SpringerWienNewYork

Constantine Ch. Karaliotas Christoph E. Broelsch Nagy A. Habib (Eds.)

Liver and Biliary Tract Surgery

Embryological Anatomy to 3D-Imaging and Transplant Innovations

SpringerWienNewYork

Constantine Ch. Karaliotas, MD, PhD Chairman of 2nd Surgical Department and Surgical Oncology Unit in Red Cross Hospital, Athens, Greece

Christoph E. Broelsch, MD, FACS Professor and Chairman, Department of General Surgery and Transplantation, University Clinic Essen, Germany

Nagy A. Habib, ChM, FRCS Professor of Hepatobiliary Surgery, Imperial College, Hammersmith Hospital, London, UK

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© 2006 Springer-Verlag/Wien Printed in Greece

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ISBN-10 3-211-49275-5 SpringerWienNewYork ISBN-13 978-3211-49275-8 SpringerWienNewYork

This Book is Dedicated to

Evangelos Papaevangelou

MD, PhD Professor of Surgery- University of Athens

Former Chairman of Surgery in Red Cross Hospital, Athens - Greece

Former President of the Hellenic Surgical Society

and 23 d Panhellenic Surgical Congress

"In admiration for his scholarship in many fields, for his zeal as teacher, surgeon, and administrator"

"In the judicious discharge of these interdependent functions he has unfailingly strengthened the natural alliance

between humanism and surgery"

We are like dwarfs seated on the shoulders of giants.

If we see more and further than they,

it is not due to our own clear eyes or tall bodies,

but because we are raised on high

and upborne by their gigantic bigness.

Bernard of Chartres

Chancellor in 1119

PREFACE

The 25th Panhellenic Surgical Congress is offering the present textbook of surgery to all participants on one of the hot surgical topics: hepatobiliary surgery: "I wonder what the young surgeon learn when they attend a national surgical congress?" It is well known that delegates and young surgeons attend sessions on surgical topics of great interest, such as round table discussions, lectures on specific issues by distinguished Greek and foreign guests, postgraduate courses, follow live operations transmitted from operating rooms, meet experts describing their own techniques, debate scientific problems and ideas with well known pioneers in the field, and go home to review the scientific programme and their notes from the sessions attended.

Pioneers from both the international and Greek Hepatobiliary Club, present their combined experience, describe techniques for hepatic and biliary surgery and explore future trends. It is important for all of us to know

what is really "innovative" in hepatobiliary surgery. New thinking is both an initiation and a "nouveaute" that pushes at the frontiers in surgery. This book addresses all the main topics in Hepatobiliary surgery including living related and conventional cadaveric transplantation, new trends in hepatic surgery, new applications for laparosco- pic surgery, especially laparoscopic exploration of the biliary tree, the changing face of biliary reoperation and iatrogenic biliary stenoses and strictures, etc.

The book also covers cutting-edge research and technological advances that will shape the surgery of to- morrow. There is little doubt that technological advances in preoperative imaging, such as 3-D reconstruction, preoperative preparation with portal vein embolisation and operative techniques using bloodless RF resection methods, are already changing the nature of liver surgery.

It will be interesting to see how surgery will benefit from advances in stem cell research, gene therapy, geno- mics, proteomics and miRNA. I hope that this book will inspire young surgeons to invent, to dream and believe in their imagination.

As a surgeon who has participated in the evolutionary steps of biliary and hepatic surgery over the last deca- des, I want to express my enthusiasm for this book, and my deep appreciation to the Organising Committee and especially the President of the Congress, my friend Constantine Karaliotas, and the hope that this book will be appreciated by all members of the 2006 Congress.

Evangelos J. Papaevangelou Professor of Surgery

Former President of Hellenic Surgical Society

PREFACE

With the coming of 2007, we are celebrating seventy nine years since the institution of the Hellenic Surgical

Society.

These years have proven very productive for surgery in Greece, mainly because the founders of our Society,

as well as all the great scientists of the Executive Committees that followed, offered all their knowledge in an

effort to upgrading surgery in Greece, so that it is now considered as worthy as surgery worldwide.

Wishing to honour the 79th anniversary of our Society and at the same time holding the 25th Panhellenic Congress of Surgery, the present Executive Committee decided, among other, to publish a book titled "Liver and Biliary Tract Surgery".

The aforementioned book, written in English so as to be read by doctors beyond Greek frontiers, is the result of a very successful team work of some of the most significant scientists of our days. The President of the congress

and elect President of the Hellenic Surgical Society, Dr C. Karaliotas, Chairman of the Surgery and Surgical Onco-

logy Department of Red Cross Hospital in Greece, Professor Chistoph Broelsch, Chairman of the Transplantation

Center of Essen University in Germany and Professor Nagy Habib Chairman of the Hepatobiliary Department of

the Hammersmith Hospital in United Kingdom, are the editors of the present book.

The catalogue of authors includes 68 scientists very well known for their work, knowledge and literature

contribution, worldwide, from Greece, Germany, United Kingdom, United States and France.

SpringerWienNewYork, the Publisher is one of the highest reputed publishing Houses, and an additional gua- rantee of the book's high quality.

Being the representative of the Hellenic Surgical Society, I wish to thank the editors, Doctors Karaliotas, Broelsch and Habib for their hard work, all the authors for their valuable contribution and Springer publishers who gave us the opportunity for that great edition. We look forward to a future cooperation.

It is our wish, this very special work of so many remarkable authors to receive the welcome it deserves.

Theophilos Polymeropoulos President of the Hellenic Surgical Society

FOREWORD

Since in 2006 the art and practice of HPB surgery can be learnt from a variety of sources, which circumstances

did determine and touched the genesis of this book? In spite of the internet and e-learning and the many scientific

and medical meetings, a textbook still has a place in today's world as it provides junior and senior surgeons with a

definite and fundamental source of information to enhance clinical skill and management strategy.

