Hepatobiliary And Pancreatic Surgery

Front Cover
Title Page
Copyright
Series Editors’ preface
Editors’ preface
	Acknowledgements
Evidence-based practice in surgery
Contributors
Liver function and failure
	Overview of liver functions and evolution
	Symptoms of liver failure: acute and chronic
		Common causes of acute liver failure: hepatic insufficiency following liver resection
		Chronic liver failure
		Metabolic liver function
		Why do patients die from liver failure?
	Assessment of the liver
		Measuring liver volume
		Blood tests of liver function
		Tests of liver function measuring substance clearance
			Indocyanine green (ICG)
			Hepatobiliary scintigraphy and SPECT
			Lidocaine (MEG-X)
			Aminopyrine breath test
			Urea synthesis
			Glutathione synthesis
		Measuring liver blood flow
			Effect of major liver resection on hepatic blood flow
		Assessment of innate immunity
		Liver regeneration
			Molecular signals for hepatic regeneration
			Cell populations involved in liver regeneration
		Consequences of surgery
		Small-for-size syndrome
		Hepatic steatosis
			Assessment of steatosis
		Chemotherapy-induced liver changes
		Portal vein embolisation
			Technique
		Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS procedure)
	Supporting the failing liver
		N-Acetyl cysteine
		Nutritional support in liver failure
		Extracorporeal liver support
		Artificial liver support
		Bioartificial liver systems
		Liver transplantation
		Cell therapy for liver failure: general principles
		Haemopoetic stem cell therapy for liver disease in humans
	Future developments
	Key references
Hepatic, biliary and pancreatic anatomy
	Liver
		Overview of hepatic anatomy and terminology
			Divisions of the liver based on the hepatic artery
			Resectional terminology
		Surgical anatomy for liver resections
			Hepatic arteries and liver resections
			Bile ducts and liver resections
				Prevailing pattern and important variations of bile ducts draining the right hemiliver
				Prevailing pattern and important variations of bile ducts draining the left hemiliver
				Prevailing pattern of bile ducts draining the caudate lobe (Sg1)
			Portal veins and liver resections
				Ramification of the left portal vein
			Hepatic veins and liver resection (Fig. 2.14)
				Liver capsule, attachments and the plate system
			Liver volume and regeneration
	Gallbladder and extrahepatic bile ducts
		Gallbladder
			Agenesis of the gallbladder
			Double gallbladder
			Cystic duct
			Cystic artery
		Extrahepatic bile ducts
			Anomalies of extrahepatic bile ducts
			Extrahepatic arteries
			Blood supply of bile ducts
	Pancreas
		Embryological development of the pancreas
		Anatomical structure and functions of the pancreas
			Pancreatic ducts
			Blood supply of the pancreas
			Lymphatics of the pancreas
			Anatomical relations and ligaments of the pancreas
			Innervation of the pancreas
	Key references
Staging and assessment of hepatobiliary malignancies
	Introduction
	Colorectal liver metastases
		Transabdominal ultrasound
		Computed tomography and magnetic resonance imaging
		Positron emission tomography
		Diagnostic laparoscopy and laparoscopic ultrasound
		Staging and assessment of resectability
	Hepatocellular carcinoma
		Transabdominal ultrasound
		Computed tomography and magnetic resonance imaging
		Diagnostic laparoscopy and laparoscopic ultrasound
		Staging and assessment of resectability
	Pancreatic and periampullary carcinoma
		Transabdominal ultrasound
		Computed tomography and magnetic resonance imaging
		Endoscopic retrograde cholangiopancreatography
		Endoscopic ultrasound (EUS)
		Positron emission tomography
		Diagnostic laparoscopy and laparoscopic ultrasound
		Staging and assessment of resectability
	Proximal bile duct tumours
		Transabdominal ultrasound
		Computed tomography and magnetic resonance imaging
		Endoscopic retrograde cholangiopancreatography
		Positron emission tomography
		Diagnostic laparoscopy and laparoscopic ultrasound
		Staging and assessment of resectability
	Key references
Benign liver lesions
	Introduction
	Hepatocellular liver lesions
		Focal nodular hyperplasia (FNH)
			General
			Clinical presentation
			Diagnosis
			Pathology
			Management
		Hepatocellular adenoma
			General
			Clinical presentation
			Diagnosis
			Pathology
			Management
		Nodular regenerative hyperplasia
	Cholangiocellular liver lesions
