The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases

Foreword
Preface
Introduction
Contents
Contributors
1: Surgical Anatomy of the Liver
	1.1	 Introduction
	1.2	 Arterial Anatomy
	1.3	 Portal Venous Anatomy
	1.4	 Biliary Anatomy
	1.5	 Venous Anatomy
	1.6	 Conclusion
	References
2: Surgical Anatomy of the Pancreas
	2.1	 Introduction
		2.1.1	 Arteries of the Pancreatic Head/Duodenum
			2.1.1.1	 IPDA
			2.1.1.2	 Posterior Superior Pancreatoduodenal Artery (PSPDA)
			2.1.1.3	 Anterior Superior Pancreatoduodenal Artery (ASPDA)
				Posterior Inferior Pancreatoduodenal Artery (PIPDA) and Anterior Inferior Pancreatoduodenal Artery (AIPDA)
			2.1.1.4	 Dorsal Pancreatic Artery (DPA)
	2.2	 The Veins of the Pancreatic Head
	2.3	 Surgical Techniques
		2.3.1	 Treitz Ligament Approach for Artery-First PD
	2.4	 Discussion
	2.5	 Conclusion
	References
3: Surgical Anatomy of the Biliary Tract
	3.1	 Introduction
	3.2	 Intrahepatic Biliary Tract
		3.2.1	 Right Hepatic Confluent and Its Anterior and Posterior Branches
		3.2.2	 Left Hepatic Confluent and Its Affluents
		3.2.3	 Biliary Drainage of Segment 1
		3.2.4	 Accessory Biliary Ducts
		3.2.5	 Biliary Confluence and Its Variations
	3.3	 Extrahepatic Biliary Tract
		3.3.1	 Supraduodenal Portion: Hepatic Pedicle
		3.3.2	 Retroduodenopancreatic Portion
		3.3.3	 Intramural Portion
	3.4	 Vascularization of the Main Biliary Tract
		3.4.1	 Vascularization of the Biliary Confluence
		3.4.2	 Vascularization of the Common Bile Duct
		3.4.3	 Vascularization of the Major Duodenal Papilla
	3.5	 Accessory Biliary Tract
		3.5.1	 Gallbladder and Cystic Duct
		3.5.2	 Vascularization
		3.5.3	 Triangle of the Biliary Tract
	References
4: Liver Function and Posthepatectomy Liver Failure
	4.1	 Introduction
	4.2	 Posthepatectomy Liver Failure (PHLF)
	4.3	 Preoperative Evaluation of Liver Function
		4.3.1	 Portal Hypertension
		4.3.2	 Model for End-Stage Liver Disease (MELD) Score
		4.3.3	 Blood Chemistry Tests
		4.3.4	 Indocyanine Green (ICG) Clearance Test
	4.4	 M2BPGi
	4.5	 Scintigraphy
	4.6	 Measuring Future Liver Remnant (FLR) Volume
	4.7	 Measuring FLR Function
	4.8	 Conclusions
	References
5: Surgical Approach to Pancreas, Liver, Biliary Physiologic Impairment
	5.1	 Benign Liver Disease: Pathophysiology and Indications for Surgical Treatment
		5.1.1	 Hemangioma
		5.1.2	 Focal Nodular Hyperplasia
		5.1.3	 Simple Hepatic Cyst
		5.1.4	 Hepatic Adenoma
		5.1.5	 Biliary Cystadenoma and the Potential for Cystadenocarcinoma
	5.2	 Malignant Liver Disease: Pathophysiology and Indications for Surgical Treatment
		5.2.1	 Hepatocellular Carcinoma
		5.2.2	 Metastatic Disease
		5.2.3	 Intrahepatic Cholangiocarcinoma
		5.2.4	 Hepatic Angiosarcoma
	5.3	 Benign Biliary Disease: Pathophysiology and Indications for Surgical Treatment
		5.3.1	 Acute Calculous Cholecystitis
		5.3.2	 Chronic Cholecystitis
		5.3.3	 Acalculous Cholecystitis
		5.3.4	 Biliary Dyskinesia
		5.3.5	 Choledocolithiasis
		5.3.6	 Sphincter of Oddi Dysfunction
		5.3.7	 Choledochal Cysts
		5.3.8	 Primary Sclerosing Cholangitis
		5.3.9	 Benign Biliary Stricture
	5.4	 Malignant Biliary Disease: Pathophysiology and Indications for Surgical Treatment
		5.4.1	 Extrahepatic Cholangiocarcinoma
		5.4.2	 Gall Bladder Cancer
	5.5	 Benign Pancreas Disease: Pathophysiology and Indications for Surgical Treatment
		5.5.1	 Acute Pancreatitis
		5.5.2	 Chronic Pancreatitis
		5.5.3	 Pancreas Neuroendocrine Tumors
		5.5.4	 Pancreas Cystic Neoplasms
			5.5.4.1	 Intraductal Papillary Mucinous Neoplasm
			5.5.4.2	 Mucinous Cystic Neoplasm
			5.5.4.3	 Solid Pseudopapillary Neoplasm
	5.6	 Malignant Pancreas Disease: Pathophysiology and Indications for Surgical Treatment
		5.6.1	 Pancreas Adenocarcinoma
	References
6: Biliary Tract Functions and Impairment
	6.1	 The Structure of the Biliary Tract
	6.2	 The Functions of the Biliary Tract
		6.2.1	 Gallbladder
		6.2.2	 Sphincter of Oddi
	6.3	 Impairment of Biliary Tract
		6.3.1	 Gallbladder Dysfunction
		6.3.2	 Dysfunction of the Sphincter of Oddi
		6.3.3	 Pancreaticobiliary Maljunction
	6.4	 The Functions of Bile
		6.4.1	 The Physiology of Bile
		6.4.2	 Enterohepatic Circulation
		6.4.3	 Bile Acids
		6.4.4	 Cholesterol and Bile Pigments
		6.4.5	 Nuclear Receptors and Bile Acid Metabolism
	References
7: Preinvasive Intraductal Biliary Neoplasm: Biliary Intraepithelial Neoplasm and Intraductal Papillary Neoplasm of Bile Duct
	7.1	 Introduction
		7.1.1	 Clinical Features, Risks, and Background Lesions and Imaging Findings of BIlINs and IPNBs
			7.1.1.1	 Clinical Features, Risks, and Background Lesions
				BilINs
				IPNBs
			7.1.1.2	 Imaging Findings
				BilINs
				IPNB
		7.1.2	 Pathologies of BIlINs and IPNBs
			7.1.2.1	 Gross
				BilIN
				IPNB
				Controversial Cases: BilIN or IPNB
			7.1.2.2	 Histologies
				BilINs
				IPNB.
