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Hepato Biliary Pancreatic Surgery

Hepatobiliary surgery is increasingly accepted today as a subspecialty especially with the advent of liver transplant programs. Good results in complex hepatobiliary surgery are dependent not only on expert surgical skills, but a team effort. It begins preoperatively with planning of extent of resection with 320-slice 4-phase contrast enhanced CT angiography and volumetry. Intraoperatively low central venous pressure anesthesia reduces blood loss during liver parenchymal transection thereby avoiding blood transfusions. The use of technically advanced equipment for transection such as Hydrojet (ERBE), CUSA has enabled precise dissection with ligation and division reducing intraoperative blood loss and the incidence of postoperative bleeding or bile leakage. The process continues into the postoperative period with liberal use of epidural analgesia facilitating early ambulation and emphasis on early resumption of oral intake. Close monitoring of nutritional supplementation and restriction of salt and fluid intake reduce ascites formation in cirrhotic patients.

This has enabled us to undertake complex resections in patients with early cirrhosis. Laparoscopic RFA (Radiofrequency ablation) is another addition to our armamentarium in the management of liver tumors in cirrhotic patients. Liver surgery has traditionally been performed through big incisions and the laparoscopic approach has reduced postoperative pain allowing early recovery and discharge. In keeping with evidence from across the world demonstrating improved survival in patients with cholangiocarcinoma, extended liver resections are being performed with a view to achieving negative histological margins. Due to our increasing experience in handling small bile ducts in the living donor liver transplant setting we are comfortable offering early surgery in patients with bile duct strictures where small segmental ducts have to be anastomosed. Stenting of biliary or bilioenteric anastomoses is no longer performed reducing postoperative morbidity.

The burden of liver disease in our society is increasing at alarming proportions. A large number of patients are detected with Hepatitis B and C, due to the widespread availability of screening tests and their adoption as part of pre-employment screening. Alcohol related liver disease is not new but a large number of younger people are presenting in recent times due to increasing social acceptability, being construed as a sign of upward social mobility and stress of modern day life. In addition, an increasing number of patients are presenting with fatty liver in combination with the metabolic syndrome (obesity, diabetes, hypertension, dyslipidemia). Worldwide, NASH (Non alcoholic steatohepatitis) is being recognized as an important cause of end stage liver disease requiring transplantation. Early detection and correction of underlying factors may result in resolution of fatty liver.

The commencement of liver clinics at Apollo Hospitals has facilitated the evaluation and management of patients with liver disease. A multidisciplinary team consisting of specialists from medical and surgical hepatology and if required oncology and interventional radiology assess patients under one roof and advise appropriate management. This has streamlined the management of patients who would otherwise be at a loss to decide which specialist to consult or end up taking several appointments to meet doctors from different specialties.

Acute Pancreatitis
The severity of acute pancreatitis varies from mild swelling to destruction of the gland. The edematous form of the disease occurs in about 80-85% of patients and is self-limited, with recovery in a few days. In the 15-20% of patients with the most severe form of pancreatitis, hospitalization is prolonged and commonly associated with infection and other complications including multiple organ failure. Operative intervention may be required and mortality may be high in the severe forms. The incidence of acute pancreatitis is between 17-28 per 100,000 population. Patients with severe pancreatitis should be identified as early as possible (within 7 days) and managed by a team experienced in preventing and treating its complications.
  • Patients often complain of severe upper abdominal pain radiating straight through to the back, with associated nausea and vomiting. Abdominal findings vary from epigastric tenderness on deep palpation to an acute abdomen with distention. Serum amylase and lipase levels are usually elevated, but correlate poorly with disease severity. It is essential to establish the etiology of pancreatitis. In some cases, treatment of a specific cause of pancreatitis is indicated, such as cholecystectomy for patients with gallstone pancreatitis. It may initially be difficult to distinguish severely ill patients from those with mild disease. Afteradequate resuscitationof patients with severe pancreatitis, a CT scan with contrast should be obtained if renal function is adequate. Pancreatic necrosis, estimated on early, contrast-enhanced helical CT is a specific predictor of morbidity and mortality. The presence or absence of cholelithiasis should be determined as early as possible, usually with ultrasonography. Other useful diagnostic tests include arterial blood gases, CBC, and serum chemistries such as calcium, glucose, and creatinine.
