The hepato-biliary-pancreatic area makes reference to a specific anatomical and functional area that includes the following organs: liver, pancreas, gallbladder and bile ducts. It is a vital area of complex anatomy and it consists of solid organs which are not accessible by conventional endoscopic procedures. Diseases affecting these organs are often difficult to diagnose, relevant and require a complex treatment. The hepato-biliary-pancreatic surgery is a super-specialty within general and digestive system surgery and it requires years of experience and training in order to achieve good results.
Primary Liver Tumors
The lesions most often found in the liver are the EPITELIAL CYSS (SIMPLE HEPATIC CYSTS) and HEMANGIOMAS. Both are benign lesions that usually cause no symptoms and require no treatment. They are easily diagnosed by ultrasound scan and/or CT, although some hemangiomas may present an unusual behavior which makes necessary to confirm their diagnosis by MRI. Simple cysts are full of liquid and can sometimes grow exorbitantly, get infected, cause pain and slow digestion. In these cases, we recommend the surgical treatment of laparoscopic excision. Hemangiomas do not become malignant and that is why it is not necessary any treatment or monitoring. Only in exceptional cases of giant hemangiomas that cause symptoms we advise to extirpate them surgically.
The liver ADENOMAS are benign tumors that usually arise in young women who have taken oral contraceptives over a period of time. After their diagnosis, patients should diminish their administration to prevent them from growing. Since they have a real malignization potential, the surgical excision is recommended when measuring more than 4 cm in diameter, depending on their location. Generally, a limited hepatectomy of the tumor is required, but depending on where it is located it could be necessary to perform a major hepatectomy. They can usually be extirpated laparoscopically (Europa Press news link).
HEPTOCELULAR CARCINOMA is the most frequent primary malignant liver tumor and it is usually developed in the context of a chronic liver disease or cirrhosis. The most frequent causes of cirrhosis are the HCV infection (hepatitis C virus), HBV (hepatitis B) and chronic alcoholism. It is a disease with a bad prognosis because there is a high rate of relapse and multifocality. The best treatment for HCC is the liver transplantation, but it is only possible in a small percentage of patients who fulfill the so-called “The Milan Criteria”; the most important of these criteria is that the patient has less than 66 years, a tumor with a size smaller than 5 cm and less than 3 nodules. The hepatectomy (surgical extirpation) is the alternative treatment to transplantation, but it can only be performed in patients with mild liver disease (Grade A in Child classification) and without portal hypertension (esophageal varices). This would be the treatment that ensures the lowest rates of relapse. The “Radiofrequency ablation” is a technique that “burns” the tumor by applying an electric current through an electrode (needle) which is inserted inside the tumor. This treatment can be performed percutaneously, i.e. without having to operate guided by ultrasonography on the patient’s tumor puncture, according to their location, or surgically. Nowadays, radiofrequency ablation shows some results that are similar to hepatectomy, regarding tumor recidivation. There are other ablative treatments such as alcoholization, in which alcohol is injected into the tumor in order to denature it. When none of these treatments can be performed, there are still other alternatives such as embolization, although it is considered as a palliative treatment.
The fibrolamellar hepatocarcinoma is a type of hepatocellular carcinoma which has the peculiarity that is developed on a non-cirrhotic and healthy liver, so it is usually possible its surgical extirpation (hepatectomy).
The peripheral cholangiocarcinoma has its origin in the epithelial cells of the intrahepatic bile duct. The only possible curative treatment is surgical resection (hepatectomy). Its prognosis, even though it may be extirpated completely, is bad. It has some specific radiological features, but a directed biopsy is usually required to reach the final diagnosis.