		7.1.3	 Pathogenesis: Molecular and Genetic Alterations of BIlINs and IPNBs
			7.1.3.1	 Progression of BilINs and IPNBs
			7.1.3.2	 Molecular Alterations in BilINs and IPNBs
			7.1.3.3	 Genetic Changes in BilIN and IPNB
				BilIN
				IPNB
		7.1.4	 The Prognosis and Outcomes of BilINs and IPNBs
			7.1.4.1	 BilIN
			7.1.4.2	 IPNB
	7.2	 Conclusion
	References
8: Pathology of Biliary Tract Cancers
	8.1	 Introduction
	8.2	 Intrahepatic Cholangiocarcinoma
		8.2.1	 Gross Features
		8.2.2	 Microscopic Features
		8.2.3	 Molecular Features
	8.3	 Extrahepatic Cholangiocarcinoma
		8.3.1	 Gross Features
		8.3.2	 Microscopic Features
		8.3.3	 Molecular Features
	8.4	 Gallbladder Carcinoma
		8.4.1	 Gross Features
		8.4.2	 Microscopic Features
		8.4.3	 Molecular Features
	References
9: Multifocal Hepatocellular Carcinoma: Genomic and Transcriptional Heterogeneity
	9.1	 Introduction of Multifocal Hepatocellular Carcinoma
	9.2	 Heterogeneity of Multifocal HCC
		9.2.1	 Genomic Heterogeneity of Multifocal HCC
		9.2.2	 Transcriptional Heterogeneity of Multifocal HCC
	9.3	 The Influences of Genomic and Transcriptional Heterogeneity on Management of Multifocal HCC
	References
10: Intraductal Neoplasms of the Pancreas
	10.1	 Intraductal Papillary Mucinous Neoplasm (IPMN)
		10.1.1	 Definition
		10.1.2	 Epidemiology
		10.1.3	 Etiology
		10.1.4	 Clinical Features
		10.1.5	 Radiology
		10.1.6	 Pathology
			10.1.6.1	 Macroscopic Appearance
			10.1.6.2	 Microscopic Appearance and Variations
			10.1.6.3	 Immunohistochemistry
			10.1.6.4	 Grading
			10.1.6.5	 Differential Diagnosis
			10.1.6.6	 Molecular Pathology
			10.1.6.7	 Treatment and Prognosis
	10.2	 Intraductal Oncocytic Papillary Neoplasms (IOPN)
		10.2.1	 Definition
		10.2.2	 Epidemiology
		10.2.3	 Etiology
		10.2.4	 Clinical Features
		10.2.5	 Radiology
		10.2.6	 Pathology
			10.2.6.1	 Macroscopic Appearance
			10.2.6.2	 Microscopic Appearance
			10.2.6.3	 Immunohistochemistry
			10.2.6.4	 Differential Diagnosis
			10.2.6.5	 Molecular Pathology
			10.2.6.6	 Treatment and Prognosis
	10.3	 Intraductal Tubulopapillary Neoplasms (ITPN)
		10.3.1	 Definition
		10.3.2	 Epidemiology
		10.3.3	 Etiology
		10.3.4	 Clinical Features
		10.3.5	 Radiology
		10.3.6	 Pathology
			10.3.6.1	 Macroscopic Appearance
			10.3.6.2	 Microscopic Appearance and Variations
			10.3.6.3	 Immunohistochemistry
			10.3.6.4	 Differential Diagnosis
			10.3.6.5	 Molecular Pathology
		10.3.7	 Treatment and Prognosis
	References
11: Mucinous Cystic Neoplasms
	11.1	 Introduction
	11.2	 Clinical Aspects
	11.3	 Pathological Findings
		11.3.1	 Macroscopical Features
		11.3.2	 Histological Features
	11.4	 Molecular Abnormalities
	11.5	 Treatment and Prognosis
	References
12: Pathology of Pancreatic Cancer
	12.1	 Introduction
		12.1.1	 General Features
		12.1.2	 Diagnostic Features
		12.1.3	 Clinical Implications
		12.1.4	 Desmoplastic Stroma
		12.1.5	 Venous Invasion
		12.1.6	 Variants
		12.1.7	 Pathology in Familial Syndromes
	12.2	 Conclusions
	References
13: CT in Hepato-Bilio-Pancreatic Surgical Pathology
	13.1	 Technical CT Considerations in Hepato-Bilio-Pancreatic Evaluation
	13.2	 CT in Focal Liver Mass
		13.2.1	 Benign Liver Tumors
		13.2.2	 Malignant Liver Tumors
		13.2.3	 Infectious and Parasitic Hepatic Pathology
			13.2.3.1	 Liver Abscess
		13.2.4	 CT in Pre-/and Post Liver Transplantation
	13.3	 CT in Liver, Biliary Tree and Pancreatic Traumatic Injuries
	13.4	 CT in Acquired Biliary Tract Pathology
		13.4.1	 Biliary Tree Tumors
	13.5	 CT in Pancreatic Pathology
		13.5.1	 Pancreatic Tumors
	13.6	 CT of Postoperative Complications in HBP Surgery
	References
14: Magnetic Resonance Elastography (MRE) to Assess Hepatic Fibrosis
	14.1	 MRE Technique
	14.2	 MRE Performance
	14.3	 Pitfalls in Stiffness Measurement
	14.4	 Technical Limitations
	14.5	 Summary
	References
15: FDG-PET for Management on Hepato-Pancreato-Biliary Disease
	15.1	 Introduction
	15.2	 FDG-PET Examination for Liver Cancer
		15.2.1	 PET for Hepatocellular Carcinoma (HCC)
		15.2.2	 PET for Cholangiocellular Carcinoma (CCC)