  • Patients with mild pancreatitis usually experience resolution of their pain within 24-48 hours after a regimen of no oral intake, analgesics for pain relief, and intravenous fluids. Once oral intake is tolerated, patients can be discharged from the hospital. Patients with mild acute pancreatitis secondary to gallstones should undergo cholecystectomy during the same hospitalization. Common bile duct obstruction from a stone at the ampulla requires urgent removal of the stone (preferably by endoscopic papillotomy) if there is evidence of cholangitis. Patients with a history of alcoholism should be counseled and encouraged to participate in a detoxification and rehabilitation program, while patients with hyperlipidemia should be placed on appropriate diet and drug therapy. Severe pancreatitis is often associated with a marked increase in microvascular permeability, leading to large volume losses of intravascular fluid into the tissues, thereby decreasing perfusion of the lungs, kidneys, and other organs. Probably the single most important element in preventing multiple organ failure is vigorous fluid resuscitation with electrolyte solutions in order to optimize cardiac index and maintain hemodynamic stability. Central venous pressure monitoring is helpful in such patients and guided resuscitation has been demonstrated to reduce progression to multiple organ failure. Patients with severe pancreatitis should be treated in an intensive care unit because of the associated high mortality and morbidity rates. If these patients do not improve within 7 days referral should be made to a medical center with a team experienced in caring for severe pancreatitis. Nonoperative management is recommended for sterile pancreatic necrosis, while surgical debridement and drainage remains the preferred approach for infected pancreatic necrosis. Repeated scheduled reoperation for necrosectomy until all necrotic tissue has been debrided may be required. When infection supervenes two or more weeks after onset of symptoms, the infected pancreatic and peripancreatic tissue is more readily defined and removed at operation, with a decreased mortality rate. Treatment of infected fluid collections may include endoscopic, radiologic, and operative procedures. Preventing or delaying infection with appropriate antibiotics possibly reduces morbidity and mortality. Aggressive nutritional support is also essential for these patients.
  • The overall mortality of severe pancreatitis is approximately 15%. The average length of hospital stay for uncomplicated pancreatitis is 5-14 days. The average length of hospital stay for complicated pancreatitis can range as high as 40 to 65 days. These outcomes should improve with adequate early resuscitation and the judicious use of invasive procedures.
Chronic Pancreatitis
Chronic pancreatitis has an incidence in the United States of 5-10 per 100,000 population. It is most commonly associated with chronic alcohol use (75%). Patients usually present with chronic pain, either persistent continuous pain or postprandial pain. An anatomic abnormality should be evident in any patient selected for operative treatment for pancreatic pain. Patients with chronic pancreatitis may be at increased risk of developing pancreatic cancer.
  • Pain is the major disabling symptom in patients with chronic pancreatitis, often leading to associated weight loss and/or narcotic dependency. Diabetes, jaundice, and problems with digestion are also frequently seen. Ultrasonography,CT scan, MRCP, or ERCP usually makes the diagnosis of chronic pancreatitis and its complications. Typical findings can include a dilated pancreatic duct or strictures with dilatations of the duct ("chain of lakes"), pancreatic calcification, or pseudocyst. Biliary or duodenal obstruction and evidence of portal hypertension may also be present. It is difficult to distinguish between chronic pancreatitis and pancreatic cancer, especially in patients without pancreatic calcification. Marked elevation of serum CA 19-9 in a patient without jaundice is highly suggestive of pancreatic cancer. By clearly defining pancreatic and biliary ductal anatomy, MRCP and ERCP can help to select patients who might benefit from surgery and to plan the most appropriate operation. In patients with atypical gastrointestinal bleeding and pancreatitis, angiography of the celiac and superior mesenteric arteries can detect and embolize a pseudoaneurysm.It is also important to establish a baseline of pancreatic exocrine and endocrine function, nutritional status, pain severity, use of pain medication or narcotics, employment status, and quality of life. Continued ingestion of alcohol or narcotics should be addressed in either a medical or surgical management plan.