Liver Metastasis are secondary tumors, i.e., implants (dissemination) from other tumors which arise in an organ other than liver. They originate from cancer cells that have gone through the bloodstream and that then are deposited in the liver, where they develop. The liver, as the lung, acts as a filter for tumor cells that circulate in the blood by facilitating their retention and their further growth. The gastrointestinal tumors (colon, rectum, pancreas and stomach) often cause more liver metastases and are indicative of an advanced disease. Nowadays, some cases of liver metastases can be treated with curative intent, performing a surgical extirpation. The liver metastases which are considered operable are those derived from colorectal cancer, although some operable metastases may also be derived from the hypernephroma (kidney cancer), neuroendocrine tumors and breast cancer. We must keep in mind that every hepatic metastases of every tumor may be considered for surgical extirpation if it fulfils specific requirements such as: it is the only one, it is only limited to the liver without affecting other organs, it has passed enough time since the extirpation or treatment of the original tumor and it is proved that the primary (original) tumor is cured.
About 50% of patients with Colorectal Cancer will develop hepatic metastases at some point of its development and these are going to mark the prognosis of the disease. Approximately, 40% of patients with colorectal cancer hepatic metastases can have surgery in order to extirpate it. Chemotherapy has been shown to be effective in treating colon cancer and allows us to save a great number of patients in order to perform a surgical treatment (hepatectomy) with curative intent.
When we talk about Pancreatic Cancer as such, we make reference to ductal carcinoma or adenocarcinoma. It is the 11th leading cause of cancer in the U.S.A. and the 4th leading cause of death by cancer in developed countries. The only curative treatment that at present exists is the complete extirpation of the tumor. It should be noted that there are other pancreatic tumors with better prognosis such as the neuroendocrine tumors, solid-cystic tumors and the intraductal papillary-mucinous tumor (IPMT). The incidence of pancreatic cancer is 10 new cases per 100,000 people per year. Of these people, only 30% will be operated, as the rest of them will show hepatic metastasis or peritoneal carcinomatosis at the time of their diagnosis. The prognosis is not good because the survival percentage is around 30% after 3 years in those cases in which the patient has been able to be operated and the tumor has been completely extirpated. The survival average in inoperable cases ranges between 6 and 9 months. Chemotherapy does not have good results when treating these tumors but it is usually performed after surgery.
Generally, pancreatic cancer appears with jaundice (yellowing of the skin) and it is usually located at the head of pancreas. To completely extirpate these tumors should be performed a cefalic pancreaticoduodenectomy (Whipple procedure), which consists on the extirpation of the duodenum, the head of pancreas, the gallbladder, the main biliary duct and, depending on the case, part of the stomach. This is a complex operation, 5 to 6 hours long, with a risk of complications up to 30% and a non-negligible postoperative mortality rate of 2-5% in experienced centers. This operation should only be performed by experienced surgeons who perform a minimum number of cases per year. In January 2006, both Dr. Sánchez-Cano and Dr. Poves jointly conducted the first totally laparoscopic Whipple operation performed in Spain. However, very few patients are candidates for laparoscopy and the improvement in its outcomes are yet to be shown.
Tumors located in the body and tail of pancreas should be treated by a left pancreatectomy, also called distal spleno-pancreatectomy. In this operation, the spleen is extirpated with the part of the body and tail of pancreas. Since it is a tumor with a high capacity of lymphatic disemination it should be associated with an extense lymphadenectomy (ganglionic clearance). This intervention is only performed by laparoscopy in experienced centers and in selected cases.
Distal Cholangiocarcinoma is a tumor of the biliary ducts (choledoch) in its intrapancreatic course. Its presentation is the same as that of the pancreatic cancer and it is treated the same way, by cefalic duodenopancreatomy. It has a better prognosis than the ductal carcinoma, with a percentage of survival after 5 years up to 40%. Since the clinical behavior is identical, usually, when performing a cefalic pancreaticoduodenectomy for head of pancreas tumor, it is unclear whether this is a ductal adenocarcinoma or a cholangiocarcinoma until the tumor has been extirpated and analyzed under the microscope after some days.