		15.2.3	 PET Examination for Metastatic Liver Cancer
	15.3	 FDG-PET Examination for Biliary Cancer
	15.4	 FDG-PET Examination for Gallbladder Cancer
	15.5	 FDG-PET Examination for Pancreatic Cancer
	15.6	 Conclusion
	References
16: Endoscopic Ultrasound for Hepato-Pancreato-Biliary Diseases
	16.1	 Introduction
	16.2	 Diagnosis
		16.2.1	 Pancreatic Cancers
			16.2.1.1	 Imaging
			16.2.1.2	 EUS-FNA
			16.2.1.3	 Staging
		16.2.2	 Intraductal Papillary Mucinous Neoplasms (IPMNs)
			16.2.2.1	 Imaging
			16.2.2.2	 EUS-FNA
		16.2.3	 Ampullary Cancers
		16.2.4	 Bile Duct Cancers
		16.2.5	 Gallbladder Cancers
	16.3	 Therapy
		16.3.1	 Drainage
			16.3.1.1	 EUS-Guided Biliary Drainage (EUS-BD)
			16.3.1.2	 EUS-Guided Pancreatic Duct Drainage (EUS-PD)
			16.3.1.3	 EUS-Guided PFC Drainage
			16.3.1.4	 EUS-Guided Postoperative Pancreatic Fluid Collection (POPFC) Drainage
			16.3.1.5	 EUS-Guided Celiac Plexus Neurolysis (EUS-CPN)
			16.3.1.6	 EUS-Guided Ablation Therapy
	16.4	 Conclusions
	References
17: Intraoperative Imaging Techniques in Liver Surgery
	17.1	 Intraoperative Cholangiography
	17.2	 Intraoperative Ultrasound
		17.2.1	 Anatomy
		17.2.2	 Diagnosis
		17.2.3	 Resection Guidance
			17.2.3.1	 Demarcation of the Resection Area
			17.2.3.2	 Resection Guidance
			17.2.3.3	 Identification of Intrahepatic Vessels
			17.2.3.4	 Evaluation of Post-Resection Results
	17.3	 Intraoperative Fluorescence Imaging
	17.4	 Navigation Assisted Liver Resection
	References
18: Use of Radiotherapy Alone and in Combination with Other Therapies for Hepatocellular Carcinoma: Rationale and Future Directions
	18.1	 Introduction
	18.2	 Photon Therapy
	18.3	 Charged Particles Therapy
	18.4	 MRI Guided Therapy
	18.5	 Combination Strategies Using Cytotoxics
	18.6	 Radioimmunotherapy
	18.7	 Challenges and Opportunities
	18.8	 Summary
	References
19: Recent Update in Chemotherapy of Cholangiocarcinoma
	19.1	 Introduction
	19.2	 Systemic Chemotherapy
		19.2.1	 Adjuvant Therapy
		19.2.2	 First-Line Therapy
		19.2.3	 Second-Line Therapy
	19.3	 Targeted Therapy
	19.4	 Immunotherapy
	19.5	 Precision Medicine
	19.6	 Summary and Conclusion
	References
20: Chemotherapy in Pancreatic Ductal Adenocarcinoma
	20.1	 Introduction
	20.2	 Chemotherapy in PDAC
		20.2.1	 Neoadjuvant Chemotherapy
		20.2.2	 Adjuvant Chemotherapy
		20.2.3	 Palliative Chemotherapy
	20.3	 Immunotherapy
	20.4	 Tumor Microenvironment
	20.5	 Summary
	References
21: Immune-Checkpoint Inhibitors in Hepatocellular Carcinoma
	21.1	 Background
	21.2	 Rationale and the Evolving Role of Immunotherapy in Cancer Treatment
	21.3	 The Unique Microenvironment and Immune System of the Liver
	21.4	 Single-Agent Immune Checkpoint Inhibitors Trials
	21.5	 Combination Strategies
	21.6	 ICIs Use in the Neoadjuvant and Adjuvant Settings in Resectable HCC
	21.7	 Future Perspectives
	References
22: Molecularly Targeted Therapy in Cholangiocarcinoma
	22.1	 FGFR Alterations
	22.2	 IDH Mutations
	22.3	 BRAF Alterations
	22.4	 Microsatellite Instability (MSI) and Tumor Mutation Burden (TMB)
	22.5	 HER2 Amplifications and Mutations
	22.6	 NTRK and Other Targets
	22.7	 Conclusions
	References
23: Systemic Therapies for Pancreatic Cancer
	23.1	 Introduction
	23.2	 Adjuvant Systemic Therapy
	23.3	 Neoadjuvant Systemic Therapy
	23.4	 Systemic Therapy for Locally Advanced and Metastatic Disease
		23.4.1	 First-Line Therapy for Locally Advanced and Unresectable Disease
		23.4.2	 First-Line Therapy for Metastatic Disease
		23.4.3	 Second-Line Therapy
		23.4.4	 Targeted Therapy
	References
24: Endoscopic Biliary Drainage and Associated Procedures Required for Patients with Malignant Biliary Strictures
	24.1	 Introduction
	24.2	 The Tokyo Criteria: A Standard Reporting System
	24.3	 Biliary Drainage in Patients with Malignant Biliary Strictures
	24.4	 The Various Stents Available
	24.5	 Preoperative Management of a Distal Stricture
	24.6	 Palliative Management of Distal Strictures
	24.7	 Efforts to Prolong the TRBOs of Covered SEMSs
	24.8	 Hilar Strictures (Resectable Cases)
	24.9	 Hilar Stricture: Palliative Cases
	24.10	 Radiofrequency Ablation of the Bile Duct