This textbook has three Editors-authors and four sections, each reflective of their own particular perspective.

As each author has chosen different co-authors and topics, the textbook has been enriched with different philoso-

phies and ways of thinking about clinical approaches from which the reader will benefit.

The first and second sections are dedicated to embryology, anatomy and physiology, current diagnostic

techniques in hepatobiliary surgery and management of benign and malignant diseases of the biliary tract. Is one

of the most classical but basic and difficult knowledge for the HPB surgeon. The topics are mainly written by

authors from university centers of Greece and Red Cross Hospital of Athens and Hannover. Invaluable is the offer

of the two famous writers, professors A. Dalley and K.L. Moore from USA and Canada who have written the

chapter I.

The third section, is written from the Hammersmith Hospital doctors. They contributed to chapters covering

three different areas.

The first area reflects the unique activities where HPB department excels. Chapters are dedicated to new

techniques developed at the Hammersmith Hospital, such as radiofrequency assisted liver resection. This concept

was born and developed at the Hammersmith. It is with great pride that on the first anniversary of the launch of

Hammersmith device that one in four of all liver resections in the USA is performed with this technique. The new

technique allows HPB surgeons to perform liver resection with excellent results. In the vast majority of cases liver

resection can be performed without blood transfusion, and without the need to admit patients to intensive care

unit or high dependency unit. The development of the laparoscopic RF resection device is even more significant

as it will finally give the liver surgeon the opportunity to undertake laparoscopic liver resection safely. It will also

significantly reduce the length of hospitalisation and overall cost, rendering liver resection more competitive than

percutaneous tumour ablation and other non-surgical approaches.

The second area describes techniques that were developed by other teams, but adopted recently in Hammer-

smith HPB service. This includes the use of 3D imaging in the pre-operative planning of surgery and the adjuvant

use of SIRTEX for locally delivered radiotherapy.

The third area gives an insight into some of the research undertaken in the department of surgery, such as stem

cell and gene therapy. Several clinical trials have been performed and results, so far, are promising. We believe

that academic research goes hand in hand with modern surgery. Research holds the key for improvements in HPB

surgical outcomes. The up-to-date modern HPB surgeon will have to rely more and more on stem cell biology,

gene therapy, molecular engineering, microarray technology, chemotherapy signatures, genomics, proteomics,

metabonomics, nanotechnology, tissue engineering, medical device engineering and above all his or her creative

surgical handicraft to optimise the management of HPB patients.

The fourth section is dedicated to Liver Transplantations and is written from doctors of Liver Transplantation

Unit of Essen University from Germany. In the past two decades liver transplantation has become the standard

treatment in patients with chronic liver failure. Currently, it also represents the most effective therapy in acute

liver failure and in carefully selected patients with hepatocellular carcinoma. Technical innovations as well as an

i i

Xll Foreword

explosion of basic and clinical knowledge in organ transplantation contributed to the success of liver transplan-

tation. This includes a standardization of operative preservation techniques and in particular new developments in the field of immunosuppression. As a consequence, short term survival has improved tremendously.

Concerning the factors which gained increasing interest are those determining long-term survival, in

particular, recurrence of primary disease. It is one of the major challenges for the future to develop successful strategies for the prevention and therapy of recurrent disease to reduce the risk for recurrence and to increase survival. With increasing success the indication for liver transplantation is more and more broadened, although organ availability will become the limiting factor. To reduce organ shortage, an optimal use of available organs and an extension of the donor pool is inevitable. Split liver transplantation and living-related liver transplantation are the most effective innovations to increase organ availability and to relieve organ shortage.

This textbook comes at a critical time for liver surgery. During the last 3 decades there have been major

advances in liver surgery, such as complex liver surgery and liver transplantation. However, no major break-

through has happened in the last few years, even laparoscopic liver surgery did not gain its expected popularity

because of the technology gap. Unfortunately, liver surgery has been on the defensive. Instead of progressing, the

contrary has happened, and liver surgery is receding from the high ground. Facing the onslaught of major break- throughs in interventional radiology and oncology conventional orthodox liver surgery indications, such as rese- ction of small solitary tumour, were being questioned. Furthermore, major HPB meetings were uninspiring, rich in style, but poor in substance. The major chiefs of liver surgery were repeating old positions with loud voices, but with no convincing arguments.

In all our sections of this textbook we have concentrated on new developments, which Professor Papaevan- gelos alluded to in his preface as "nouveaut6s", in the hope of firing the imagination of HPB surgeons and of attra- cting young talent to this speciality.

HPB surgery and medicine are in dynamic motion propelled by knowledge, discovery and innovation. Curren-

tly, the HPB surgeon has to face the challenge of how to integrate and to work closely with the oncologist, gastro- enterologist, radiologist and pathologist in a multi-disciplinary approach. In the future the challenge will be even greater. In this new era, the HPB surgeon will have to interact with new officers who will make discoveries lead by science and technology. It is in this spirit that this textbook has been designed and prepared.

Finally, we would like to thank our co-authors and all contributors for giving us the privilege to contribute to this textbook and to all our colleagues who assisted with the manuscripts. Lastly, we hope that readers of this book will be inspired by the science, technical surgical handicraft, and spirit of this book which will equip them with new skills to offer optimal management to their patients.

Constantine Karaliotas Christoph Broelsch

Nagy Habib

Editors

SPECIAL ACKNOWLEDGMENTS

I take special pleasure and satisfaction in acknowledging the assistance of the special and daily contribution of Doctors G. Sgourakis, Th. Christofides, G. Sotiropoulos, Mike Hatzikalis and Ch. Karaliotas during the course of preparation the last 18 months.