  • Patients with disabling abdominal pain, evidence of chronic pancreatitis, and pancreatic ductal dilatation are best managed by pseudocyst decompression or ductal decompression (Lateral panceraticojejunostomy procedure), while patients without ductal dilatation are best treated with resection. Biliary-enteric decompression may also be required in patients with chronic pancreatitis and bile duct obstruction. Although preservation of pancreatic tissue is desired to maintain both exocrine and endocrine function, partial pancreatic resection (such as distal pancreatectomy,pancreaticoduodenectomy, or duodenal preserving pancreatic head resection/decompression [i.e. Beger or Frey procedures]) is at times the preferred treatment. While alternative procedures such as endoscopic sphincterotomy, short-term stent placement in the major pancreatic duct or pancreatic pseudocyst may provide short-term relief of symptoms; long-term results are as yet unknown.
  • Risks and complications associated with operation for chronic pancreatitis include infection, bleeding, biliary and pancreatic anastomotic leaks, and aggravation of existing acute pancreatitis, with a frequency in the range of 0.5% to 5%. While it varies with the procedure, the mortality rate of pancreatic surgery is currently below 5% for major resections and even less for non-resective decompressive operations.
  • Initial pain relief can be expected in 75-80% of patients and sustained in selected patients for 3-5 years. The incidence of postoperative diabetes and steatorrhea (fatty stool) depends upon the amount of pancreatic tissue resected and the disease status of the remaining gland. Among non-diabetic patients, 10-15% will develop diabetes within 10 years due to the natural progression of associated exocrine and endocrine insufficiency, which can be slowed in some patients by abstinence from alcohol or by decompression of an obstructed main ductal system. Successful relief of pain after operation is associated with weight gain in most patients. Overall, the best outcomes occur in patients who are compliant with pancreatic enzyme replacement and abstain from alcohol and narcotics use. The average length of hospital stay after major pancreatic surgical procedures is 7-14 days. Hospital stay tends to be longer after pancreaticoduodenectomy than after distal pancreatectomy or ductal decompression operations.
Surgical Treatment of Pancreatic Cancer
Pancreatic cancer is the second most common gastrointestinal malignancy, with 29,000 new cases diagnosed each year. It also has the worst prognosis, with less than 20% of patients surviving one year after diagnosis and less than 5% surviving five years. The only potentially curative treatment is operative resection. Alternative treatments are reserved for more extensive disease, but offer only temporary relief of symptoms. A pancreatic mass or suspected cancer will require surgical consultation for diagnosis, resection (if feasible), biliary or gastric bypass, or assistance in planning treatment.
  • More than 90% of patients with pancreatic cancer present with pain, jaundice, and/or weight loss. Acute pancreatitis or recent onset of diabetes mellitus may occasionally be the initial presentation. Vague upper abdominal symptoms may precede the onset of jaundice or overt pain by months, and illustrate the difficulty of early diagnosis in this disease. Whenever pancreatic cancer is suspected, a contrast enhanced CT scan of the upper abdomen should be obtained. If a mass is not seen, but clinical suspicion remains high, endoscopic ultrasound or endoscopic retrograde pancreatography (ERCP) may be indicated. It should be noted that a normal endoscopic ultrasound does not rule out the presence of a tumor.
  • Preoperative staging in pancreatic cancer is used to determine if a patient has a resectable tumor, a localized but unresectable tumor, or metastatic disease. Contemporary staging utilizes multidetector or multislice CT scanning with intravenous contrast to determine the presence or absence of metastatic disease, vascular invasion (often precluding resection), and variations in arterial anatomy. Endoscopic ultrasonography may be helpful in assessing vascular involvement, local nodal metastasis, or extrapancreatic tumor extension, and adds the dimension of transduodenal fine-needle aspiration to confirm the diagnosis cytologically, which is important if resection is not feasible and chemotherapy or chemoradiation is planned. Laparoscopy may be useful in identifying small metastatic hepatic and/or peritoneal implants, in which case further surgery may be avoided. Surgeons with experience in pancreatic surgery should evaluate all patients with pancreatic carcinoma to ascertain their candidacy for resection unless they clearly have distant metastatic disease.