	24.11	 Endoscopic Ultrasound-Guided Biliary Drainage
	24.12	 Conclusions
	References
25: Endoscopic Management of Peripancreatic Fluid Collection
	25.1	 Introduction
	25.2	 Indications of Drainage
	25.3	 EUS-TD Technique
	25.4	 EN Technique
	25.5	 Treatment Algorithm and Outcomes
	25.6	 Conclusion
	References
26: Endoscopic Ultrasound and Fine Needle Tissue Acquisition for Pancreatic Tumors
	26.1	 Background
	26.2	 Short History
	26.3	 EUS Equipment and Accessories
	26.4	 EUS for Pancreatic Solid Tumors
		26.4.1	 Indications for Evaluation of a Suspected Pancreatic Tumor
		26.4.2	 Technical Aspects of Endoscopic Ultrasound (EUS)-Guided Sampling
		26.4.3	 EUS for Pancreatic Ductal Adenocarcinoma
		26.4.4	 EUS for Pancreatic Neuroendocrine Tumors
		26.4.5	 EUS for Other Pancreatic Tumors
		26.4.6	 Personalized Cancer Treatment
	References
27: Enhanced Recovery After Surgery (ERAS): Concept and Purpose
	27.1	 Introduction
	27.2	 Philosophy of ERAS
	27.3	 Pathophysiology and Basis of ERAS Practices
		27.3.1	 Pre-Admission Optimization
		27.3.2	 Avoidance of Prolonged Fasting
		27.3.3	 Carbohydrate Loading
		27.3.4	 Avoidance of Mechanical Bowel Preparation
		27.3.5	 Avoidance of Nasogastric Drainage
		27.3.6	 Early Feeding
	27.4	 Clinical and Financial Outcomes Associated with ERAS
	27.5	 ERAS Implementation and Audit
	27.6	 Conclusion
	References
28: Multidisciplinary Enhanced Recovery After Surgery (ERAS) Pathway for Hepatobiliary and Pancreatic Surgery
	28.1	 Introduction
	28.2	 ERAS: Moving from Evidence-Based into Clinical Practice
	28.3	 ERAS Benefits in Hepato-Biliary and Pancreatic Surgery
	28.4	 ERAS as a Multidisciplinary Team Approach
	28.5	 Conclusion
	References
29: ERAS in Pancreatic Surgery
	29.1	 ERAS Guidelines in PD
	29.2	 Impact of ERAS on Postoperative Outcomes
	29.3	 Impact of ERAS on Hospital Costs
	29.4	 ERAS and Compliance
	29.5	 Implementation Strategy and Keys of Success
	29.6	 Conclusion
	References
30: Ultrasound-Guided Anatomic Resection of the Liver
	30.1	 Introduction
	30.2	 Anatomical Principles and Definition of Anatomic Resection of the Liver
	30.3	 Surgical Indication
	30.4	 Surgical Technique
		30.4.1	 Exposure
		30.4.2	 Exploration and Intraoperative Ultrasound
		30.4.3	 Identification of Segmental Border on the Liver Surface
		30.4.4	 Parenchymal Transection
		30.4.5	 Hemostasis and Check for Bile Leak
	30.5	 Clinical Advantages
		30.5.1	 Technical Advantages
		30.5.2	 Prognostic Advantages
	30.6	 Conclusions
	References
31: Parenchyma-sparing Hepatic Resection for Multiple Metastatic Tumors
	31.1	 Introduction
	31.2	 Multiple Bilobar CLM
		31.2.1	 Intraoperative Ultrasound
		31.2.2	 Tumor-vessel Detachment
		31.2.3	 Communicating Veins
	31.3	 New Procedures
		31.3.1	 Systematic Extended Right Posterior Sectionectomy (SERPS) [30]
			31.3.1.1	 Eligibility Criteria
		31.3.2	 Upper Trasversal Hepatectomy (UTH))
			31.3.2.1	 Mini-Upper Transversal Hepatectomy
			31.3.2.2	 Right Upper Transversal Hepatectomy [33]
			31.3.2.3	 Left Upper Transversal Hepatectomy [24]
			31.3.2.4	 Total Upper Transversal Hepatectomy [24, 34]
				Eligibility Criteria
		31.3.3	 Mini-mesohepatectomy (MMH) [35, 36]
			31.3.3.1	 Eligibility Criteria
		31.3.4	 Liver Tunnel [37, 38]
			31.3.4.1	 Liver Tunnel Without Resection of the Middle Hepatic Vein
			31.3.4.2	 Liver Tunnel with the Resection of the Middle Hepatic Vein
				Eligibility Criteria
	31.4	 Discussion
	31.5	 Concerns & Future Directions
	31.6	 Conclusions
	References
32: Open and Laparoscopic Liver Hanging Maneuver
	32.1	 Introduction
	32.2	 Advantages of LHM
	32.3	 Anatomical Basis of the LHM
	32.4	 Techniques of LHM
	32.5	 Variations of LHM
	32.6	 Limits and Contraindications
	References
33: The Glissonean Pedicle Approach: The Takasaki Technique
	33.1	 Introduction
	33.2	 Fundamental Concept of Liver Segmentation Based on the Glissonean Pedicle (Takasaki’s Liver Anatomy)
	33.3	 Glissonean Pedicle Approach at the Hepatic Hilus (Extrafascial Approach)
	33.4	 Ligation of the Glissonean Pedicle
	33.5	 Dissection of the Liver Parenchyma
