1. Hepatobiliary Surgery Anil S. Paramesh, MD, FACS Associate Professor of Surgery and Urology Tulane Transplant Institute Tulane University School of Medicine New Orleans

2. Bile is 90% water Bile Salts – 80% 1° Bile Acids – cholic and chenodeoxycholic 2° Bile Salts – lithocholic and chenodeoxycholic Phospholipids – 15% Cholesterol – 5%

4. Function of bile Bile facilitates fatty acid and monoglyceride absorption via formation of micelles Bile facilitates fatty acid and monoglyceride absorption via formation of micelles Fat soluble vitamins A,D,E & K dependant on this Fat soluble vitamins A,D,E & K dependant on this Sole mechanism of cholesterol loss in the body Sole mechanism of cholesterol loss in the body

5. Gallbladder Actively absorbs salt and water to concentrate bile Actively absorbs salt and water to concentrate bile Secretes H+ ions (keeps Ca+ soluble) and mucus Secretes H+ ions (keeps Ca+ soluble) and mucus Contracts with parasympathetic and CCK stimulation – normal contraction should be ~ 80% Contracts with parasympathetic and CCK stimulation – normal contraction should be ~ 80%

6. Gallstones Cholesterol obesity, rapid wt loss, ileal resection, pregnancy, TPN Pigment Hemolytic anemias, brown vs. black CalciumPTH

7. Asymptomatic Cholelithiasis  Cholecystectomy only if: 1. diabetes mellitus 2. anticipated pregnancy 3. concurrent abdominal operation (bypass) 4. anticipated transplant Also for polyps > 1cm

8. HIDA scan  Calculous and acalculous acute cholecystitis the gallbladder is not visualized as a result of cystic duct obstruction  No visualization or delayed visualization are common in chronic cholecystitis  <33%EF indication for surgery

9. Cholecystectomy Lap chole has higher risk of bile duct injury than open Lap chole has higher risk of bile duct injury than open 10% - 12% of pts with cholelithiasis will have choledocholithiasis 10% - 12% of pts with cholelithiasis will have choledocholithiasis

11. Bile duct injury Sharp, < 2mm, consider primary repair, ± T- tube Sharp, < 2mm, consider primary repair, ± T- tube Bovie injury, > 2mm, Roux en Y hepaticojejunostomy Bovie injury, > 2mm, Roux en Y hepaticojejunostomy Use absorbable sutures!! Use absorbable sutures!!

12. Compl of cholecystectomy Injury to R hepatic artery – may present with biliary strictures/abscesses later on Injury to R hepatic artery – may present with biliary strictures/abscesses later on Hemobilia – pseudoaneurysm of traumatized art. Presents with hematemesis, jaundice, RUQ pain. Tx is embolization Hemobilia – pseudoaneurysm of traumatized art. Presents with hematemesis, jaundice, RUQ pain. Tx is embolization

13. Cholangitis Charcot’s Triad Charcot’s Triad Raynaud’s Pentad Raynaud’s Pentad Always treat with hydation and abx first – chance of stone passage Always treat with hydation and abx first – chance of stone passage CBD exploration vs. ERCP CBD exploration vs. ERCP Transduodenal sphincterotomy if above unsuccessful Transduodenal sphincterotomy if above unsuccessful May do PTC first if pt is septic May do PTC first if pt is septic

14. Gallstone ileus  Tumbling obstruction  X Ray- small bowel obstruction with pneumobilia  Most common site of obstruction is in the terminal ileum  Initial therapy is appropriate resuscitation followed by surgery  Proximal enterotomy with milking back of stone  Search for additional intestinal stones, which are present in 10% of patients  Do not repair fistula if inflammation acute or hard tissue

15. Choledochal cysts Type I most common Type I most common Risk of CCA, esp type I & IV – comp excision Risk of CCA, esp type I & IV – comp excision II/III – exc/endosc opening II/III – exc/endosc opening V (Caroli’s) diff from PCLD – bile ducts are involved. May need resection/transplant V (Caroli’s) diff from PCLD – bile ducts are involved. May need resection/transplant