I also take matching special pleasure in acknowledging the contribution of Georgina St John in language editing and the contribution of Tania Gaggou in the phototypesetting, giving an excellent result.

Finally I would also like to express my indebtedness for their help to J. Sideris Publishing House, Athens- Greece and to SpringerWienNewYork Publishing House, especially to Raimund Petri-Wieder, Editor-Medicine of Springer in Wien.

My special thanks to Professors Chr. Broelsch and N. Habib, to the President Th. Polymeropoulos and to the members of the Executive Committee of Hellenic Surgical Society. Without the support of all these people I could not have succeeded in this venture.

Constantine Ch. Karaliotas Editor

CONTENTS

SECTION 1

Chapter 1 Embryological and Surgical Anatomy of the Intrahepatic and Extrahepatic Biliary Tree

(A.F. Dalley, K.L. Moore) ..........................................................................................................................................................................

1.1. Embryology ........................................................................................................................................................................................... 3 1.2. Surgical Anatomy ................................................................................................................................................................................ 10 References and Sources of Illustrations ............................................................................................................................................... 16

Chapter 2 Surgical Anatomy of the Liver (P. Kekis, B. Kekis) ........................................................................................................................ 17

2.1. I n t r o d u c t i o n l 7

2.2. E m b r y o l o g y l 7

2.3. Liver Topography and Gross Anatomy ...................................................................................................................................... 19

2.4. Liver Lobes and Segments ............................................................................................................................................................... 25

References ........................................................................................................................................................................................................ 32

Chapter 3 Anatomical Variations and Anomalies of the Biliary Tree, Veins and Arteries

(Con. Ch. Karaliotas, T. Papaconstantinou. Ch. Con. Karaliotas) ............................................................................................. 35

3.1. I n t r o d u c t i o n 3 5

3.2. Aberrant Ducts ..................................................................................................................................................................................... 35

3.3. Anatomical Variations of Vessels ................................................................................................................................................. 41

3.4. Anatomical Variations of CBD Union and the Main Pancreatic Duct ........................................................................... 47

3.5. Conclusion ............................................................................................................................................................................................. 47

References ........................................................................................................................................................................................................ 47

Chapter 4 Ultrasonographical Anatomy for the Surgeon. The Value of Intra-operative Ultrasonography

(S. Mylona, A. Papaevangelou, G. Sgourakis, Con. Ch. karaliotas) .......................................................................................... 49

4.1. Introduction .......................................................................................................................................................................................... 49

4.2. Transabdominal Ultrasound ........................................................................................................................................................... 49

4.3. Intra-Operative Ultrasound ( IOUS)of the Liver .................................................................................................................... 58

References ........................................................................................................................................................................................................ 60

Chapter 5 Elements of the Biliary Tract and Liver Physiology

(Th. Christofides, Ch. Con. Karaliotas, G. Sgourakis, Con. Ch. Karaliotas) .......................................................................... 61

xv i Contents

5.1. Bile Composi t ion ................................................................................................................................................................................ 61

5.2. Mechanism of Emptying of the Gallbladder ............................................................................................................................ 62

5.3. Physiologic Anatomy of the Liver ................................................................................................................................................ 65

5.4. Bilirubin Metabolism and the Enterohepatic Circulation ................................................................................................... 66

References ........................................................................................................................................................................................................ 66

Chapter 6 Conventional Imaging Studies of the biliary Tract

(I. Thanos, S. Mylona) ................................................................................................................................................................................. 69

6.1 Introduction - Abdominal Plain X-Ray 69 6 2 Transabdominal Ultrasonography of the Biliary Tract ..................................................................................................... 69

6 3 Gallbladder Ultrasonographic Imaging ................................................................................................................................... 70

6 4 C o m m o n Bile Duct Imaging ........................................................................................................................................................ 72

6 5 Choledocholithiasis Ultrasonographic Imaging .................................................................................................................. 72

6 6 Cholangiocarcinoma Imaging ..................................................................................................................................................... 72

6 7 Computer ized Tomography (CT) Imaging ............................................................................................................................ 74

6 8 Magnetic Resonance Imaging (MRI) ......................................................................................................................................... 77

6 9 Biliary Scintigraphy ......................................................................................................................................................................... 80

6.10. Percutaneous Transhepatic Cholangiography (PTHC) ..................................................................................................... 81

References ........................................................................................................................................................................................................ 83

Chapter 7 Endoscopic Retrograde Cholangiopancreatography (Kon. Goumas, A. Poulou) .............................................................. 87

7.1. Introduction .......................................................................................................................................................................................... 87

7.2. Technical Features .............................................................................................................................................................................. 87

7.3. Indications ............................................................................................................................................................................................. 89

7.4. Contraindications ................................................................................................................................................................................ 90

7.5. ERCP and Diseases of the Biliary Tract ...................................................................................................................................... 90

7.6. Complications of ERCP ..................................................................................................................................................................... 104

7.7. The Role of ERCP in Biliary Disorders in the Era of MRCP and EUS ............................................................................ 105

References ........................................................................................................................................................................................................ 106

Chapter 8 Endoscopic Ultrasonography on Gallbladder and Biliary Tract (Kon. Goumas, A. Poulou) ........................................ 111

8.1. Equipment and Technique .............................................................................................................................................................. 111 8.2. The Role of EUS in Biliary Diseases ............................................................................................................................................ 112

8.3. Complications of EUS ........................................................................................................................................................................ 115 References ........................................................................................................................................................................................................ 116

SECTION 2

Chapter 9 ': Hepatobil iary Disease and Anaesthesia (P. Georgakis, L. Rizzotti, I. Katsouli-Liapis) .................................................... 121