	33.6	 Segmentectomy, Cone Unit Resection
	33.7	 Surgical Outcomes
	References
34: Laparoscopic Major Hepatectomy and Parenchymal-Sparing Anatomical Hepatectomy
	34.1	 Introduction
	34.2	 Developments of LLR
	34.3	 Definitions of LMH
	34.4	 Difficulty Scoring System (IWATE Criteria) and Learning Curve of LMH
	34.5	 Feasibility and Safety of LMH
	34.6	 Laparoscopic Parenchymal Sparing Anatomical Hepatectomy (Lap-PSAH)
	34.7	 Surgical Procedures at Ageo Central General Hospital (ACGH)
		34.7.1	 Laparoscopic Left Hemihepatectomy (Fig. 34.3)
		34.7.2	 Lap-PSAH (Segment 7) (Fig. 34.4)
	34.8	 Conclusion
	References
35: Laparoscopic Anatomical Resection of the Liver: Segmentectomy and Sub-segmentectomy
	35.1	 Patient Position and Trocar Placement
	35.2	 Laparoscopic Segmentectomy I (S1)
	35.3	 Laparoscopic Segmentectomy II (S2) and Segmentectomy III (S3)
	35.4	 Laparoscopic Segmentectomy IV (S4) (Subsegmentectomy IVa and IVb)
	35.5	 Laparoscopic Segmentectomy V (S5)
	35.6	 Laparoscopic Segmentectomy VI (S6)
	35.7	 Laparoscopic Segmentectomy VII (S7)
	35.8	 Laparoscopic Segmentectomy VIII (S8)
	References
36: Modified ALPPS Procedure
	36.1	 Introduction
	36.2	 Discussion
		36.2.1	 Parenchymal Transection
		36.2.2	 Hepatoduodenal Ligament Dissection
		36.2.3	 Interval Between the First and Second Stage Hepatectomy
		36.2.4	 Various Modified Subtypes of the ALPPS Procedure
			36.2.4.1	 Partial ALPPS
			36.2.4.2	 Hybrid ALPPS
			36.2.4.3	 Mini-ALPPS/ALPTIPS
			36.2.4.4	 Segment 4 Portal Pedicle-spared ALPPS
			36.2.4.5	 Tourniquet ALPPS
	36.3	 Conclusion
	References
37: Artery-First Approach in Pancreaticoduodenectomy
	37.1	 Introduction
	37.2	 Artery-First Approaches in PD
	37.3	 Right-Posterior Approach
	37.4	 Right-Uncinate Approach
	37.5	 Mesenteric Approach
	37.6	 Left-Posterior Approach
	37.7	 Anterior Approach
	37.8	 Mesopancreatic Resection
	37.9	 The Outcome of Artery-First Approaches
	37.10	 Summary
	References
38: Organ- and Parenchyma-sparing Pancreatic Surgery
	38.1	 Introduction
	38.2	 Organ-Sparing Techniques
		38.2.1	 Spleen-Preserving Distal Pancreatectomy
		38.2.2	 Duodenum-Preserving Pancreatic Head Resection
	38.3	 Parenchyma-Sparing Techniques
		38.3.1	 Central Pancreatectomy (The Dagradi-Serio-Iacono Operation)
		38.3.2	 Dorsal Pancreatectomy
		38.3.3	 Resection of the Ventral or Uncinate Process of the Pancreas
		38.3.4	 Middle-Preserving Pancreatectomy
	38.4	 Conclusion
	References
39: Isolated Pancreatoduodenectomy with Portal Vein Resection Using the Nakao Mesenteric Approach
	39.1	 Introduction
	39.2	 Surgical Techniques Used in the Nakao Mesenteric Approach
		39.2.1	 Laparotomy
		39.2.2	 Supramesocolic Approach
		39.2.3	 Inframesocolic Approach
	39.3	 Mesenteric Incision
	39.4	 Connective Tissue Clearance around the SMV and SMA
	39.5	 Division of the MCA and MCV
	39.6	 Division of the Gastrocolic Ligament and Incision of the Mesocolon
	39.7	 Connective Tissue Clearance Around the Root of the SMA and Exposure of the Mesopancreas (PLph II)
	39.8	 Exposure of the Jejunal Arteries and the IPDA and Total Mesopancreas Excision
	39.9	 Antithrombogenic PV Catheter Bypass
	39.10	 Typical Procedures After the Mesenteric Approach to Perform Isolated PD
	39.11	 Portal Vein Resection and Reconstruction
	39.12	 Reconstruction of the Alimentary Canal
	39.13	 Discussion
	References
40: Pancreaticoduodenectomy with Hepatic Artery Resection
	40.1	 Introduction
	40.2	 Indication and Preparation
	40.3	 The Dissection or Resection of HA
	40.4	 HA Reconstruction
		40.4.1	 Simple Reconstruction Case
		40.4.2	 Complicated Reconstruction Case
		40.4.3	 Concomitant Vein Resection
		40.4.4	 Management after HA Reconstruction
	40.5	 Conclusions
	References
41: Pancreaticoduodenectomy with Splenic Artery Resection for Tumors of the Pancreatic Head and/or Body Invading the Splenic Artery
	41.1	 Introduction
	41.2	 Surgical Procedures of PD-SAR
	41.3	 Patients and Methods
		41.3.1	 Patients
		41.3.2	 Preoperative Treatments
		41.3.3	 Preoperative Characteristics and Surgical Outcomes