  • Less than one in five patients will have resectable tumors. Tumors in the head of the pancreas are treated by pancreaticoduodenectomy, with or without preservation of the pylorus. Preoperative or intraoperative histologic evidence of malignancy is not required to carry out resection in experienced hands. While a distal pancreatectomy with splenectomy is the procedure of choice for tumors of the body or tail of the pancreas, it is only possible in about 1 in 20 patients. Adjuvant therapy should be considered in all patients following surgery for pancreatic adenocarcinoma. For the majority of patients with unresectable tumors, treatment is primarily one of palliation. In patients with jaundice and gastric outlet obstruction, biliary and/or gastric bypass is indicated. At the time of surgery, a celiac plexus block with 50% alcohol may prevent or relieve pain. In the presence of jaundice alone, treatment is determined by the availability of resources. An endoscopic stent is as effective as surgical bypass, with slightly less morbidity and expense. Patients with locally advanced or metastatic disease, and acceptable performance status, should be considered for protocol-based therapy. In the absence of an available clinical trial, gemcitabine (alone or in combination) is the evolving standard treatment. Patients with locally advanced disease, especially those with pain as a major symptom, may benefit from chemoradiation (capecitabine-based chemoradiation).
  • The mortality rate following pancreaticoduodenectomy or distal pancreatectomy is currently less than 5%. Significant complications following pancreatic resection occur in 10-12% of patients and include pancreatic fistula, intra-abdominal abscess, or hemorrhage. These are increasingly managed by medical therapy or ultrasound or CT guided drainage and reoperation for this complication is seldom necessary. Complication and mortality rates are similar in younger patients and in patients 70 years or older.
  • The average hospital stay following pancreaticoduodenectomy is less than two weeks, and for distal pancreatectomy is about one week. Recent data suggest that patients have a 5-year survival rate of 15% to 25% following resection, depending upon the histology and completeness of resection. . With current chemotherapy or chemoradiotherapy the median survival for patients with locally advanced disease is10-12 months. Patients with metastatic disease have a median survival of only 3-6 months.
Gallstones and Cholecystitis
Gallstone disease leads to approximately 750,000 cholecystectomies per year. The overwhelming majority of operations (cholecystectomy) are for symptomatic gallstones, and about 90% are by a laparoscopic approach.
  • Most patients have asymptomatic gallstones. Studies on the natural history show that only 20% of patients with asymptomatic stones diagnosed by clinical manifestations will happen at some point. The presenting symptoms of gallstones include biliary colic, cholecystitis (calculous and acalculous), biliary pancreatitis and choledocholithiasis (common bile duct stones). The characteristic pain caused by gallstones is temporary (lasts half an hour to 24 hours), is located in the epigastrium and right upper quadrant and appears with the intake, sometimes may radiate to the right flank or back and is often accompanied by nausea. In some patients, symptoms are mild and consist of slight indigestion or dyspepsia. The diagnosis of gallstones is commonly performed ultrasound (ultrasound). The ultrasonography signs of gallbladder wall thickening and surrounding liquid to suspect acute cholecystitis. The scan is not used to diagnose stones but is useful for detecting acute cholecystitis. Patients with biliary dyskinesia may have symptoms characteristic of biliary pain without radiographic stones. Often the fraction of gallbladder evacuation is decreased (<30%) in the low radionuclide scanning with cholecystokinin stimulation.