9.1. Introduction .......................................................................................................................................................................................... 121

Contents xvii

9.2. Clinical Forms of Hepatobil iary Disease ................................................................................................................................... 121

9.3. Pathophysiologic Mechanisms of Hepatocellular Injury .................................................................................................... 122

9.4. Anaesthesia for Hepatobi l iary Disease ....................................................................................................................................... 123

9.5. Anaesthetic Considerat ions for Hepatic Resection Procedures ...................................................................................... 130

9.6. Conclusion ............................................................................................................................................................................................. 131

References ........................................................................................................................................................................................................ 131

Chapter 10 Congenital Malformations in the Extrahepatic biliary Tree in Children Biliary Atresia (D.C. Keramidas) ............ 135

10.1. In t roduct ion ........................................................................................................................................................................................ 135

10.2. E t i o l o g y 1 3 5

10.3. Classification ...................................................................................................................................................................................... 136

10.4. Clinical Manifestation and Diagnosis ....................................................................................................................................... 136

10.5. Surgery in Biliary Atresia .............................................................................................................................................................. 137

10.6. Kasai Hepatic Por toen te ros tomy ............................................................................................................................................... 137

10.7. Complicat ions After Hepatic Po r toen te ros tomy ................................................................................................................. 139

10.8. Results of Hepatic Por toen te ros tomy ...................................................................................................................................... 134

10.9. P r o g n o s i s 1 4 0

R e f e r e n c e s 1 4 0

Chapter 11 Choledochal Cysts of the Biliary Tree in Children (D.C. Keramidas) .................................................................................... 143

11 1. Choledochal Cysts- In t roduct ion .............................................................................................................................................. 143

11 2 E t i o l o g y 1 4 3

11 3 Classification ...................................................................................................................................................................................... 143

11 4 Clinical Presentat ion ....................................................................................................................................................................... 144

11 5 D i a g n o s i s 1 4 4

11 6 Surgica lTrea tment ........................................................................................................................................................................... 145

11 7 Laparoscopic Surgery .................................................................................. . ................................................................................... 146

11 8 Postoperat ive Complicat ions ...................................................................................................................................................... 146

References ................................................................................................................... : .................................................................................... 146

Chapter 12 Gallstone Disease (Kon. N. Birbas, I.G. Kaklamanos, G.N. Bonatsos) ................................................................................... 149

12.1. In t roduct ion - Prevalence and Incidence ................................................................................................................................ 149

12.2. Symptomat ic Gallstones ................................................................................................................................................................ 149

12.3. Preoperat ive Management of Gallstone Disease ......................................................................... : ....................................... 154

R e f e r e n c e s 1 6 6

Chapter 13 Complications in the Per formance of Laparoscopic Cholecystectomy. What Can Go Wrong?

How Do Complicat ions Have to Be Managed? (G. Quast, A. Kuthe) - 169

13.1. Introduct ion ........................................................................................................................................................................................ 169

13.2. The Per ioperat ive Setting 169

13.3. The Use of Per ioperat ive Prophylactic Antibiotics 169

xviii Contents

13.4. The Approach to the A b d o m e n ................................................................................................................................................ 170

13.5. Bile Duct Injuries - Anatomy, Prevent ion Techniques, Trea tment .......................................................................... 170

13.6. Gallbladder Perforat ion and Loss of Stones ........................................................................................................................ 172

13.7. Blood Vessel Injuries .................................................................................................................................................................... 173

13.8. Specific Points for a Successful End to the Laparoscopic Procedure ....................................................................... 174

13.9. Forensic Aspects and Malpractice in Laparoscopic Cholecys tec tomy ..................................................................... 175

13.10. Conclusion ........................................................................................................................................................................................ 176

References ........................................................................................................................................................................................................ 176

Chapter 14 Iatrogenic Injury of the Extrahepatic Bile Ducts. Surgical Reconstruct ion

(I.G. Kaklamanos, Kon. N. Birbas, G.N. Bonatsos) " 179

14.1. Int roduct ion - History .................................................................................................................................................................... 179

14.2. Types of Injury .................................................................................................................................................................................. 179

14.3. Mechanisms of Injury and Risk Factors ................................................................................................................................... 181

14.4. Diagnosis of the Injury ................................................................................................................................................................... 184

14.5. Management of Bile Duct Injuries ............................................................................................................................................. 184

14.6. Repair of Injuries Recognized at the Time of Initial Surgery ................. ........................................................................ 186

14.7. Repair of Biliary Strictures and Injuries Recognized Postoperat ively ........................................................................ 187

14.8. Per ioperat ive and Long-Term Results ..................................................................................................................................... 189

References ........................................................................................................................................................................................................ 190

Chapter 15 Principles of the Surgical Management of the C o m m o n Bile Duct Stones

(Con. Ch. Karaliotas, S. Lanitis, G. Sgourakis) 193

15.1. In t roduct ion .................................................................................................................................................................................... 193

15.2. Incidence of Choledocholi thiasis .......................................................................................................................................... 194

15.3. Pathogenesis of CBD Stones .................................................................................................................................................... 194

15.4. Clinical Findings ............................................................................................................................................................................ 195

15.5. The Surgeon's View in Per ioperat ive Imaging Study of CBD .................................................................................... 196

15.6. Trea tment of Choledocholi thiasis .......................................................................................................................................... 202

15.7. Cholecys tec tomy in Patients with Choledocholi thiasis ................................................................................................ 212

15.8. Postoperat ive Care ....................................................................................................................................................................... 213

15.9. Lithotripsy as a Compl imenta ry Modality for the Management of the C o m m o n Bile Ducts ........................ 213

15.10. Management of Retained Stones After Cholecys tec tomy ............................................................................................ 216