		41.3.4	 Assessment of LPH: Incidence of Variceal Formation, Serial Changes of Platelet Count, Spleen Volume, and Hemodynamics in the Left-Side Area
		41.3.5	 Statistical Analyses
	41.4	 Results
		41.4.1	 Patients’ Background and Surgical Outcomes
		41.4.2	 Arterial Blood Supply to the Left-Sided Area after PD-SAR
		41.4.3	 Serial Changes of Platelet Count and Spleen Volume
		41.4.4	 OS Rates After the Initial Treatment
	41.5	 Discussion
	References
42: Pancreaticoduodenectomy with Superior Mesenteric Resection and Reconstruction for Locally Advanced Tumors
	42.1	 Introduction
		42.1.1	 Preoperative Planning
	42.2	 Surgical Technique
		42.2.1	 Basic Preliminary Maneuvers
		42.2.2	 Management of the Mesenteric Venous System
		42.2.3	 Dissection of the Superior Mesenteric Artery and of the Hepatic Pedicle
		42.2.4	 Section of the Pancreas and Vascular Resection
	42.3	 Postoperative Management
	42.4	 Conclusions
	References
43: Robotic Pancreaticoduodenectomy
	43.1	 Background
	43.2	 Robotic PD
	43.3	 Conclusion
	References
44: Duodenum-Preserving Pancreatic Head Resection
	44.1	 History of DPPHR
	44.2	 Classification
	44.3	 Blood Supply to Pancreatic Head and Pertinent Adjacent Organs
	44.4	 Technical Aspects of Total DPPHR
	44.5	 Technical Aspects of Subtotal DPPHR
	44.6	 Technical Aspects of Partial DPPHR
	44.7	 Outcomes of DPPHR
	References
45: Artery-First Approaches to Distal Pancreatectomy
	45.1	 Introduction
	45.2	 Surgical Technique
		45.2.1	 Dissection Behind the Pancreatic Body
		45.2.2	 Partial Resection of the Mesentery of Transverse Colon
		45.2.3	 Dissection on the Left Side of the Left Gastric Artery
		45.2.4	 Hanging Maneuver of the Pancreas
		45.2.5	 Dissection Around the Superior Mesenteric Artery (SMA) and Celiac Artery
		45.2.6	 Division of the Pancreas and Splenic Vein
		45.2.7	 Division of the Splenic Artery and Completion of Resection
	45.3	 Discussion
	References
46: Spleen-Preserving Distal Pancreatectomy
	46.1	 Introduction
	46.2	 Indications
	46.3	 Patient Positioning and Setup
	46.4	 Technique
		46.4.1	 Warshaw’s Technique
	46.5	 Postoperative Follow-Up
	References
47: Distal Pancreatectomy with En Bloc Celiac Axis Resection
	47.1	 Concepts of Distal Pancreatectomy with Celiac Axis Resection (DP-CAR)
	47.2	 Resected and Preserved Organs in DP-CAR
	47.3	 Arterial Supply to the Liver and the Stomach After DP-CAR
	47.4	 Selection of Candidates for DP-CAR
	47.5	 Surgical Procedure of DP-CAR
	47.6	 Postoperative Course Following DP-CAR
	47.7	 Long-Term Outcomes Following DP-CAR
	References
48: Modified Distal Pancreatectomy with Celiac Axis En-bloc Resection
	48.1	 Introduction
	48.2	 History, Background, and Modification of Appleby Operation for Pancreatic Cancer
	48.3	 The Anatomical Features About Celiac Trunk and Its Branches
	48.4	 The Organs and Tissues Resected by the Modified Appleby Operation (DP-CAR)
	48.5	 The Indication of Modified Appleby Operation (DP-CAR) in Patient with Pancreatic Body/Tail Carcinoma
	48.6	 Risk Score for the Modified Appleby Operation (DP-CAR)
	48.7	 Preoperative Preparation for the Modified Appleby Operation (DP-CAR)
	48.8	 The Procedure and Pitfalls of Modified Appleby Operation (DP-CAR)
	48.9	 Preservation of the Left Gastric Artery on the Basis of Anatomical Features
	48.10	 Surgical Technique Preserving Left Gastric Artery
	48.11	 Postoperative Complications After Modified Appleby Operation (DP-CAR)
	48.12	 Conclusions
	References
49: Robotic Distal Pancreatectomy
	49.1	 Surgical Technique
		49.1.1	 Instruments and Tools
		49.1.2	 Operating Room Configuration
		49.1.3	 Distal Splenopancreatectomy
		49.1.4	 Spleen-Preserving Distal Pancreatectomy
	49.2	 Results
	49.3	 Discussion
	References
50: Total Pancreatectomy
	50.1	 Introduction
	50.2	 Indications
	50.3	 Surgical Procedure
	50.4	 Vascular Resection
	50.5	 Comment
	References
51: Pancreatic Resection for Solid Pseudopapillary Neoplasms
	References
52: Pancreatic Resection for Neuroendocrine Neoplasms of the Pancreas
	52.1	 Introduction
	52.2	 Indication of Pancreatic Resection for PNENs
		52.2.1	 Non-Functional PNEN (NF-PNEN)
