitis – acute and chronic.
Biliary tract disorders.
Incidentally detected mass lesion/ SOL in the liver:
What to do……..?
Clinical history …. h/o liver disease, cirrhosis, previous malignancy? HBV, HCV?
Other symptoms and medications…. i.e. jaundice, pain, weight loss, drugs like OCPs.
Most of the time biopsy is not required!
Solid lesions with malignant potential
J Am Coll Surg. 2010 Oct;211(4):443-9. Epub 2010 Aug 8. Perioperative management of hepatic resection toward zero mortality and morbidity: analysis of 793 consecutive cases in a single institution. Kamiyama T, Nakanishi K, Yokoo H, Kamachi H, Tahara M, Yamashita K, Taniguchi M, Shimamura T, Matsushita M, Todo S.
Hokkaido University, Sapporo, Japan.
- CONCLUSIONS: Shorter operative times and reduced blood loss were obtained by
- Improved surgical technique and
- New surgical devices and
- Intra-operative management, including anesthesia.
Liver functional reserve and liver remnant volume
Precise delineation of vascular relations using CT angiography and volumetry The independent relative risk for morbidity was influenced by an operative time >360 minutes, blood loss of more than 400 mL, and serum albumin levels of less than 3.5 g/dL.
Assessment of liver reserve.
Hepatic resection can be undertaken safely, and increasing experience as a hepatic surgeon is associated with greater utilization of parenchymal sparing and extended resections.
Laparoscopic liver surgery:
Easily done procedures – left lateral segmentectomy, exophytic tumors, pedunculated tumors.
CUSA/ staplers. Laparoscopic liver surgery is available at Inamdar hospital.
Pushing the limits – Extended hepatectomy
128 patients underwent extended hepatectomy for malignant diseases (n =15; 11.5%). Thirty-two left and ninety-five right extended hepatectomies were performed. Eight patients also underwent caudate lobe resection, and 40 patients underwent a synchronous intraabdominal procedure. Multivariate analysis showed that asynchronous intraabdominal procedure was the only factor associated with an increased risk of morbidity (hazard ratio [HR], 4.9; P = 0.02). The median survival was 41.9 months. The overall 5-year survival rate was 25.5%.
Annals of Surgery. 239(5):722-732, May 2004. Vauthey, Jean-Nicolas University of Texas M.D. Anderson Cancer Center, Houston, TX. Is Extended Hepatectomy for Hepatobiliary Malignancy Justified?
2 types of portal hypertension:
In NCPF, liver function is well preserved. Other problems with NCPF include UGIB, hypersplenism, splenomegaly, ectopic varices.
Rare problems with NCPF: Portopulmonary hypertension, Hepatopulmonary syndrome and more often portal biliopathy.
Whom to operate and when?
Surgical shunts are indicated in patients with failure of endotherapy, ectopic varices, symptomatic hypersplenism or symptomatic biliopathy. Persistent growth failure, impaired quality of life or massive splenomegaly that interferes with daily activities are other surgical indications.
Rex-shunt / MLPVB is the recommended shunt for EHPVO.
NCPF, Hepatic schistosomiasis, CHF and NRH have similarpresentation and comparable prognosis.
Surgical shunt procedures continue to be safe, highly effective and durable procedures to control variceal bleeding in patients with good liver function.
For patients with noncirrhotic portal hypertension, esp. EHPVO, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years and improves hypersplenism without deteriorating liver function.
Surgery for portal hypertension, i.e. porto-systemic shunt surgery and devascularization procedures are commonly done at Inamdar Hospital.
PLACE OF SHUNT SURGERY IN CLINICAL PRACTICE:
- Operative portal decompression is more effective, more durable, and less costly than TIPS in Child-Pugh class A and B cirrhotic patients with variceal bleeding.
- Good-risk patients with portal hypertensive bleeding should be referred for surgicalshunt.
- Shunt surgery is an important treatment for noncompliant patients or patients living in areas where access to TIPS, repeated hospitalization, and liver transplantation, is limited. It is safe and effective.
In patients with high-risk esophagogastric varices or symptomatic splenomegaly and hypersplenism,
Patients with high-risk esophagogastric varices or symptomatic splenomegaly and hypersplenism.
Patients with other complications of portal hypertension.
Patients with poor access to prompt healthcare.
2 types of liver failure:
Acute: fulminant liver failure – reversible or irreversible.