R e f e r e n c e s 2 1 6

Chapter 16 Laparoscopic C o m m o n Bile Duct Exploration

(Con. Ch. Karaliotas, G. Sgourakis, Th. Christofides, S. Lanitis) ............................................................................................... 219

16.1. In t roduct ion ........................................................................................................................................................................................ 219

16.2. Transcholedocal Laparoscopic CBD Exploration ............................................................................................................... 222

16.3. Non-Choledochoscopic Manoeuvres ..... .................................................................................................................................. 222

16.4. Cho ledochoscopy ............................................................................................................................................................................. 223

References ............................................................................. . .......................................................................................................................... 224

Contents xix

Chapter 17 Endoscop ic M a n a g e m e n t of C o m m o n Bile Duct Stones

(Kon. Goumas , A. Poulou) ........................................................................................................................................................................ 227

17.1. In t roduc t ion ........................................................................................................................................................................................ 227

17.2. Endoscop ic S p h i n c t e r o t o m y ....................................................................................................................................................... 227

17.3. Bal loon Sph inc te rop las ty .............................................................................................................................................................. 230

17.4. Effect iveness and Technica l Aspects of Endoscop ic Stone Extract ion ...................................................................... 231

17.5. The Role of ERCP in C o m b i n e d Choledocho l i th ias i s and Cholel i thiasis .................................................................. 234

References ........................................................................................................................................................................................................ 235

Chapter 18 Current Changes in Biliary Reopera t ions (E.J. Papaevange lou , A. P a p a e v a n g e l o u - N o m i k o u ) .................................... 239

18.1. I n t roduc t ion ........................................................................................................................................................................................ 239

18.2. Reta ined or Recurrent Stones ...................................................................................................................................................... 239

18.3. Stenosis of the Sphinc ter of O d d i ............................................................................................................................................. 240

18.4. Malfunct ioning "Low" Bil io-Digest ive Anas tomoses ........................................................................................................ 240

18.5. Benign Strictures of the Biliary Tract ....................................................................................................................................... 241

18.6. Reopera t ions for " P o s t c h o l e c y s t e c t o m y S y n d r o m e " . ........................................................................................................ 241

18.7. Reopera t ions for Cases wi th "Cystic Duct S y n d r o m e " . .................................................................................................... 241

18.8. Conclus ion ........................................................................................................................................................................................... 241

References ........................................................................................................................................................................................................ 242

Chapter 19 Othe r Benign Biliary Diseases and Lesions (G. Sgourakis, Th. Mitellas, Con. Ch. Karal iotas) .................................... 243

19 1. Mirizzi 's S y n d r o m e .......................................................................................................................................................................... 243

19 2. Funct ional Disorde rs of the Biliary Tract ............................................................................................................................... 244

19 3. Acalculous Cholecyst i t is ................................................................................................................................................................ 246

19 4. Biliary In t rahepa t ic and C o m m o n Bile Duct Cysts in Adults .......... i .............................................................................. 246

19 5. Biliary Str ictures Mimick ing Mal ignancy ............................................................................................................................... 249

19 6. HIV Cho lang iopa thy (AIDS Cho lang iopa thy ) ...................................................................................................................... 250

References ........................................................................................................................................................................................................ 251

Chapter 20 Cholangi t is (G.P. Fragulidis, A.A. Po lydorou , D.C. Voros) .......................................................................................................... 253

20.1. In t roduc t ion ........................................................................................................................................................................................ 253

20.2. Acute Suppura t ive Cholangi t is .................................................................................................................................................... 253

20.3. Recurrent Pyogen ic Cholangi t is .................................................................... i ............................................................................. 256

20.4. P r imary and S e c o n d a r y Scleros ing Cholangi t is ................................................................................................................... 260

20.5. Fibrosis of Papilla-Papill i t is ............................................................ • ........... ................................................................................... 264

References ............................................................................................................. . ........................................................................................... 265

Chapter 21 Cancer of the Extrahepat ic Biliary Tract ............................................................................................................................................. 267

Cal lb ladder Ca rc inoma (G. Karatzas, E. Misiakos) .............. ........................................................................................................... 267

XX Contents

2 la. 1. Inc idence ........................................................................................................................................................................................ 267

21a.2. Risk Factors .................................................................................................................................................................................... 267

21a.3. Genet ics ........................................................................................................................................................................................... 268

21 a.4. Pa tho logy ........................................................................................................................................................................................ 268

• 21 a.5. Clinical Manifesta t ions ......................................................... : .................................................................................................... 269

21a.6. Diagnost ic Me thods .................................................................................................................................................................... 270

21a.7. Surgical T r e a t m e n t ...................................................................................................................................................................... 270

2 la.8. Inc identa l Finding at C h o l e c y s t e c t o m y ............................................................................................................................. 271

21a.9. Resectable Malignant T u m o r Preopera t ive ly Suspec ted or Co n f i rmed ................................................................ 272

21 a. 10. A d v a n c e d Mal ignancy ............................................................................................................................................................... 273

21 a. 11. Prognosis ........................................................................................................................................................................................ 274

References ........................................................................................................................................................................................................ 275

Bile Duct Cancer (G. Karatzas, E. Misiakos) ...................................................................................................................................... 279

21b.12. Inc idence ........................................................................................................................................................................................ 279

21b.13. His tory ............................................................................................................................................................................................. 279

21b.14. Risk Factors .................................................................................................................................................................................... 279

21 b. 15. Molecular Pa thogenes i s ............................................................................................................................................................ 281

21 b. 16. Locat ion ........................................................................................................................................................................................... 281

2 lb. 17. Pa tho logy and Staging ................................................................................................................................................................ 282

2 lb. 18. Clinical P resen ta t ion .................................................................................................................................................................. 282

