Dr. Harshal Rajekar MS MRCS DNBHepatobiliary, GI and transplant Surgeon,

Pune

The myth• 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 massive loss of

substance, and is able, in many ways, to forgive 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.Why?

Complex physiology.Medical intricacies.Blood loss, vascularity and portal

hemodynamics.Anatomical complexities.Difficult to access.

So… whats new?Many advances in the last 2 decades.

Liver surgery.Liver failure and liver transplantation.Portal hypertension.Cholangiocarcinoma.Liver metastases.Pancreatitis – acute and chronic.Biliary tract disorders.

Liver TumoursIncidentally 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.Tumor markers.Imaging.

Most of the time biopsy is not required!

Algorithm for Solitary SOL of Liver on USG

Solid lesions with malignant potential

Liver resection: 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.

CommentsLiver functional reserve and liver remnant volumePrecise delineation of vascular relations using CT

angiography and volumetryThe 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:

Feasible.Easily done procedures – left lateral

segmentectomy, exophytic tumours, pedunculated tumors.

CUSA/ staplers.Problems: -

ExposureBleedingRetraction and instrumentation.Retrieval.

Pushing the limits128 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 a synchronous 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?

Portal Hypertension:

2 types of portal hypertension: cirrhotic and non- cirrhotic.

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 similar

presentation and comparable prognosis.

Khanna R, Sarin SK. Non-cirrhotic portal hypertension - Diagnosis and management. J Hepatol. 2013 Aug 23.

Surgery for portal hypertension:Zentralbl Chir. 2010 Jun;130(3):238-45.

Surgical treatment of portal hypertension.

Wolff M, Hirner A. Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefässchirurgie, Rheinische Friedrich-Wilhelms Universität, Bonn.

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.

Arch Surg. 2007 Jan;136(1):17-20.Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients: a case-control comparison.Helton WS, et al. Providence Seattle Medical Center, USA.

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 surgical shunt.

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.

Indian J Gastroenterol. 2005 Nov-Dec;24(6):239-42.Prophylactic surgery in non-cirrhotic portal fibrosis:is it worthwhile?Pal S, Radhakrishna P, Sahni P, Nundy S, Chattopadhyay TK.Department of GI Surgery, AIIMS, New Delhi

INDIAN SCENARIO: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.

Liver failure

2 types of liver failure:Acute : fulminant liver failure – reversible or

irreversible.Irreversible FHF qualifies for a transplant

Chronic : i.e. cirrhosisDecompensated cirrhosis, or cirrhosis with

cancer and in patients with PSC, quality of life indicators

ACUTE LIVER FAILUREIndian J Crit Care Med. 2012 Jan;16(1):1-7. Structured approach to treat patients with acute liver failure:

A hepatic emergency. Kumar R, Bhatia V. Department of Hepatology, ILBS Delhi.

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.

Fulminant liver failureKings College criteria

Clichy criteria.

PGIMER (Chandigarh) criteria.

Acute Liver Failure (irrespective of etiology) • Contact transplant team when INR is >2.

End-stage Chronic Liver Disease.Refer to transplant team when

• Child-Pugh score reaches >6 points. OR

• At first decompensation with ascites, encephalopathy, variceal bleeding or jaundice

OR • At diagnosis of HCC in cirrhosis, provided the Milan

criteria are met. OR

• Impairment of quality of life due to liver disease becomes intolerable (intractable pruritus, invalidating fatigue

and/or performance status).

What's new?

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.

Transplanation for HCC

Milan criteria.UCSF criteria.Asan criteria.Rule of 7.Japanaese liver tumor study group criteria.

Transplantation superior to surgical excision in patients with cirrhosis. Surgery is better than RFA, which is better than TACE.

RFA and TACEIs 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 liverChild’s B group, RFA and surgical resection similar

survival, therefore they should be transplantedNot 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.

(Vivarelli et al, Annals of Surg)

PancreatitisAcute.

Alcohol.Gall stone.