		52.2.2	 Functional PNEN
		52.2.3	 PNEN with Distant Metastasis
		52.2.4	 High-grade PNEN
	52.3	 Procedures Based on the Need for Systematic LND
	52.4	 Conclusions
	References
53: International Consensus Guidelines for the Management of Intraductal Papillary Mucinous Neoplasms
	53.1	 Introduction
		53.1.1	 Fukuoka Guidelines 2012 (Revised 2017)
		53.1.2	 European Guidelines 2018 (EG18)
		53.1.3	 Surgery for IPMN
		53.1.4	 Surveillance for IPMN
	53.2	 Discussion
	References
54: Remnant Pancreatic Cancer After Surgical Resection for Pancreatic Cancer
	54.1	 Introduction
		54.1.1	 Developmental Mechanism
		54.1.2	 Designations
		54.1.3	 Incidence
		54.1.4	 Predictive Factors
		54.1.5	 Treatment
	54.2	 Conclusion
	References
55: Benign Biliary Diseases
	55.1	 Introduction
	55.2	 Congenital Anomalies
		55.2.1	 Biliary Atresia
		55.2.2	 Choledochal Cyst
	55.3	 Diagnosis
	55.4	 Complications
	55.5	 Management
		55.5.1	 Gallstones
	55.6	 Pathogenesis
	55.7	 Natural History of Gallstones
	55.8	 Complications
	55.9	 Bile Duct Stones
	55.10	 Management
	55.11	 Intrahepatic Stones
	55.12	 Gallstones in Pregnancy
	55.13	 Gallbladder Stones and Biliary Cancer
		55.13.1 Benign Biliary Strictures (BBS)
	55.14	 Iatrogenic Biliary Injury
	55.15	 Mirizzi Syndrome (MS)
	55.16	 Liver Transplantation Related BBS
	55.17	 Primary Sclerosing Cholangitis (PSC)
		55.17.1 Biliary Dyskinesia
	References
56: Major Hepatic Resection for Peri-hilar Biliary Cancers
	56.1	 Introduction
	56.2	 Preoperative Evaluation
		56.2.1	 Preoperative Biliary Drainage
		56.2.2	 Portal Vein Embolization
	56.3	 Principles of Surgical Resection
		56.3.1	 Major Hepatectomy and Concomitant Resection of Segment 1
		56.3.2	 Hilar No Touch “En-bloc” Technique
		56.3.3	 Vascular Resection
		56.3.4	 Margin Status
		56.3.5	 Lymph Node Dissection
		56.3.6	 Minimally Invasive Surgery
	56.4	 Short-term Results
	56.5	 Long-term Results
	56.6	 Conclusions
	Bibliography
57: Surgical Management of Intrahepatic Cholangiocarcinoma
	57.1	 Introduction
	57.2	 Clinical Presentation
	57.3	 Serum Tumor Markers
	57.4	 Imaging
	57.5	 Treatment
	57.6	 Surgical Management
		57.6.1	 Liver Resection
	57.7	 Aim of Surgical Resection
	57.8	 Indications for Surgical Resection
	57.9	 Strategies to Improve the Future Liver Remnant
	57.10	 Staging Laparoscopy and Intraoperative Assessment of Resectability
	57.11	 Surgical Resection Procedure
	57.12	 Status of Lymphadenectomy
	57.13	 Results of Surgery
		57.13.1 Morbidity and Mortality
		57.13.2 Long-Term Outcomes
	57.14	 Recurrence
		57.14.1 Liver Transplantation
	References
58: Hepatopancreatoduodenectomy (HPD) for Biliary Tract Cancers
	58.1	 Introduction
		58.1.1	 Terminology Associated with HPD
		58.1.2	 Surgical Techniques
		58.1.3	 Pioneers of HPD
		58.1.4	 Outcomes After HPD
		58.1.5	 Practical Management During Surgery
	References
59: Hepato-biliary Injuries
	59.1	 Etiology
	59.2	 Risk Factors for Biliary Injury
	59.3	 Strategies to Avoid Biliary Injury
		59.3.1	 Classification Systems
	59.4	 Diagnosis
		59.4.1	 Clinical Presentation
		59.4.2	 Imaging
		59.4.3	 Evaluation of Bile Duct Injury
		59.4.4	 Management of Bile Duct Injuries
	References
60: Surgical Treatment for Severe Liver Injuries
	60.1	 Background
	60.2	 Diagnostics
	60.3	 Treatment
		60.3.1	 Nonoperative Management
		60.3.2	 Interventional Treatment
		60.3.3	 Surgery
		60.3.4	 Morbidity and Mortality
	References
61: Indications for Liver Transplantation in Adults: Selection of Patients with End Stage Liver Diseases
	61.1	 Historical Overview
	61.2	 Referral for Liver Transplantation
		61.2.1	 Indications for LT
			61.2.1.1	 Acute Liver Failure (ALF)
			61.2.1.2	 Chronic Liver Failure
		61.2.2	 Cholestatic and Autoimmune Liver Diseases
		61.2.3	 MELD Exceptions
		61.2.4	 Other Standardized MELD Exceptions
			61.2.4.1	 Non-Standardized MELD Exceptions
		61.2.5	 Contraindications for LT
	61.3	 Management of the Patients Included on the Waiting List
	61.4	 Allocation of Available Organs
	References
62: Indications for Liver Transplantation in Acute Liver Failure