21b.19. Invest igat ive Techn iques ......................................................................................................................................................... 283

21b.20. Surgical T r e a t m e n t ...................................................................................................................................................................... 285

References ........................................................................................................................................................................................................ 286

Endoscop ic Pallative M a n a g e m e n t of the Mal ignancies of the Biliary Tract (Kon. Goumas , A. Poulou) ................ 289

2 lc .21. In t roduc t ion .................................................................................................................................................................................. 289

21c.22. Endoscop ic or Surgical Palliative M a n a g e m e n t ? ............................................................................................................ 289

21c.23. Technical Aspects ........................................................................................................................................................................ 290

References ........................................................................................................................................................................................................ 295

Chapter 22 Opera t ions of the Biliary Tract. Tecnical Aspects (J. Bramis, I.P. Gomatos , M.M. Kons tandou lak i s ) ...: .................. 297

22.1 In t roduc t ion .................................................................................................................................................................................... 297

22.2 P reopera t ive Evaluation ............................................................................................................................................................. 297

22.3 To Stent or Not to Stent ............................................................................................................................................................. 297

22.4 Genera l P r inc ip l e s - Exposure ................................................................................................................................................. 298

22.5 Hilar Dissec t ion ............................................................................................................................................................................. 299

22.6 Bi l ia ryTrac t Recons t ruc t ion ..................................................................................................................................................... 300

22.7. Pa renchymal liver t ransec t ion ................................................................................................................................................. 301

22.8. Ope ra t i ons of the Biliary Tract ............................................................................................................................................... 3 0 2

22.9. C h o l e d o c h o d u o d e n o s t o m y - Indica t ions ........................................................................................................................... 304

22.10. Ope ra t i ve Bile Duct Dra inage Via Segmen t III - " T h e Round Ligament Approach" . ...................................... 306

22.11. The R o d n e y - Smith P rocedu re ............................................................................................................................................... 307

22.12. The Longmi re P rocedu re ................... ....................................................................................................................................... 308

22.13. Specific Condi t ions ...................................................................................................................................................................... 308

References ....................................................... : ................................................................................................................................................ 312

Contents xxi

SECTION 3

Chapter 23 Imaging Studies of the Liver (L. Thanos, S. Mylona) ..................................................................................................................... 317

23.1. Introduct ion - Plain X-Ray ............................................................................................................................................................ 317

23.2. Ultrasonography ............................................................................................................................................................................... 317

23.3. Computed Tomography ................................................................................................................................................................ 319

23.4. MRI of the Liver ................................................................................................................................................................................ 322

23.5. Scintigrams - PET Scanning ......................................................................................................................................................... 324

23.6. Angiography ....................................................................................................................................................................................... 325

23.7. Needle Biopsy of the Liver ........................................................................................................................................................... 327

References ........................................................................................................................................................................................................ 329

Chapter 24 Three Dimensional (3D) Computed Tomography Images Reconstruction in Liver Surgery

(O. Damrah, R. Canelo, D. Zacharoulis, P. Tait, L.R. Jiao, N. Habib) ...................................................................................... 333

24.1. Introduct ion .................................................................................................................................................................................... 333

24.2. Liver Anatomy ................................................................................................................................................................................ 333

24.3. Clinical Application of 3-D Reconstruction of the Liver: 3-D Imaging

and Liver Transplantation ......................................................................................................................................................... 334

24.4. Oncologic Resections ................................................................................ . ................................................................................. 334

24.5. 3-D and Training ........................................................................................................................................................................... 335

24.6. Technique ........................................................................................................................................................................................ 336

24.7. Segmentat ion .................................................................................................................................................................................. 336

24.8. Data Processing ............................................................................................................................................................................. 336

24.9. Visualization .................................................................................................................................................................................... 336

24.10. A n a l y s i s 3 3 6

24.11. Softwares for 3-D CT Reconstruction ................................................................................................................................... 337

24.12. 3-D CT and Navigation ............................................................................................................................................................... 338

References ........................................................................................................................................................................................................ 338

Chapter 25 Preoprative Assessment of Liver Function

(G. Sgourakis, Th. Christofides, Ch. Con. Karaliotas, Con. Ch. Karaliotas) ............................. i ............................................ 339

25.1. Introduction .................................................................................................................................................................................... 339

25.2. Indocyanine Green Retention ................................................................................................................................................. 340

25.3. 99m-Tc-Galactosyl-Human Serum Albumin Scintigraphy ........................................................................................... 343

25.4. Hippurate Ratio .............................................................................................................................................................................. 347

25.5. Amino Acid Clearance Test ............................................................................................................ : ......................................... 347

25.6. Aminopyr ine and Phenylalanine Breath Test ................................................................................................................... 347

25.7. Monoethylglycinexylidide Test .............................................................................................................................................. 348

25.8. Measurement of Liver Volume ................................................................................................................................................ 348

25.9. D-Sorbitol ......................................................................................................................................................................................... 348

25.10. Clearance of Galactose ............................................................................................................................................................... 349

25.11. Other Tests ...................................................................................................................................................................................... 349

xxi i Contents

25.12. Patient Selection, Scoring Systems and Resection Outcomes ................................................................................... 349

References ........................................................................................................................................................................................................ 351

Chapter 26 Indications for Liver Resection (A. Healy, J. Tracey, N.A. Habib, L.R. Jiao) ....................................................................... 357

26.1. Int roduct ion 357

26.2. Indications ........................................................................................................................................................................................... 357

26.3. Preoperat ive Management ............................................................................................................................................................ 360

26.4. Standard Resect ions-Segmentectomies " 361

References ........................................................................................................................................................................................................ 362

Chapter 27 Liver Resection and Stapling Devices - Laparoscopic Resection (A. Healy, J. Tracey, N.A. Habib, L.R. Jiao) ...... 363