Role of surgery – Necrosectomy;Complications of acute pancreatitis.

Chronic.

Intervention in acute pancreatitisInfected necrosis, pancreatic abcess, infected

peri-pancreatic collections.Bleeding.

May be laparoscopically OR retroperitoneoscopic, endoscopic.

Severity of disease,Multi-organ failureFluid collections.

ARE NOT INDICATIONS FOR SURGERY OR INTERVENTION!!

Acute pancreatitisWe 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.

CONCLUSIONS: 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.

Ann Surg. 2013 Apr;257(4):737-50.Predictors of surgery in patients with severe acute pancreatitis

managed by the step-up approach.Babu RY, et al. PGIMER, Chandigarh

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.

Chronic pancreatitisWhom to evaluate?Recurrent pancreatitis.Unexplained pancreatitis.Pancreatic calcification/ stones.Dilated MPD.Pancreatic pain.

Classical triad:Pain (radiating to back0.Recurrent attacks of

pancreatitis.Diabetes.

Weight loss.Stones.

Surgical options in chronic pancreatitisPancreaticojejunostomy (Partington-Rochelle) Drainage and resection of pancreatic tail (Puestow-

Mercadier) Left resection of the pancreas with retrograde

pancreaticojejunostomy (Duval) Extended drainage with limited excision of the pancreatic

head (Frey) Customized cephalic and longitudinal ductal drainage

(Hamburg) Duodenum-preserving resection of the pancreatic head

(Beger) Pylorus-preserving partial duodenopancreatectomy

(Whipple) Total pancreatectomy

J Gastrointest Surg. 2000 Jul-Aug;4(4):355-64.

Quality of life and long-term survival after surgery for chronic pancreatitis.

Sohn TA, et al. The Johns Hopkins Medical Institutions, BaltimorePatients reported improvements in all aspects of the quality-of-life survey

including enjoyment out of life, satisfaction with life, pain, number of hospitalizations, feelings of usefulness, and overall health (P < 0.005).

In addition to improved quality of life after surgery, narcotic use was decreased (41% vs. 21%, P < 0.01) and alcohol use was decreased (59% vs. 33%.

These data suggest that surgery for patients with chronic pancreatitis can be performed safely with minimal morbidity and excellent long-term survival.

CholangiocarcinomaHilar Cholangiocarcinoma – complex disease

Proximity to large vessels.Difficult to get margins.

Klatskin tumors – even more difficult.Liver resection is must for adequate

clearance.

Annals of Surgery. 240(1):95-101, July 2004. Kondo, Satoshi et al; Hokkaido University Graduate School of Medicine, Japan.Forty Consecutive Resections of Hilar Cholangiocarcinoma With No Postoperative Mortality and No Positive Ductal Margins: Results of a Prospective Study

Results: Hospital or 30-day mortality and morbidity rates were 0% and 48%, respectively. The overall 3-year survival rate and median survival time were 40% and 27 months. Survival of patients with Bismuth type III or IV tumors or of patients who underwent right hepatectomy was significantly better. Survival of patients who underwent concomitant vascular resection was similar to survival of those who did not. Univariate analysis indicated the type of hepatectomy, histopathologic grade, Bismuth classification, concomitant hepatic artery resection, and International Union Against Cancer stage as significant prognostic factors.

Preoperative biliary decompressionPortal vein embolizationNo positive ductal margins

Acta Gastroenterol Latinoam. 2012 Dec;42(4):291-300.

Surgical resection with curative intent of hilar cholangiocarcinoma. Our experience.

Vaccarezza H, Ardiles V, et al. Hospital Italiano de Buenos Aires, Argentina.

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.

Associated vascular resection seems to be a feasible and safe option in the treatment of locally advanced disease.

What's Hot ?Preoperative biliary decompressionIntraarterial chemotherapy for colorectal

metsPVE alone without TACE in HCCWait, wait, wait for biliary fistulaLiver transplant for metastatic cancer.TIPS – covered stents….?