		Simple cysts of the liver
			General
			Clinical presentation
			Diagnosis
			Management
		Polycystic liver disease
			General
			Clinical presentation
			Management
		Cystadenoma
			General
			Clinical presentation
			Imaging
			Management
		Bile duct adenoma
		Intraductal papillary neoplasm of the bile duct
	Mesenchymal liver lesions
		Haemangiomata
			General
			Clinical presentation
			Diagnosis
			Pathology
			Management
		Hepatic lipoma and angiolipoma
	Inflammatory liver lesions
		Pyogenic liver abscess
			General
			Clinical presentation
			Diagnosis
			Management
		Amoebic liver abscess
			General
			Clinical presentation
			Management
		Hydatid cysts
			General
			Clinical presentation
			Diagnosis
			Management
	Other liver lesions
	Key references
Primary malignant tumours of the liver
	Hepatocellular carcinoma
		Incidence of HCC
		Risk factors for HCC
			Cirrhosis vs no underlying liver disease
			HBV infection
			HCV infection
			Human immunodeficiency virus (HIV) infection
			Other viral infections
			Alcohol
			Non-alcoholic fatty liver disease (NAFLD)
			Hereditary haemochromatosis
			Cirrhosis of other aetiologies
			Aflatoxin
			Metabolic liver diseases and HCC
			Adenoma, contraceptives and androgens
		Pathology of HCC and of nodular lesions in chronic liver disease
		Clinical presentation
		Liver function tests and tumour markers
			Liver function tests
			Serum tumour markers
				Alpha-fetoprotein
				Others serum tumour markers
		Morphological studies
			Ultrasound
			Computed tomography
			Magnetic resonance imaging
			Contrast-enhanced ultrasound
			Other imaging
				Angiography
				Positron emission tomography
			Accuracy of imaging techniques
		Requirement for and reliability of histological study
		Diagnosis of HCC
		Natural history of HCC and staging systems
		Screening for HCC
		Treatment options
			HCC in normal liver
			Liver resection of HCC in cirrhotic patients
				Liver resection
					Main limitations
					Risk of surgery and patient selection
					Technique
					Outcome after resection
					Treatment of recurrence
				Liver transplantation (LT)
					Rationale
					Patient selection
					Treatment on the waiting list
				Transarterial chemoembolisation (TACE)
					Technique
					Contraindications
					Morbidity and mortality
					Monitoring
					Efficacy
				Percutaneous local ablative therapy
					Technique
					Advantages and drawbacks
					Contraindications and limitations
					Methods and margins
					Indication
			Other palliative treatments
				Conventional systemic chemotherapy
				Anti-angiogenic targeted therapies
				Radioembolisation
				Other treatments
		Defining a treatment strategy
			Uncomplicated HCC associated with chronic liver disease
			Treatment of complicated HCC
	Fibrolamellar carcinoma (FLC)
	Intrahepatic cholangiocarcinoma (ICCA)
		Incidence
			Risk factors
		Classification and staging
		Pathology and progression analysis
		Clinical presentation and laboratory tests
		Imaging studies
		Diagnosis
		Treatment
	Epithelioid haemangioendothelioma (EHE)
	Angiosarcoma
	Primary hepatic lymphoma
	Key references
Colorectal liver metastases
	Introduction
	Diagnosis
	Surgical resection
		Patient selection
		Issues in management of CRLM
			Current practice for margin status
			Role of the FLR in resection of CRLM
			Extrahepatic metastatic disease and role of surgery
			Role of diagnostic laparoscopy before CRLM resection
			Current surgical strategy in management of patients with bilateral CRLM
		Preoperative chemotherapy
			Resectable metachronous CRLM
			Unresectable metachronous CRLM
			Synchronous CRLM
		Adjuvant chemotherapy
			Systemic chemotherapy
			Hepatic artery infusion (HAI) chemotherapy
			Portal vein infusion chemotherapy
		Survival and prognosis
		Surveillance
	Management of unresectable CRLM
		Chemotherapy
			Systemic chemotherapy
			HAI chemotherapy
		Ablation therapy
		Radiation therapy
	Conclusion
	Key references
Non-colorectal hepatic metastases
	Introduction
		Pathophysiology and molecular basis of liver metastases
		Clinical approach to non-colorectal liver metastases
		Treatment strategies
	Management of liver metastases by primary tumour
		Neuroendocrine tumours
		Gastrointestinal stromal tumours
		Breast cancer
		Ovarian cancer
		Renal cell carcinoma
		Melanoma
		Non-colorectal gastrointestinal adenocarcinoma
			Oesophagus
			Stomach
			Small bowel