  • Once the patient begins to have gallstone symptoms cholecystectomy is indicated. Following resolution of amild acute episode, the surgeon will advise a planned or elective laparoscopic cholecystectomy. Patients presenting with right upper quadrant tenderness, fever or leukocytosis are assessed the same day and an emergency cholecystectomy is performed for acute cholecystitis within 48-72 hours of onset of symptoms. In the presence of abdominal symptoms without stones, cholecystectomy is not indicated unless the patient is immunocompromised or there is a predisposition for malignancy, as calcification of the gallbladder wall or a family history of cancer of the gallbladder. Pancreatitis, choledocholithiasis and gallstone cholangitis causes are indications for urgent consultation with the surgeon. Patients with recurrent symptoms typical biliary pain without stones on ultrasonography are referred for surgical consultation. The indication for cholecystectomy in these cases could be supported by scintigraphic studies of the biliary tree under cholecystokinin stimulation, endoscopy, and consultation with a gastroenterologist or all of them. Cholecystectomy can be performed by laparoscopy and laparotomy. The advantages of the laparoscopic approach are less pain, shorter hospital stay and early return to normal activities. Other treatment modalities such as dissolution therapy have limited effectiveness and are expensive. Percutaneous cholecystostomy is an acceptable treatment for severely ill patients with acute cholecystitis.
  • The risks are low in patients undergoing cholecystectomy, and include bile duct injury, the residual stones in the bile ducts or the injury of adjacent organs. The bile duct injury occurs in approximately 0.5% of laparoscopic cholecystectomies. The existence of anatomical variations, inflammation, or both, increases the risk of complications, as does the frequent coexistence of serious illness in elderly patients. Mortality risk in patients undergoing elective surgery are less than 0.1%. The operative risks usually are due to comorbid conditions such as heart or lung disease.
  • Open cholecystectomy may be the appropriate approach for specific sets of patients. This may include cirrhosis, masswith suspected malignancy, previous abdominal surgery and third trimester of pregnancy. Apart from these cases laparoscopy is feasible in most patients. Conversion to open surgery may be necessary when the anatomy is unclear or suspicion of a complication. The conversion is usually more necessary in the elderly and patients with previous upper abdominal operations or acute cholecystitis. The incidence of conversion to open procedure is between 2% and 5% depending on the type of patient population.
  • Most low-risk patients undergoing laparoscopic cholecystectomy can be discharged the same day or the next day. Patients at high risk and emergency surgery or undergoing open cholecystectomy usually remain hospitalized longer. Hospitalization may be prolonged in patients requiring placement of abdominal drains, exploration of the bile duct or complicated with diseases of the biliary tree. Laparoscopic surgery is currently showing that in pregnancy, especially in the second quarter is as safe as open surgery. About 95% of patients expressed relief cholecystectomy biliary type pain. The remaining 5% is another cause of pain outside the gallbladder.Cholecystectomy for biliary dyskinesia provides better symptomatic relief than nonsurgical treatment. Patients with dyspepsia or diarrhea before surgery may persist with these symptoms after surgery.
  • The common bile duct stones can be removed endoscopically or surgically. The endoscopic approach may be indicated in patients with cholangitis, obstructive jaundice and in selected cases of pancreatitis caused by gallstones. The cleaning of common duct stones endoscopically is an effective treatment, but may be accompanied by complications such as pancreatitis, bleeding or perforation in about 3% of cases. Surgical removal of common duct stones can be performed by open or laparoscopic surgery. Since most of the common bile duct stones originate in the gallbladder, cholecystectomyis necessary either in the same admission or subsequently.Open cholecystectomy with common bile duct exploration is a safe and effective treatment in an acute setting.
Surgery for Hepatic Colorectal Metastases
In the United States, approximately 150,000 patients are diagnosed with colorectal cancer each year. About 20% of these patients have metastatic deposits of colorectal cancer in the liver only at the time of diagnosis or develop such metastases during the course of their illness. If hepatic colorectal metastases are not treated, the prognosis is poor. There is now evidence that resection of such metastases can improve the prognosis.