The ampuloma is a tumor originating in the ampulla or papilla of Vater, which is the anatomical area where the common bile duct and the Wirsung (pancreatic duct) join the duodenum. In very incipient cases, in which an invasive tumor has yet not been developed, the ampullectomy or extirpation of the ampulla of Vater may be performed, re-implanting the distal choledoch and the Wirsung into the duodenum. In these cases the extirpation of the duodenum or the pancreas is not necessary. However, the most common case is that, at the time of the diagnosis, the disease is an invasive cancer, and that is why the operation to be performed is the pancreaticoduodenectomy. Among all malignant tumors of the biliary-pancreatic area this is the one with the best prognosis, with 5-year survival rates of up to 60%.
The Acute Pancreatitis is an inflammation of the pancreas. In our environment, 60% of these cases are caused by cholelithiasis (calculus or “stones” in the gallbladder which are shocked at the end of the choledoch, where it joins the pancreatic duct). In 20% of cases, the underlying cause is the alcohol and the remaining 20% belongs to multiple causes of pharmacological, metabolic nature, anatomical anomalies, etc. In countries of northern and central Europe the alcohol is the cause of almost 60% of all cases. 80% of cases are a mild inflammation with quick recovery, but the remaining 20% are severe. The Severe Acute Pancreatitis is difficult to manage and treat, with a mortality rate of 20%. Its main feature is that the pancreas develops a necrosis, i.e. “cellular death.” When a necrosis infection is detected the action to take is usually the surgical debridement (extirpation) of the necrotic tissue and the cleaning of the infection around it.
After an outbreak of acute biliary pancreatitis it should be performed a LAPAROSCOPIC CHOLECISTECTOMY to prevent further episodes.
PSEUDOCYSTS are collections of pancreatic juice that may develop after episodes of acute pancreatitis. They are usually located in the lesser sac, between the stomach and pancreas, but they can also be located in the tail of pancreas and in the root of the mesentery. The attitude is often monitoring and waiting for them to be reabsorbed. If the pseudocysts are symptomatic (pain, vomiting, fever) they should be operated. The conventional treatment is the derivation of the pseudocyst into the stomach (CYST-GASTROSTOMY) or into the intestine (CYST-JEJUNOSTOMY), and it is usually done by laparoscopy in experienced centers. An alternative to surgery is the placement of a cyst-gastric prosthesis endoscopically. For this method, the pseudocyst should be in retrogastric position and it should measure at least 6 cm in diameter.
Surgery of the gallbladder and bile ducts
The CHOLELITHIASIS is the calculations (commonly called “stones”) of the gallbladder. Although they may occur at any time of life, are more frequent after 40 years and more predominant in females. It is caused by an imbalance in the components of bile. When this balance is broken, some microcrystals are created and layers of sediment of bile are deposited on them; these will form stones eventually. The gallbladder stores bile during fasting, but it does not create it, the bile is produced in the liver and, that is why cholecystectomy (surgical extirpation of the gallbladder) does not alter the normal production of bile.
The gallstones (or cholelithiasis) can cause the following symptoms and/or diseases:
- Hepatic colic: It is a sudden pain that appears on the right side of the abdomen, below the ribs, and it is usually unleashed by foods, especially when they are abundant and rich in fat. This pain is often very intense and of short duration, about 1-2 h long. When it appears for first time, it is premonitory of new attacks.
- Gallbladder hydrops: When the hepatic colic is maintained and does not cease, it is usually caused by gallstones that are blocking the duct of the gallbladder and this is distended. This strain causes a severe pain that only ceases when the gallbladder is surgically extirpated.
- Acute cholecystitis: It happens when the gallbladder becomes inflamed. This inflammation is usually accompanied by infection and, that is why, in addition to the typical pain of hepatic colic or gallbladder hydrops, appears fever. This is an emergency that requires immediate treatment with antibiotics and that must be followed by surgery or immediate surgery. If the cholecystitis evolves, it may puncture the gall bladder and produce choleperitoneo peritonitis (discharge of bile into the abdominal cavity).