			Pancreas
		Testicular cancer
		Urothelial cancer
		Lung cancer
		Adrenocortical tumours
		Endometrial cancer
	Conclusion
Portal hypertension and liver transplantation
	Introduction
	Aetiology
		Definition of portal hypertension
		Pathophysiology
		Natural history
		Severity of liver disease
	Presentation
		Evaluation
	Management
		First line therapy options
			Pharmacotherapy
			Endoscopy
		Second-line therapy options
			Balloon tamponade
			TIPSS (Transjugular intrahepatic portosystemic shunt)
			Surgical shunts (Fig. 8.2)
	Clinical scenarios
		Prevention of variceal bleeding
		Treatment for bleeding varices
			Gastric varices
			Portal hypertensive gastropathy
			Segmental portal hypertension
			Budd–Chiari syndrome
			Portal vein thrombosis
			Prevention of re-bleeds
	Liver transplantation
		Indication
		Donor hepatectomy
		Recipient hepatectomy
		Implant
		Complications
		Immunosuppression
		Results
	Key references
Pancreas and islet transplantation
	Introduction
	Pancreas transplantation
		History of pancreas transplantation
			Indications for pancreas transplantation
	Pancreas retrieval operation
		The pancreas transplant operation
			General considerations
			Management of exocrine secretions
			Management of the venous drainage
		Immunosuppression in pancreas transplantation
		Diagnosis and management of acute rejection following pancreas transplantation
		Complications of pancreas transplantation
			Vascular complications
				Thrombosis
				Haemorrhage
				Infective complications
				Allograft pancreatitis
				Complications specific to bladder drainage
		Outcome following pancreas transplantation
			Factors influencing pancreas transplantation outcome
				Recipient age
				Re-transplantation
				HLA matching
				Management of exocrine secretions and management of venous drainage
				Immunosuppression
				Donor factors
			Long-term outlook following pancreas transplantation
				Pancreas transplantation and life expectancy
			Influence of pancreas transplantation on diabetic complications
				Nephropathy
				Retinopathy
				Neuropathy
				Cardiovascular disease
	Islet transplantation
		Patient selection and assessment
		Islet isolation
		The islet transplant
		Immunosuppression and outcomes
		Barriers to long-term function
		Islets as a cell therapy
	Key references
The spleen and adrenal glands
	Introduction
	Anatomy and embryology
	Indications for splenectomy
		Trauma
		Haematological
		Neoplastic
		Infectious
	Splenectomy
		Open
		Laparoscopic
		Partial splenectomy
		Splenectomy vaccinations
	Adrenal
		Introduction
	Anatomy and embryology
		Physiology
		Indications for adrenalectomy
			Aldosteronoma (primary hyperaldosteronism)
			Cushing syndrome
			Pheochromocytoma
			Primary adrenocortical carcinoma
			Incidentaloma
		Secondary adrenal metastases
		Adrenalectomy
			Open
				Left
				Right
			Laparoscopic
				Left
				Right
	Key references
Gallstones
	Introduction
	Pathogenesis of gallstones
	Risk factors
	Pigment stones
	Presentation
		Biliary pain
		Acute cholecystitis
		Common bile duct stones
		Acute pancreatitis
		Mirizzi syndrome
		Intrahepatic stone disease
	Management of gallstones
		Conservative
		Non-operative management
		Cholecystectomy
		Intraoperative bile duct imaging and prevention of bile duct injury
		Acute cholecystitis
		Prophylactic cholecystectomy
		Bile duct stones
			ERCP
			Surgical bile duct exploration
	Approaches to the management of simultaneous CBD and gallbladder stones
	Approaches to abnormal LFTs prior to LC
	Management of specific scenarios
		Gallstone ileus
		Mirizzi syndrome
	Postcholecystectomy complications – identification and management
		Early presentation
		Delayed presentation
		Bile duct injury
		Postoperative problems (chronic)
		Gallstones and cancer
		Porcelain gallbladder
	Other diseases of the gallbladder
		Acute acalculous cholecystitis
		Primary infections of the gallbladder
		Chronic acalculous cholecystitis
		Gallbladder disease in childhood
		Adenomyomatosis
	Key references
Benign biliary tract diseases
	Introduction
	Congenital anomalies
		Biliary atresia
		Choledochal cysts
			Classification
			Risk of malignancy
			Management
			Special operative techniques
	Iatrogenic biliary injury
		Aetiology
		Techniques to avoid injury
		Classification
		Presentation
		Management
			Intraoperative recognition
			Postoperative recognition: biliary fistula
