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.