  • Patients who present with hepatic colorectal metastases are usually asymptomatic. Symptoms such as abdominal pain and weight loss are associated with advanced (high-volume) metastases and a poor prognosis. Serum carcinoembryonic antigen (CEA) concentration is pivotal in the detection of colorectal cancer recurrence. After resection of primary colorectal cancer, an increasing CEA concentration usually indicates recurrence. Overall, 78% of patients with hepatic colorectal metastases have an elevated CEA concentration. Appropriate radiologic imaging is the cornerstone for evaluation of patients with suspected hepatic colorectal metastases. These examinations include a chest x-ray and helical computed tomography of the chest and abdomen If there is doubt about the diagnosis of metastases in the liver, magnetic resonance imaging may better characterize hepatic lesions, especially if a benign condition is suspected (e.g., a hemangioma or cyst). Positron emission tomography (PET) can be used in selected patients to detect occult disease. PET is most useful in patients at high risk for recurrence after hepatic resection (for more on high-risk patients, see Expected Outcomes below).
  • Although liver resection is not the primary treatment for most patients with hepatic colorectal metastases, appropriate liver resection is the standard of care for treatment of patients with isolated hepatic colorectal metastases. Possible contraindications to the resection of hepatic colorectal metastases are the presence of extrahepatic disease and the inability to achieve complete resection. Patients with lung metastasis and direct invasion of adjacent organs such as the diaphragm, gallbladder, and colon may be candidates for resection if resection can be complete. The preoperative evaluation should include an assessment of associated co-morbid medical conditions, which may preclude safe hepatic resection. The resection of hepatic colorectal metastases begins with laparoscopy or a laparotomy through a midline or a subcostal incision. The abdomen is examined for evidence of extrahepatic disease. An ultrasound is performed to further evaluate the hepatic metastases. Any suspicious nodule outside the liver is biopsied, and frozen sections are obtained. The goal of the operation is to eliminate all metastases with clear resection margins. In the past, hepatic colorectal metastases were not resected in patients with more than 3 lesions or with lesions within 1 cm of major vessels (vena cava or main hepatic veins). However, currently surgeons with experience in hepatobiliary surgery are able tooffer resection for patients with multiple metastases (more than 3) or lesions close to major vessels. Treatment must be individualized and may require a combination of techniques. Thermal ablation techniques (cryoablation or radiofrequency ablation) have been used as an adjunct to resection or in patients who are not candidates for resection. Because ablation procedures involve relatively new techniques, the proof of efficacy is awaiting mature data. The majority of patients experience recurrence (recur) following hepatic resection of colorectal metastases. New systemic (intravenous) chemotherapy agents (such as irinotecan or oxaliplatin combined with fluoropyrimidines) have been associated with improved survival in advanced colorectal cancer. Adjuvant systemic chemotherapy should therefore be considered after hepatic resection. Because of the lack of proven efficacy, hepatic artery infusion pump chemotherapy should only be used as part of investigational protocols. Trials including combination chemotherapy (systemic and regional) are currently under way.
  • The perioperative mortality rate for resection of hepatic colorectal metastases at major centers is less than 5%, with complications occurring in 30% or less of patients. In patients without significant cirrhosis, up to 80% of the liver can be resected safely because of its capacity for regeneration. However, in selected patients, there may be concerns about postoperative liver failure or complications due to the small size of the remaining liver. In such patients, other measures such as preoperative portal vein embolization to induce hypertrophy of the liver remnant or the use of systemic chemotherapy to reduce the size of the metastases may be considered.
  • In the absence of treatment, the prognosis for patients with hepatic colorectal metastases is dismal, with 5-year survival rates of 3% or less. Among patients treated with complete resection of hepatic colorectal metastases, 30-40% will remain alive for at least 5 years. Recent studies indicate an increase in the survival rates, most likely as a result of improved imaging techniques and patient selection. Patients at high risk for recurrence after hepatic resection are those who present with multiple hepatic metastases (vs single metastases), large metastatic tumors (> 5 cm), a high CEA serum concentration (> 200 ng/mL), a node-positive primary colorectal cancer, or synchronous tumors (primary colorectal cancer and hepatic colorectal metastases).