16. Sclerosing Cholangitis  Primary vs. Secondary  Strong association with UC and autoimmune diseases  Frequent biliary septic episodes  Tx is medical unless localized extrahepatic  Risk of development of cholangioca  Liver transplant for diffuse PSC

17. Cancer of the gallbladder  Stage 1b (muscle) and higher requires radical cholecystectomy  Wedge resection of Seg IVA and V, portal lymphadenecetomy  Need to check cystic duct margin @ surgery  Good survival (>75%) if earlier stage and completely excised

18. Surgical Anatomy of the Liver

19. GROSS ANATOMY

20. PROMETHEUS WAS HE THE FIRST LIVER RESECTION? Liver regenerates in 6 weeks

21. Hepatic Arteries Derived from the celiac axis, which becomes the common hepatic artery after giving off the gastroduodenal branch Derived from the celiac axis, which becomes the common hepatic artery after giving off the gastroduodenal branch 15 to 20% of persons, the right hepatic artery can arise from the superior mesenteric artery 15 to 20% of persons, the right hepatic artery can arise from the superior mesenteric artery the left hepatic artery originates from the left gastric artery and is located in the gastrohepatic ligament in 15% of individuals the left hepatic artery originates from the left gastric artery and is located in the gastrohepatic ligament in 15% of individuals the arterial blood supply accounts for only 25% of hepatic blood flow the arterial blood supply accounts for only 25% of hepatic blood flow

22. Portal Vein Supplies 75% of blood to liver Supplies 75% of blood to liver Formed by SMV and SV Formed by SMV and SV Portal vein pressure is 3 -5 mm Hg Portal vein pressure is 3 -5 mm Hg No valves in the portal vein No valves in the portal vein

23. Hepatic Veins 3 hepatic veins! 3 hepatic veins! Hepatic veins begin in the liver lobules and coalesce to form the right, left, and middle hepatic veins Hepatic veins begin in the liver lobules and coalesce to form the right, left, and middle hepatic veins Left and middle typically join just before reaching IVC Left and middle typically join just before reaching IVC Short hepatic veins Short hepatic veins

24. Each segment has it’s own triad

25. Elevated LFTs AST (SGOT), ALT (SGPT), and LDH are indicators of the integrity of the membranes and increase suggests cellular damage AST (SGOT), ALT (SGPT), and LDH are indicators of the integrity of the membranes and increase suggests cellular damage Bilirubin, alk phos, 5’-nucleotidase, leucine aminopeptidase, and γGT reflect excretory capacity and increase suggest biliary stasis Bilirubin, alk phos, 5’-nucleotidase, leucine aminopeptidase, and γGT reflect excretory capacity and increase suggest biliary stasis

26. Infections - Bacterial Most common cause of pyogenic liver abscess is from biliary source Most common cause of pyogenic liver abscess is from biliary source E.coli most common, may be anaerobes E.coli most common, may be anaerobes May be from portal seeding – diverticulitis, etc. May be from portal seeding – diverticulitis, etc. Tx – drainage and antibiotics Tx – drainage and antibiotics

27. Infection amebic Infection route via portal vein – may not have diarrhea Infection route via portal vein – may not have diarrhea History of third world country exposure History of third world country exposure CT scan typically single collection with peripheral rim of edema CT scan typically single collection with peripheral rim of edema “Anchovy paste” aspiration frequently neg – need serologic testing for E. Histolytica “Anchovy paste” aspiration frequently neg – need serologic testing for E. Histolytica Tx – antibiotics (Flagyl) only Tx – antibiotics (Flagyl) only

28. Infections - Echinococcal Dog are definitive host. Sheep and humans are intermediate hosts Dog are definitive host. Sheep and humans are intermediate hosts History of sheep exposure History of sheep exposure Pain, cholangitis, anaphylaxis Pain, cholangitis, anaphylaxis CT scan - daughter cysts. CT scan - daughter cysts. Dense calcification usually signifies dead parasites and may be left alone Serolog testing – no aspirate ! Serolog testing – no aspirate !

