ADVANCES IN HEPATO-ADVANCES IN HEPATO-BILIARY & PANCREATIC BILIARY & PANCREATIC

SURGERY: SURGERY: WHERE ARE WE TODAY?WHERE ARE WE TODAY?

Dr. Harshal Rajekar MS MRCS DNBConsultant hepatobiliary, GI and transplant Surgeon,Pune

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, et al.Hokkaido University , Sapporo, Japan.

CONCLUSIONS: Shorter operative times and reduced blood loss:- improved surgical technique- using new surgical devices and - intraoperative management, including anesthesia.

Additionally, decision making using our algorithm and perioperative management according to CDC guidelines reduced the morbidity and mortality associated with hepatectomy.

High volume hepatobiliary centre Major resection (sectionectomy, hemihepatectomy, and extended

hemihepatectomy), was performed in 535 patients (67.5%) and re-resection in 81 patients (10.2%).

Only a small percentage were colorectal metastasis. Liver functional reserve and liver remnant volume

Torzilli Arch Surg, 1999, no mortality after 107 consecutive resections (first report). Ascites, serum bilirubin, ICG 15 <14%

Precise delineation of vascular relations using CT angiography and volumetry The independent relative risk for morbidity was influenced by an operative

time of more than 360 minutes, blood loss of more than 400 mL, and serum albumin levels of less than 3.5 g/dL, as determined using multivariate logistic regression analysis.

Assessment of liver reserve Child-Pugh scoring, Class B and above ICG clearance at 15 minutes, retention > 14% bad risk

- 99m-Tc-galactosyl human serum albumin - Functional scintigraphy

Hepatic resection can be undertaken safely, and increasing experience as a hepatic surgeon is associated with greater utilisation of parenchymal sparing and extended resections.

- Low CVP. - Vascular inflow occlusion, - Ischaemic preconditioning (Clavien Ann Surg 2003) may be useful. - Equipment:- CUSA, harmonic scalpel (laparoscopic resection), bipolar drip

diathermy, Argon beam coagulator

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 low operative risk and good liver function.

For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, 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 or encephalopathy.

CONCLUSIONS: 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.

CONCLUSIONS: In patients with high-risk esophagogastric varices or symptomatic

splenomegaly and hypersplenism, patients had high-risk esophagogastric varices or symptomatic splenomegaly and hypersplenism.

Conclusions: RFA is a safe and effective treatment of small HCC in cirrhotics awaiting OLT, although tumor size (>3 cm) and time from treatment (>1 year) predict a high risk of tumor persistence in the targeted nodule. RFA should not be considered an independent therapy for HCC.

ROLE OF INTERVENTIONAL RADIOLOGY - RFA/ TACE

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.

Conclusions: RFA has still to be confirmed as an alternative to surgery for potentially-resectable HCCs.

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 Not an independent therapy for HCC!

Indian 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.

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, BAL / liver dialysis therapy is marked as the most promising solution

to bridge ALF patients to liver transplantation or to liver regeneration,

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.

Ann Surg. 2004 Sep;240(3):438-47; Five-year survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET).Fernandez FG, Drebin JA, Linehan DC, Dehdashti F, Siegel BA, Strasberg SM.Washington University School of Medicine, St. Louis, Missouri, USA.

RESULTS: One hundred patients (56 men, 44 women) were studied. Resections were major (>3 segments) in 75 and resection margins were > or = 1 cm in 52. Median follow up was 31 months, with 12 actual greater than 5-year survivors. The actuarial 5-year overall survival was 58% (95% confidence interval, 46-72%). Primary tumor grade was the only prognostic variable significantly correlated with overall survival.

19 studies (6070 patients) >40% median 5-year survival

Results not improved in recent studies Operative mortality <2% FDG-PET scan detects 25% extrahepatic disease Primary tumor grade was the only prognostic variable significantly

correlated with overall survival A resection margin which was often less than 1cm but

microscopically negative PET Scan is poor for HCC and false negative for patients on

chemotherapy

Annals of Surgery. 240(6):1002-1012, December 2004.One Hundred Thirty-Two Consecutive Pediatric Liver Transplants Without Hospital Mortality: Lessons Learned and Outlook for the Future. University Hospital Eppendorf, University of Hamburg, Hamburg, Germany.

Conclusions: Progress during the past 15 years has enabled us to perform pediatric liver transplantation with near perfect patient survival.

The long-term treatment of the transplanted patient, with the aim of avoiding late graft loss and achieving optimal quality of life, is easily achieved with minimal effort.

PEDIATRIC LIVER FAILURE

Most important prognostic factor after multivariate analysis - the year of transplantation

Only 3 recipients (2%) died during further follow-up Sixteen children (12%) had to undergo retransplantation This paper marks a turning point at which immediate

survival after transplantation will be considered the norm!

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, Gupta R, Kang M, Bhasin DK, Rana SS, Singh R. PGIMER, Chandigarh RESULTS: Of the 70 consecutive patients with SAP, 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.

Cochrane Database Syst Rev. 2012 May. Early routine endoscopic retrograde cholangiopancreatography strategy versus

early conservative management strategy in acute gallstone pancreatitis. Tse F, Yuan Y. Department of Medicine, Division of Gastroenterology, McMaster University,

Hamilton, Canada

Early 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.

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, Baltimore Patients 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.

Br J Surg. 2013 Nov;100(12).Meta-analysis of randomized clinical trials on safety and efficacy of biliary

drainage before surgery for obstructive jaundice.Fang Y et al.

CONCLUSION: Pre-op biliary drainage (PBD) in patients undergoing surgery for obstructive

jaundice is associated with similar mortality but increased serious morbidity compared with no PBD. Therefore, PBD should not be used routinely.

Detailed preoperative reconstruction of biliary anatomy and Reliable identification of choledocholithiasis Acceptable sensitivity and specificity in a clinical setting. Newer software developments may further enhance its accuracy Replace more invasive diagnostic measures in the near future.

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 UICC stage as significant prognostic factors.

Preoperative biliary decompression Portal vein embolization No positive ductal margins

Lymph node metastasis is a powerful, independent prognostic factor in perihilar cholangiocarcinoma and is better classified based not on location but on the number of involved nodes. To adequately assess nodal status, histologic examination of 5 or more nodes is recommended. (Ann Surg. 2013 Apr;257(4):718-25. Assessment of nodal status for hilar cholangiocarcinoma: location, number, or ratio of involved nodes. Aoba T et al).

Caudate resection.

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.

Conclusion: 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.

Delaying cholecystectomy may aggravate another episode of pancreatitis

If pseudocyst does not resolve, may need surgery Early ERCP in biliary pancreatitis may improve outcome No data was available to guide timing of cholecystectomy Complication rates were higher in the early group(5.5% versus

44%)

128 patients underwent extended hepatectomy for colorectal metastases (n = 86; 67.7%), hepatocellular carcinoma (n =12; 9.4%), cholangiocarcinoma (n =14; 11.0%), and other malignant diseases (n =15; 11.5%). 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%.

Conclusions: Extended hepatectomy can be performed with a near-zero operative mortality rate and is associated with long-term survival in a subset of patients with malignant hepatobiliary disease.

128 patients with more than 5 segment resection Median survival 42 months 5 year survival 26% Operative mortality 0.8% Adverse outcome if combined with any other intraabdominal

procedure Behari A, (SGPGI) extended resection for CaGb also showed good long

term results (BJS)