	62.1	 Current Definition of ALF
	62.2	 Aetiology of ALF
	62.3	 Patient Assessment
	62.4	 Prognostic Factors
	62.5	 Bridging Patients to Liver Transplantation
	62.6	 Extracorporeal Liver Support Systems
	62.7	 Timing of Liver Transplantation
	62.8	 Conclusion
	References
63: Liver Graft Retrieval in Deceased Donors
	63.1	 Introduction
	63.2	 Donation After Brain Death
	63.3	 Donors after Circulatory Death
	63.4	 Hypothermic Oxygenated Machine Perfusion
		63.4.1	 Surgical Technique
			63.4.1.1	 Cross-clamping
		63.4.2	 Technical Variants
			63.4.2.1	 Split Liver Retrieval
			63.4.2.2	 En-bloc Liver-pancreas Retrieval
			63.4.2.3	 En-bloc Liver-bowel Retrieval
		63.4.3	 Back-table
			63.4.3.1	 Incidents: Accidents
	References
64: Deceased Donor Liver Transplantation: The Pendulum of Visions and Ideas
	64.1	 Introduction
	64.2	 The Pendulum of History
	64.3	 The Pendulum of Indications
	64.4	 The Pendulum of Liver Transplantation Technique
	64.5	 The Pendulum of Organ Procurement and Preservation
	64.6	 The Pendulum of Donor–Recipient Matching
	64.7	 The Pendulum of Immunosuppression
	64.8	 The Pendulum of Post-transplant Follow-up
	64.9	 The Pendulum of Liver Transplantation Combined with Other Organs
	64.10	 The Pendulum of Ethics in Liver Transplantation
	64.11	 Conclusions
	References
65: Living Donor Liver Transplantation
	65.1	 Introduction
	65.2	 Increasing the Donor Pool in Adult LDLT: Various Graft Types
		65.2.1	 Graft Size
		65.2.2	 Left Liver Graft
		65.2.3	 Right Liver Graft
		65.2.4	 Right Lateral Sector Graft
		65.2.5	 Dual Graft
		65.2.6	 ABO Blood Type Incompatible Graft
	65.3	 LDLT for HCC: Expanding the Indication
		65.3.1	 Size and Number Expansion
		65.3.2	 Expansion with Biomarkers
		65.3.3	 LDLT Vs DDLT for HCC Recurrence
	65.4	 LDLT for Hepato-pancreato-biliary Malignancies Other than HCC
	References
66: Pyogenic Liver Abscess
	66.1	 Background
	66.2	 Risk Factors and Etiopathogenesis
	66.3	 Clinical Presentation
	66.4	 Serum Biochemistry
	66.5	 Microbiology
	66.6	 Radiological Imaging
	66.7	 Initial Management
		66.7.1	 Antibiotics
		66.7.2	 Percutaneous Aspiration
		66.7.3	 Percutaneous Drainage (PD)
		66.7.4	 Surgical Drainage (SD)
		66.7.5	 Laparoscopic Drainage (LD)
		66.7.6	 Endoscopic Ultrasound (EUS)-guided Drainage
	66.8	 Subsequent Management
	66.9	 Prognosis
		66.9.1	 Size of abscess
		66.9.2	 Presence of Gas Formation
		66.9.3	 Multiloculated abscess
		66.9.4	 Microbiology
		66.9.5	 Unique Situation: Liver Transplantation
	66.10	 Conclusion
	References
67: Liver Transplantation for Colorectal and Neuroendocrine Liver Metastases and Hepatoblastoma
	67.1	 Introduction
	67.2	 Colorectal Liver Metastases
	67.3	 Neuroendocrine Tumor Liver Metastases
	67.4	 Hepatoblastoma
	67.5	 Conclusions
	References
68: Technical Variant Liver Transplantation: Split, Dual Graft, and Auxiliary Transplantation
	68.1	 Split Liver Transplantation
		68.1.1	 Donor Recipient Matching
		68.1.2	 Graft Harvesting
			68.1.2.1	 In-situ Versus Ex-situ Splitting
		68.1.3	 Adult and Pediatric Recipients
			68.1.3.1	 Technical Features
		68.1.4	 Adult and Adult Recipients
			68.1.4.1	 Technical Features
	68.2	 Dual Graft Liver Transplantation
		68.2.1	 Small for Size Syndrome
		68.2.2	 Rationale
		68.2.3	 Technical Features
	68.3	 Auxiliary Partial Orthotopic Liver Transplantation
		68.3.1	 Rationale
		68.3.2	 Technical Features
	References
69: Domino Liver Transplantation
	69.1	 Background
	69.2	 Indications in Domino Donor
		69.2.1	 Familial Amyloidotic Polyneuropathy
		69.2.2	 Familial Hypercholesterolemia
		69.2.3	 Maple Syrup Urine Disease
		69.2.4	 Primary Hyperoxaluria
		69.2.5	 Acute Intermittent Porphyria
	69.3	 Indications in Domino Recipient
	69.4	 Technical Considerations
	69.5	 Long-term Results
	References
70: Cell Transplantation
	70.1	 Introduction
	70.2	 Allogeneic PIT
	70.3	 Problems and Solutions to Allogeneic PIT
	70.4	 TPIAT
	70.5	 Future Directions of Allogeneic PIT and TPIAT
		70.5.1	 Alternative Cell Sources for Islet Transplantation
		70.5.2	 Expanding Indication for TPIAT
	70.6	 Conclusions
	References