Irreversible FHF qualifies for a transplant
Chronic: i.e. cirrhosis
Decompensated cirrhosis, or cirrhosis with cancer and in patients with PSC, quality of life indicators
ACUTE LIVER FAILURE
Acute liver failure (ALF) is a condition of acute hepatic emergency where rapid deterioration of hepatocyte function leads to hepatic encephalopathy, coagulopathy, cerebral edema (CE), infection and multi-organ dysfunction syndrome resulting in a high mortality rate. Urgent liver transplantation is the standard of care for most of these patients.
Kings College criteria/ Clichy criteria./ PGIMER (Chandigarh) criteria.
Acute Liver Failure (irrespective of etiology)
- Contact transplantteam when INR is >2.
End-stage Chronic Liver Disease.
Refer to the transplant team when
- Child-Pugh score reaches >6 points.
- At first decompensation with ascites, encephalopathy, variceal bleeding or jaundice
- At diagnosis of HCC in cirrhosis, provided the Milan criteria are met.
- Impairment of quality of life due to liver disease becomes intolerable (intractable pruritus, invalidating fatigue and/or performance status).
- Acute liver failure (ALF) is a disease with a high mortality
- Standard therapy at present is liver transplantation.
- Liver transplantation is hampered by the increasing shortage of organ donors,
- Bioartificial liver therapy for bridging patients with ALF to liver transplantation or liver regeneration is promising.
- Its clinical value awaits further improvement of BAL devices, replacement of hepatocytes of animal origin by human hepatocytes, and assessment in controlled clinical trials.
Transplantation superior to surgical excision in patients with cirrhosis. Surgery is better than RFA, which is better than TACE.
RFA and TACE
Is RFA stand alone treatment for HCC?
Complete response rate only 55% (63% for <3 cm)
> 3 cm in size and > 1 year wait for OLTx
High rate of recurrence in explanted liver
Child’s B group, RFA and surgical resection similar survival, therefore they should be transplanted
RFA is not an independent therapy for HCC!
Surgical Resection Versus Percutaneous Radiofrequency Ablation in the Treatment of Hepatocellular Carcinoma on Cirrhotic Liver.
One- and 3-year survival were 78 and 33%; 1- and 3-year disease-free survival were 60 and 20%.
The advantage of surgery was more evident for Child-Pugh class A patients and for single tumors of more than 3 cm in diameter.
Severity of disease, Multi-organ failure, Fluid collections.
ARE NOT INDICATIONS FOR SURGERY OR INTERVENTION!!
We studied 70 consecutive patients with SAP (severe acute panc) with no mortality, 14 were managed medically, 29 managed with PCD alone, whereas 27 required surgery after initial PCD.
PCD reversed sepsis in 62% and avoided surgery in 48% of the patients. Reversal of sepsis within a week of PCD, APACHE II score at first intervention (PCD), and organ failure within a week of the onset of disease could predict the need for surgery in the early course of disease.
ERCP should be considered in patients with co-existing cholangitis or biliary obstruction. However, in patients with acute gallstone pancreatitis, there is no evidence that early routine ERCP significantly affects mortality, and local or systemic complications of pancreatitis, regardless of predicted severity. (when there is no biliary obstruction or cholangitis)
Cholecystectomy should be delayed in patients who survive an episode of moderate to severe acute biliary pancreatitis and demonstrate peripancreatic fluid collections or pseudocysts until the pseudocysts either resolve or persist beyond 6 weeks, at which time pseudocyst drainage can safely be combined with cholecystectomy.
Surgery is required in patients with:
Pancreatic calcification/ stones, Dilated MPD, Pancreatic pain.
Pain (radiating to back0.
Recurrent attacks of pancreatitis.
Multiple surgical options are available at Inamdar hospital for treatment in chronic pancreatitis (pancreatic stones).
Hilar Cholangiocarcinoma – complex disease
Proximity to large vessels.
Difficult to get margins.
Klatskin tumors – even more difficult.
Liver resection is mustfor adequate clearance.
The association of major hepatectomy with caudate lobe resection and vascular resection when needed was associated with 95% tumor-free margin and morbidity and mortality rate according to the standards of the international literature. Inamdar hospital provides specialized treatment for cholangiocarcinoma and gallbladder cancer.
Associated vascular resection seems to be a feasible and safe option in the treatment of locally advanced disease.
Dr Harshal Rajekar
MBBS MS MRCS DNB
+91 992 307 8668