			Postoperative recognition: biliary obstruction
			The timing of repair
				Early repair
				Delayed repair
				Associated vascular injury
				Further imaging
				Operative techniques
			Management of complications related to repair
				Revisional surgery
				Liver resection and transplantation
			Prognosis
				Success of repair
				Survival
				Quality of life
				Associated malignancy
	Benign biliary strictures
		Mirizzi's syndrome – see Chapter 11
		Hepatolithiasis – see Chapter 11
		Parasitic infestation causing jaundice
			Liver flukes (trematodes)
			Echinococcus
				Treatment
			Ascaris lumbricoides
		HIV/AIDS-associated cholangiopathy
		Biliary strictures imitating malignancy
		Primary sclerosing cholangitis
			Aetiology
			Presentation
			Investigation
			Management
			Exclusion of associated malignant stricture
		Immunoglobulin G4 (IgG4)-related disease
			Autoimmune pancreatitis
			IgG4-related sclerosing cholangitis
			Treatment
	Functional biliary disorders
	Key references
Malignant lesions of the biliary tract
	Introduction
	Cholangiocarcinoma
		Epidemiology
		Risk factors
			Primary sclerosing cholangitis
			Congenital cysts
			Hepatolithiasis
			Parasitic infection
			Viral hepatitis and cirrhosis
			Chemical exposure
		Classification/histopathology
		Clinical presentation
		Diagnostic assessment
			Radiological investigation
				Computed tomography
				Duplex ultrasonography
				Magnetic resonance cholangiopancreatography (MRCP)
				Positron emission tomography
			Invasive modalities
				Direct cholangiography
				Endoscopy
				Cytology
				Choledochoscopy
				SpyGlass endoscopy
			Serum markers
		Staging
			Hilar cholangiocarcinoma
			Extrahepatic cholangiocarcinoma
			Intrahepatic cholangiocarcinoma
		Management
			Preoperative tissue diagnosis
			Preoperative biliary drainage
			Neoadjuvant therapy
			Portal vein embolisation
		General operative principles
			Diagnostic laparoscopy
			Margin-negative resection
			Portal lymphadenectomy
			Caudate lobectomy
			No touch technique
		Postoperative oncological outcomes
		Technical aspects of resection
		Adjuvant therapy
		Transplantation
		Palliative therapy
			Intrahepatic biliary-enteric bypass
			Systemic therapy
			Novel agents
			Regional chemotherapy/hepatic arterial infusion
			Y-90 radioembolisation
	Gallbladder cancer
		Epidemiology/aetiology
		Clinical presentation and diagnosis
		Histopathology and staging
		Radiological assessment
		Obstructive jaundice
		General operative principles
			Margin-negative resection
			Portal lymphadenectomy
			T1/T2 tumours
			Extended resections
			Unsuspected malignancy at exploration
			Malignancy diagnosed post-cholecystectomy
		Adjuvant therapy
Complicated acute pancreatitis
	Introduction
		Initial management
		Key concepts
	Definitions and terminology in acute pancreatitis
		Acute peripancreatic fluid collection (APFC)
		Pancreatic pseudocyst
		Necrosis
			Acute necrotic collection
			Walled-off necrosis
		Sterile and infected collections
			Clinical patterns and complications
				Early phase complications (<4 weeks)
					Systemic complications
					Organ failure
				Intra-abdominal hypertension (IAH)
					The role of ERCP in acute pancreatitis
					Early haemorrhage
					Colonic ischaemia
				Late complications (>4 weeks)
				Management of collections associated with acute pancreatitis
				Management of necrosis
				Indications for intervention
			Sepsis control in an infected acute necrotic or walled-off collection (early phase, 2–6 weeks)
				Methods of sepsis control
					Minimally invasive approaches to infected necrosis
					Percutaneous drainage
					Minimally invasive surgery
					Endoscopic necrosectomy
					Open laparotomy/debridement
					Retrocolic/perineal/mesenteric necrosis
				Nutritional support
					Nutritional delivery in the patient with acute pancreatitis
					Disease modulation through content or mode of delivery
					Delayed gastric emptying/gastric outlet obstruction
				Management of acute phase complications
					Haemorrhage
		Venous thrombosis
		Enteric fistula
		Biliary obstruction
	Long-term complications
		Pancreatic duct fistula
		Pancreatic duct stricture
			Disconnected duct syndrome
		Late extrahepatic biliary stricture
		Portal and splenic vein thrombosis and cavernous transformation
	Key references
Chronic pancreatitis
	Introduction
	Definition