27.1. Int roduct ion ........................................................................................................................................................................................ 363

27.2. Techniques for Liver Parenchymal Transect ion .................................................................................................................. 363

27.3. Laparoscopic Liver Resection ..................................................................................................................................................... 364

References ........................................................................................................................................................................................................ 366

Chapter 28 Liver Resection Assisted with the Radiofrequency Technique (A. Healy, J. Tracey, N.A. Habib, L.R. Jiao) .......... 367

28.1. In t roduct ion ..................................................................................................................................................................................... 367

28.2. Background ...................................................................................................................................................................................... 367

28.3. Monopolar Electrodes .................................................................................................................................................................. 367

28.4. Bipolar Electrodes ......................................................................................................................................................................... 367

28.5. General Considerat ions ................................................................................................................................................................ 368

28.6. Design of the Habib ® 4X ............................................................................................................................................................ 368

28.7. Application ............................................................................................................................ : .......................................................... 369

28.8. Results ................................................................................................................................................................................................. 370

28.9. The InLine T M (ILRFA/ILRFC) ................................................................................................................................................... 370

28.10. Laparoscopic Hepatic Resection with RF ............................................................................................................................. 371

28.11. Trans-metastasis Hepa tec tomy Using RF ............................................................................................................................. 371

28.12. Conclusion ........................................................................................................................................................................................ 372

References ........................................................................................................................................................................................................ 372

Chapter 29 Liver Resection for Cholangiocarc inoma (G.C. Sotiropoulos, H. Lang, Ch.E. Broelsch) .............................................. 373

29.1. Resection of Hilar Bifurcation and Biliary Reconstructions ........................................................................................... 373

29.2. Vascular Reconstructions .............................................................................................................................................................. 375

29.3. Vascular Occlusion ........................................................................................................................................................................... 376

29.4. Non-convent ional Liver Resections (In Situ-Ante Situm and Ex-Situ) ....................................................................... 377

29.5. L y m p h a d e n e c t o m y by Liver Resection ................................................................................................................................... 377

29.6. Intraoperat ive Management During Liver Resection ........................................................................................................ 378

29.7. Repeated Hepa tec tomy for Reccurent Malignant Tumor ................................................................................................. 378

References ........................................................................................................................................................................................................ 379

Contents xxiii

Chapter 30 Portal Vein Embo l i s a t i on (O. Damrah , R. Canelo, L. Jiao, N.A. Habib) ................................................................................. 381

30.1. I n t roduc t i on .................................................................................................................................................................................... 381

30.2. B a c k g r o u n d ..................................................................................................................................................................................... 381

30.3. Liver Regene ra t i on ....................................................................................................................................................................... 382

30.4. Clinical Rat ionale for PVE Before Major Liver Resec t ion ............................................................................................ 383

30.5. M e a s u r e m e n t of FLR V o l u m e and Pred ic t ing Func t ion after PVE ........................................................................... 383

30.6. A n a t o m i c Cons ide ra t i ons .......................................................................................................................................................... 385

30.7. Portal Venous A n a t o m y .............................................................................................................................................................. 385

30.8. Portal Venous Variants ............................................................................................................................................................... 386

30.9. M e c h a n i s m of PVE ........................................................................................................................................................................ 387

30.10. Embol i c Material ........................................................................................................................................................................... 389

30.11. P o s t e m b o l i s a t i o n Course ............................................................................................................................................................ 389

30 12. Ind ica t ions for PVE ...................................................................................................................................................................... 389

30 13. Con t r a ind i ca t i ons ......................................................................................................................................................................... 390

30 14. O u t c o m e s After PVE and H e p a t e c t o m y .............................................................................................................................. 390

30 15. PVE in Pat ients wi th Chron ic Liver Disease ...................................................................................................................... 391

30 16. PVE in the Absence of Chron ic Liyer Disease .................................................................................................................. 391

30 17. C o m p l i c a t i o n s ................................................................................................................................................................................ 392

30 18. F u t u r e 3 9 2

Refe rences ........................................................................... ~. ........................................................................................................................... 393

Chapter 31 Hepat ic C h e m o e m b o l i z a t i o n (Paul Tait) ............................................................................................................................................ 397

31.1. I n t r o d u c t i o n ........................................................................................................................................................................................ 397

31.2. Theore t i ca l Aspects ......................................................................................................................................................................... 398

31.3. Pat ient Se lec t ion ............................................................................................................................................................................... 398

31.4. T e c h n i q u e ............................................................................................................................................................................................ 399

31.5. Post P r o c e d u r e .................................................................................................................................................................................. 403

31.6. Compl i ca t i ons ....................................................................................................................................................................... ........... .. 404

31.7. C o n c l u s i o n 4 0 5

Refe rences ........................................................................................................................................................................................................ 406

Chapter 32 Select ive In te rna l Radia t ion T h e r a p y (SIRT) in the M a n a g e m e n t of Liver T u m o u r s ........................................... i ........... 409

32a. Select ive In terna l Radia t ion t h e r a p y (A. A1-Nahhas, T. Szyszko, P. Tait, O. Damrah , R. Cane lo) ................... 409

32a. 1. I n t r o d u c t i o n ........................................................................................................................................................................ 409

32a.2. Select ive In te rna l Radia t ion T h e r a p y ....................................................................................................................... 410

32a.3. Ind ica t ions for SIR-Spheres T h e r a p y ....................................................................................................................... 410

32a.4. Con t r a ind i ca t i ons ........................................................................................................................................................... .. 411

32a.5. Pat ient Se lec t ion ............................................................................................................................................................... 411

32a.6. Diagnos t ic A n g i o g r a p h y ................................................................................................................................................ 411