29. Infections - Echinococcal If has cholangitis – ERCP first to r/o biliary connection If has cholangitis – ERCP first to r/o biliary connection Tx – antihelminthics with drainage Tx – antihelminthics with drainage PAIR PAIR Open surgery – pericystectomy vs. cyst unroofing Open surgery – pericystectomy vs. cyst unroofing 20% NS 20% NS

30. Liver Mass - FNH Thought to be due to embyologic disturbance of blood flow in liver. B9 Thought to be due to embyologic disturbance of blood flow in liver. B9 Usually incidental Usually incidental CT shows central scar CT shows central scar Confirmatory test – sulfur colloid scan. Confirmatory test – sulfur colloid scan. Tx – resect only if symptomatic Tx – resect only if symptomatic

31. FNH

32. Sulfur colloid scan – differentiate FNH vs HCC FNH takes up dye because of normal liver parenchyma and increased Kuppfer cells

33. Liver Mass - Adenoma History of OCP, steroids History of OCP, steroids CAN rupture, CAN turn malignant CAN rupture, CAN turn malignant Shows arterial enhancement on CT scan Shows arterial enhancement on CT scan May trial d/c steroids if small May trial d/c steroids if small Surgery if no improvement Surgery if no improvement

34. Liver Mass - Hemangioma Looks solid on US Looks solid on US CT – slow filling of lesion from CT – slow filling of lesion from periphery periphery Kassabach Merritt syndrome Kassabach Merritt syndrome Does not spontaneously rupture! Does not spontaneously rupture! Enucleate only if symptomatic Enucleate only if symptomatic

37. Liver Mass - HCC Usually occurs in setting of chronic liver disease Usually occurs in setting of chronic liver disease CT scan shows classic arterial enhancement with portal washout CT scan shows classic arterial enhancement with portal washout AFP may be raised not diagnostic AFP may be raised not diagnostic Does NOT typically need biopsy! Does NOT typically need biopsy! Tx based on degree of liver disease Tx based on degree of liver disease Resection vs transplant vs ablation Resection vs transplant vs ablation

38. Concerning Etiologies Hepatitis B Hepatitis C Alcohol NASH

39. HCC – arterial phase

40. HCC – venous phase

41. Child’s Pugh Score of Liver Cirrhosis Parameter Points 123 Albumin (g/dL) Albumin (g/dL) > 3.5 2.8-3.5 < 2.8 Bilirubin (mg/dL) Bilirubin (mg/dL) < 2 2 - 3 > 3 Ascites AscitesAbsentSlightModerate Encephalopathy EncephalopathyNone I - II III - IV PT (INR) PT (INR) < 1.7 1.8 – 2.3 > 2.3 ScoreABCPoints 5 - 6 7 - 9 10 - 15 Pugh, RNH, et al. British Journal of Surgery. 60(8): 646-649, 1973

42. Barcelona-Clinic-Liver-Cancer Screening HCC Child A Child A Child A-B Child A-B ECOG > 2, Child C Very early stage, Single <2 cm Intermediate stage multinodular Advanced stage, portal inv. N1, M1, ECOG 1-2 Terminal stage Single 3 nodules, ≤ 3 cm Portal pressure/bilirubin Increased Associated diseases No Yes No Yes Normal Resection Transplant PEI/RFA Chemoembo New agents Curative Treatments Palliative Options BSC Curative Treatments Palliative Options BSC Adapted from Bruix, J. et al. Management of hepatocellular carcinoma. Hepatology. 2006 Feb; 43 (2): 373. T2 tumor T2 tumor

44. Radio Frequency Ablation of Cancer

45. RFA Probe

46. Liver Mass - CCA Typically occurs in setting of chronic biliary inflammation (PSC) Typically occurs in setting of chronic biliary inflammation (PSC) Intra vs extrahepatic Intra vs extrahepatic CA 19-9 CA 19-9 Tx - resection. Excise all involved duct – frozen section! Transplant controversial Tx - resection. Excise all involved duct – frozen section! Transplant controversial Klatskins – usually one duct involved more than other Klatskins – usually one duct involved more than other