	Classification of chronic pancreatitis
	Incidence
	Aetiology
		Pathogenesis of pain in chronic pancreatitis
	Clinical presentations
		Acute presentation of chronic pancreatitis
		Chronic presentation of chronic pancreatitis
		Index presentation with complications of chronic pancreatitis
		Asymptomatic incidental finding
	Practical differential diagnoses in chronic pancreatitis
		Pancreatic cancer
		Autoimmune pancreatitis
		Intraductal papillary mucinous neoplasm (IPMN)
	Clinical course
		Baseline assessment of a patient with suspected chronic pancreatitis
	Medical management of chronic pancreatitis
		Analgesia
		Alcohol avoidance
		Smoking cessation
		Exocrine replacement therapy
		Medications of unproven benefit
	Endoscopic management of chronic pancreatitis
		Endoscopic drainage compared to surgical drainage of the main pancreatic duct
		Endoscopic drainage/stenting of the main pancreatic duct
		Endoscopic coeliac plexus block
		Endoscopic treatment of complications of chronic pancreatitis
	Surgical management of chronic pancreatitis
		Indications for surgery
		Case selection for surgery in chronic pancreatitis
		Timing of surgery
		Preparation for surgery
		Selection of surgical procedure
			Surgery for chronic pancreatitis in patients with a pancreatic head mass
			Surgery for chronic pancreatitis in patients with a dilated main pancreatic duct without pancreatic head mass
			Indications for total pancreatectomy for chronic pancreatitis
			Surgical management of small-duct chronic pancreatitis
	Complications of longstanding chronic pancreatitis
		Biliary stricture
		Duodenal stenosis
		Pancreatic ascites
		Pseudocyst complicating chronic pancreatitis
		False aneurysm of visceral vessels
		Extrahepatic portal hypertension
		Pancreatic cancer complicating chronic pancreatitis
	Key references
Pancreatic adenocarcinoma
	Introduction
	Epidemiology
	Risk factors (see Box 16.1)
		Smoking
		Diet and alcohol
		Occupation
		Past medical history
		Hereditary pancreatic cancer
	Precursor lesions
	Presentation
	Investigation
		Serology
		Markers
	Diagnosis
		Imaging studies
		Cytology/histology
		Advanced staging techniques
			Laparoscopy
	Pathology
	Treatment
		Resection
		Pancreatico-duodenectomy
		Pylorus-preserving pancreatico-duodenectomy (PPPDR)
		Extended lymph node and vascular dissection
		Distal pancreatectomy
		Laparoscopic pancreatectomy
		Total pancreatectomy
		Central pancreatectomy
	Surgical palliation
		Obstructive jaundice
		Upper GI tract outflow obstruction
	Adjuvant therapies
	Neoadjuvant therapy
	Future areas of interest
	Key references
Cystic and neuroendocrine tumours of the pancreas
	Introduction
	Intraductal papillary mucinous neoplasms
		Clinical presentation
		Investigation
	Pathology
		Management
		Outcome
	Pancreatic neuroendocrine tumours
		Clinical presentation
		Investigations
			Biochemical
			Radiology
		Treatment
		Metastatic disease
		Pathology and outcome
	Other tumours
	Key references
Hepatobiliary and pancreatic trauma
	Introduction
	Liver trauma
		Mechanisms of liver injury
		Classification of liver injury
		Diagnosis of liver injury
			Other diagnostic/therapeutic modalities for the assessment and treatment of liver injury
		Management of liver injury: selection of patients for non-operative management
		Operative management of liver injury
			General strategy
			Theatre set-up, patient positioning and choice of incision
			Initial manoeuvres and intraoperative assessment
				Perihepatic packing
			The Pringle manoeuvre
			Techniques for hepatic surgical haemostasis
			Resectional debridement
			Anatomical liver resection
			Management of hepatic venous and retrohepatic caval injury
			Ex vivo surgery and liver transplantation
		Complications of liver trauma
			Complications of non-operative management
			Postoperative complications after surgery for liver trauma
		Outcome after liver injury
	Extrahepatic biliary tract trauma
		Incidence of biliary injury
		Classification of biliary injury
		Presentation and diagnosis of Łbiliary injury
		Operative management of biliary injury
		Outcome after biliary injury
	Pancreatic trauma
		Mechanisms of pancreatic injury
		Diagnosis of pancreatic injury
		Classification of pancreatic injury
		Initial management of pancreatic injury
		Operative management of Łpancreatic injury
		Complications of pancreatic injury
	Conclusion
	Key references