- Choledocholithiasis: It happens when some of the lithiasis in the gallbladder escapes into the bile duct (choledoch) and obstruct it. The choledoch lead bile into the intestine through a sphincter of 1-2 mm (“ampulla of Vater”), so it is easier that the stones may obstruct the duct. When this happens, apart from than pain in the stomach, the bilirrubin is usually retained (a component of bile) in the liver and then enters the bloodstream, so that the patient may have a yellowing of the skin that we call jaundice. The treatment would consist on unblocking the bile duct and extirpating the gallbladde.
Acute Pancreatitis: It is the inflammation of the pancreas and it is caused by pancreatic duct obstruction by gallstones that have escaped from the gallbladder and have entered the bile duct. As the choledoch and the pancreatic duct join in its final stretch, the obstruction of one of them often leads to the obstruction of the other. Acute pancreatitis is a common disorder that can become severe, with a mortality rate of 5%. 20% of acute pancreatitis attacks are severe. It is recommended to extirpate the gallbladder when the patient has recovered from an outbreak of acute pancreatitis to prevent future attacks.
Obstructive jaundice: Its name comes from the yellowing of the skin and the eye conjunctiva. In addition to be present in hepatitis (liver inflammation), jaundice may happen for an obstructive cause, generally choledocholithiasis, although there may be other causes such as pancreatic cancer or bile duct tumors. The urine of patients with jaundice has a dark color, coca-cola type; we call it “choluria” and it is due to the filtration of an excess of bilirrubin in the blood by the kidney.
Gallbladder cancer: It is known that there is an increase in the incidence of gallbladder cancer in those patients with cholelithiasis with years of evolution. In some South American countries like Ecuador, Chile and Peru, the incidence of gallbladder cancer is very high, that is why it is usually recommended cholecystectomy (gallbladder extirpation). The gallbladder cancer has a very bad prognosis and it is among the most aggressive malignant tumors known. The so-called “porcelain gallbladder” refers to a calcification of the gallbladder walls and it is considered a premalignant injury, i.e. a precursor of a gallbladder cancer.
The surgical operation of the gallbladder is called CHOLECYSTECTOMY and it is currently performed in 99% of cases by LAPAROSCOPY. Laparoscopic cholecystectomy is a procedure that is performed routinely; this does not mean that it is not a delicate operation and that there cannot be serious problems. It is known that the risk of bile duct injury ranges between 0.02 and 0.5%, depending on the experience and skills of the surgeon. For this reason it is recommended to be carried out by surgeons with experience in laparoscopic surgery, if it is possible in hepato-biliary-pancreatic surgery. Today, besides it is possible to perform the cholecystectomy by conventional laparoscopy, through 3 or 4 incisions of 5 to 10 mm, it can also be performed in selected cases by what is known as “Single Port” or “SILS”, which is a technique that consists in making the entire operation through a single orifice of 2 cm and that is practiced at the navel.
Biliary tract tumors
Bile duct cancer is known as cholangiocarcinoma. It arises from the cells that cover the bile ducts. There are three types of cholangiocarcinoma according to their location: peripheral, hilar and distal. The peripheral cholangiocarcinoma is located in the liver and it is considered a primary liver tumor. When it can be surgically treated, hepatectomy can be performed. The distal is located in the pancreas and ampulla of Vater. When the tumor is operable, it is performed a cefalic pancreaticoduodenectomy.
The bile duct tumor par excellence is the hilar cholangiocarcinoma, known as Klatskin tumor. It is located at the confluence of the left and the right hepatic ducts, i.e. where the hepatic duct diverges into two main branches, left and right. The treatment of Klatskin tumor usually consists in performing hepatectomy. In some cases, a resection and extirpation of the bile duct is enough. In a large number of cases it cannot be operated and that is why the treatment is palliative by the placement of a biliary prosthetics.