47. Cholangioca – biliary dilation

48. Cholangioca - ERCP

50. EUS Guided Biopsy

51. Spyglass cholangioscopy

52. Cholangico – resect the bile duct

53. Liver Mass - Hepatoblastoma Most common liver malignancy in children Most common liver malignancy in children Treatment is chemotherapy first – usually shrinks tumor to make it more amenable for resection or transplant Treatment is chemotherapy first – usually shrinks tumor to make it more amenable for resection or transplant

54. Liver Mass – Colorectal Mets Resect if feasible – will confer some survival advantage! Surgery + chemo = > 50% 5 yr survival Resect if feasible – will confer some survival advantage! Surgery + chemo = > 50% 5 yr survival If initially unresectable – trial with chemo – may shrink If initially unresectable – trial with chemo – may shrink Poor prognostic features Poor prognostic features Extrahepatic disease Extrahepatic disease DFI < 1 yr DFI < 1 yr > 5 cm; > 4 tumors > 5 cm; > 4 tumors CEA > 60 CEA > 60 Positive resection margin Positive resection margin

55. Colorectal mets – do not enhance!

56. Neuroendocrine Mets Common: Common: Gastrinomas- gastrin  Zollinger-Ellison Gastrinomas- gastrin  Zollinger-Ellison Glucagonomas- alpha cell  glucagon Glucagonomas- alpha cell  glucagon Somatostatinomas-delta cell  somatostatin Somatostatinomas-delta cell  somatostatin nonfunctional neuroendocrine tumor nonfunctional neuroendocrine tumor Less Common: Less Common: Insulinomas-beta cell  insulin Insulinomas-beta cell  insulin Carcinoid-enterochromaffin cell  serotonin Carcinoid-enterochromaffin cell  serotonin Most are slow growing and long term survival is common without treatment Most are slow growing and long term survival is common without treatment Focus is directed at improving quality of life rather than prolongation because most secrete active peptides Focus is directed at improving quality of life rather than prolongation because most secrete active peptides

57. Rx Options: Long-acting somatostatin analogues Long-acting somatostatin analogues Hepatic arterial embolization Hepatic arterial embolization Thermoablative approaches- RFA Thermoablative approaches- RFA Surgery for persistent symptoms Surgery for persistent symptoms Resection – 50% -75% 5 yr survival with R0 resection Resection – 50% -75% 5 yr survival with R0 resection Transplant Transplant Cytoreductive surgery - intention is to reduce symptoms Cytoreductive surgery - intention is to reduce symptoms

58. Portal Hypertension Hepatic Portal Venous Gradient (HPVG) normally less than 10. Above 12, variceal bleeds Hepatic Portal Venous Gradient (HPVG) normally less than 10. Above 12, variceal bleeds Causes Causes Presinusoidal – PVT, Schistosomiasis Presinusoidal – PVT, Schistosomiasis Sinusoidal – cirrhosis Sinusoidal – cirrhosis Post sinusoidal – Budd-Chiari syndrome Post sinusoidal – Budd-Chiari syndrome

59. Portal hypertension Umbilical hernia with ascites – do not operate if possible! Medical therapy Umbilical hernia with ascites – do not operate if possible! Medical therapy Flood syndrome – necrosis of skin with leakage of ascites. Surgical emergency as represents risk of infection. Fix primarily if possible. High recurrence rate Flood syndrome – necrosis of skin with leakage of ascites. Surgical emergency as represents risk of infection. Fix primarily if possible. High recurrence rate

60. Portal hypertension - shunts Rare since development of TIPS Rare since development of TIPS Patient may be transplant candidate – don’t mess with the hilum! Patient may be transplant candidate – don’t mess with the hilum! Non-selective shunts – good for ascites, but make encephalopathy worse Non-selective shunts – good for ascites, but make encephalopathy worse Selective shunts – less encephalopathy, worsens ascites Selective shunts – less encephalopathy, worsens ascites

61. Non selective shunts

62. Selective shunts

63. Liver trauma 2 nd most commonly injured organ in blunt trauma (Spleen is first!) 2 nd most commonly injured organ in blunt trauma (Spleen is first!) Mainly nonoperative mgmt Mainly nonoperative mgmt Maneuvers – Pringle, TVI, embolization Maneuvers – Pringle, TVI, embolization

64. Questions/Feedback aparames@tulane.edu