32a.7. Asses smen t of H e p a t o p u l m o n a r y Shunt ................................................................................................................. 412

32a.8. Dose Calcula t ion and De l ive ry ................................................................................................................................... 412

32a.9. Adver se React ions ..................................................................................................... .- ...................................................... 413

xx iv Contents

32a. 10. Clinical Experience with SIRT .................................................................................................................................... 414

32a. 11. Follow up after 9°y-mic rosphere Therapy ............................................................................................................ 415

32a.12. Conclusion .......................................................................................................................................................................... 417

R e f e r e n c e s 4 1 7

32b. The Use of Sirtex in Inoperable Liver Tumours. A Surgeon's View

(D. Zacharoulis, N.A. Habib, R. Jiao) ......................................................................................................................................... 419

32b. 1. In t roduct ion .......................................................................................................................................................................... 419

32b.2. Results ...................................................................................................................................................................................... 420

References ........................................................................................................................................................................................................ 420

Chapter 33 Radiofrequency Ablation (RFA) of Liver Tumours ......................................................................................................................... 421

33a. Basics of Radiofrequency Tissue Ablation (L.R. Jiao, D. Zacharoulis, N.A. Habib) ................................................ 421

33a.1. In t roduct ion .......................................................................................................................................................................... 421

33a.2. Indications for Radiofrequency Ablation of Primary and Metastatic Liver Cancer ................................ 421

References ........................................................................................................................................................................................................ 422

33b. Radiofrequency Ablation of Liver Colorectal Metastases

(J. Tracey, J. Dimarakis, D. Zacharoulis, J. Anderson, P. Tait, L. Jiao, N. Habib) .................................................. 423

33b.3. Background ....................................................................................................................................................................... 423

33b.4. In t roduct ion ...................................................................................................................................................................... 423

33b.5. Basic Science of Radiofrequency Ablation .......................................................................................................... 423

33b.6. Colorectal Carcinoma ................................................................................................................................................... 425

33b.7. Lung Metastasis ............................................................................................................................................................... 427

33b.8. Liver and Lung Metastases .......................................................................................................................................... 427

33b.9. Improving Local Ablation Efficacy ......................................................................................................................... 428

33b.10. Complicat ions .................................................................................................................................................................. 428

33b.11. Local Recurrence ............................................ i ............................................................................................................... 429

33b.12. Technical Recommenda t ions .................................................................................................................................... 429

33b.13. Poor Prognostic Indicators ......................................................................................................................................... 429

33b.14. Conclusion ......................................................................................................................................................................... 429

References ........................................................................................................................................................................................................ 429

Chapter 34 Stem Cell Therapy in Liver Disease (M. Pai, N.A. Habib) ............................................................................................................ 433

34.1. In t roduct ion - Incidence ............................................................................................................................................................... 433

34.2. Causes .................................................................................................................................................................................................... 433

34.3. Current Trea tment and Recent Advances .............................................................................................................................. 433

34.. 4. General Concepts about Stem Cells .......................................................................................................................................... 434

34.5. Stem Cell Plasticity ................................................................................................................................................................... . ...... 436

34.6. Liver and Stem Cells ....................................................................................................................................................................... 436

References ........................................................................................................................................................................................................ 438

Chapter 3 5 Liver Gene Therapy: Will Gene Therapy Deliver to the Liver Patient? (N. Levicar, L. Jiao, Ph. Bachellier,

D. Zaharoulis, D. Jaeck, S. Helmy, H.Salama, J. Nicholls, S. Jensen, N.A. Habib) ............................................................. 441

Contents x x v

35.1. Introduct ion ........................................................................................................................................................................................ 441

35.2. Gene Therapy Vectors .................................................................................................................................................................... 443

35.3. Gene Therapy for Liver Tumours .............................................................................................................................................. 444

35.4. Gene Therapy for Hepatitis B and C ........................................................................................................................................ 446

35.5. Gene Therapy for Liver Cirrhosis .............................................................................................................................................. 446

References ........................................................................................................................................................................................................ 447

Chapter 36 Liver Trauma (Con. Vagianos, D.A. Tsiftsis, D. Siablis) ................................................................................................................ 451

36.1. In t roduct ion ..................................................................................................................................................................................... 451

36.2. Historical Evolution ...................................................................................................................................................................... 451

36.3. Anatomy of the Liver and Physiology of Liver Injury .................................................................................................... 451

36.4. Classification .................................................................................................................................................................................... 452

36.5. Diagnosis ........................................................................................................................................................................................... 457

36.7. Decision Making ............................................................................................................................................................................ 457

36.8. Non-Surgical Management ........................................................................................................................................................ 458

36.9. Opera t ive Management .............................................................................................................................................................. 461

36.10. Conclusion ........................................................................................................................................................................................ 466

References ........................................................................................................................................................................................................ 466

Chapter 37 Hydatid Cyst of the Liver (S. Lanitis, G. Sgourakis, Con. Ch. Karaliotas) ............................................................................. 471

37.1. In t roduc t ion - Life-Cycle, Species, Distribution ............................................................................................................... 471

37.2. Anatomy of the Paras i te- Egg .................................................................................................................................................. 472

37.3. Lodging in the Liver-Cyst Structure and Ferti l i ty-Daughter Cyst - Secondary Cyst .......................................... 472

37.4. Clinical Presentat ion .................................................................................................................................................................... 473

37.5. Diagnosis ........................................................................................................................................................................................... 473

37.6. Classification .................................................................................................................................................................................... 474

37.7. Trea tment of Liver Hydat id Cyst ............................................................................................................................................ 474

37.8. Surgical Managemen t /Genera l Principles ........................................................................................................................... 475

37.9. Radical Approach ........................................................................................................................................................................... 475

37.10. Conservat ive Approach ...............