Hepatobiliary Surgery

 

 

LIVER

The largest organ inside the body is the liver. It weighs anywhere from 1.2- 1.6kg on average and it is located in your abdomen. Although the liver has several functions, it has two main functions that are very essential for the proper functioning of the body.

These main functions are:

  • To produce bile – a green substance that helps to digest fats.
  • To breakdown harmful substances that are present in the blood into less-toxic materials so they can be removed from the body via the digestive system.

Once the liver breaks down the harmful substances, the products of the process may be incorporated into the bile or back into the bloodstream. If it is placed in the bile, it can leave the body in the form of faeces. If it enters the bloodstream, it will be sent to the kidneys where it can be excreted as urine.

HYDATID LIVER DESEASE

You can develop hydatid disease if you have been exposed to the eggs of a tapeworm known as Echinococcus granulosus. The disease mostly affects the liver and can cause what are known as hydatid cysts. More often than not, there will be multiple cysts in the liver especially on the right side.

Many individuals who have Hydatid Liver Disease are from parts of the world where they use dogs to herd sheep. Fortunately, the disease is not passed from one human to another. Nevertheless, it is quite a serious condition for the person who is infected.

Many types of cysts can rupture spontaneously and these cysts are no different. If they do rupture, their contents may enter the bile duct and this often leads to obstructive jaundice. If the cysts do not rupture, but they are large enough, they may still be able to cause jaundice if they apply a lot of pressure on the bile ducts.

Diagnoses

Your doctor may use one or more of the following diagnostics

  • Clinical history
  • Ultrasound
  • CT Scan
  • MRI

Treatment

The treatment of hydatid cyst involves the surgical removal of the cyst and post-operative medical treatment with albendazole.

CIRRHOSIS

What is cirrhosis?

In cirrhosis of the liver, progressive scarring (fibrosis) of the liver causes scar tissue to replace normal liver tissue. The scar tissue damages the normal structure of the liver which affects the normal flow of blood through the liver. The liver itself becomes distorted, hardened and lumpy. Without a good blood flow the liver can’t work as it should and its normal functions are impaired.
The liver is the largest organ in the body and is a very important organ to keep the body functioning properly. It is involved in the processing of nutrients and fats, poisons or toxins that find their way into the body, hormones and medications. It controls blood clotting and produces proteins. So, cirrhosis of the liver can affect the functioning of the entire body.

Cause of cirrhosis

Cirrhosis happens when the cells of the liver are damaged by toxins, or by inflammation and disorders of the body’s normal metabolic processes. Although many people associate liver cirrhosis with alcoholism, it can have other origins, all of which cause the same characteristic damage.

What causes it?

Cirrhosis of the liver has a number of different causes. Long-term heavy drinking of alcohol. It usually takes about 10 years of heavy drinking of alcohol for cirrhosis to develop. Women can develop cirrhosis with a daily intake of 2-3 alcoholic drinks a day, which might not be considered by some to be ‘heavy’. Similarly, men who have 3-4 alcoholic drinks a day can also develop cirrhosis.

Chronic viral hepatitis types B, C & D

These hepatitis viruses cause inflammation of the liver and liver damage that after a few decades can cause cirrhosis.

  • Wilson’s disease – this is an inherited disorder where excessive amounts of copper are absorbed in body tissues, particularly the liver

Haemochromatosis

Another inherited disorder, this time one in which too much iron is absorbed by the body and the excess is deposited in the liver.

Other inherited metabolic disorders, such as cystic fibrosis. Certain disorders that interfere with the body’s metabolism and how the liver stores substances can result in cirrhosis.

Autoimmune hepatitis

This is hepatitis caused by a problem in the body’s immune system. The immune system doesn’t recognise its own cells and tissues as ‘self’ and attacks them thinking they are ‘foreign’, like invading bacteria.

Blocked bile ducts

Bile is made in the liver and then the bile ducts carry the bile out of the liver to the gallbladder where it is stored. If the bile ducts become blocked due to scarring or inflammation, bile backs up in the liver and damages the liver tissues causing cirrhosis. Primary biliary cirrhosis is a disease of adults where the bile ducts become damaged. Biliary atresia is a condition of babies in which they are born without bile ducts or the bile ducts are damaged causing build-up of bile in the liver.

Toxic hepatitis

This is rare and is caused by severe reactions to medications or environmental toxins.

Chronic congestive heart failure with liver congestion

Repeated episodes of congestive heart failure with liver congestion can cause cirrhosis of the liver.

Diagnoses

Tests can reveal liver problems including:

  • Physical Examination
  • Blood tests, including FBC, Liver Function Tests Coagulation studies
  • Abdominal X-ray
  • CT scan

A liver biopsy confirms cirrhosis.

Treatment For Cirrhosis

The objective of treatment is to directly manage any complications that arise from cirrhosis and to prevent any further damage to the Liver.

  • Any medication causing problems are stopped
  • Alcohol intake is stopped
  • Any bleeding varices are managed through sclerosis, an upper endoscopy or banding
  • Excess abdominal fluids are treated using fluids, salt restrictions and diuretics and fluid removal
  • Vitamin K can be used to treat coagulopathy
  • Encephalopathy is treated with the medication lactulose; sometimes antibiotics are used and patients should avoid a diet high in protein
  • Antibiotics are used to treat infections
  • A liver transplant should be considered if the condition cannot be managed and becomes potentially life-threatening.

HEPATOMEGALLY

Hepatomegaly is the enlargement of the liver beyond its normal size. Hepatosplenomegaly is the enlargement of both the liver and the spleen beyond their normal sizes.

The lower edge of the liver normally comes just to the lower edge of the ribs (costal margin) on the right hand side of the body. In its normal state, the edge of the liver is thin and firm, and cannot be felt with the fingers below the edge of the costal margin.

Causes

Since the liver is involved in a multitude of bodily functions, it can be affected by a variety of conditions, many of which result in hepatomegaly. Common causes include:

  • Alcohol
  • Hepatitis A
  • Hepatitis B
  • Congestive heart failure
  • Infectious mononucleosis
  • Leukemia
  • Tumour metastases
  • Neuroblastoma
  • Hepatocellular carcinoma
  • Niemann-Pick disease
  • Hereditary fructose intolerance
  • Glycogen storage disease
  • Primary biliary cirrhosis
  • Sarcoidosis
  • Sclerosing cholangitis
  • Hemolytic-uremic syndrome (HUS)
  • Reye’s syndrome

Diagnosis

Your healthcare provider will undertake a medical history and do a physical examination.
There may be more than one diagnostic test to determine the cause of Hepatomegaly and may include:

  • Abdominal and chest X-ray
  • Ultrasound of the abdomen including the liver
  • CT scan of the abdomen
  • Blood tests, including liver function tests and blood clotting studies

Treatment

Depends on the cause of the condition.

LIVER CANCER

 

Liver cancer may either start in the liver or spread to the liver from another part of the body. When the cancer starts in the liver, it is referred to as primary liver cancer. If it originates from another part of the body, it is called secondary liver cancer.

Primary liver cancers

Primary liver cancer is one of the less common cancers in Victoria with about 170 people diagnosed each year. It is more common in men and people aged over 60 years. Most primary liver cancers are called hepatocellular carcinoma, as they start in liver cells called hepatocytes. Others start in a bile duct and are called cholangiocarcinoma.

Many people in the western hemisphere who are diagnosed with Primary Liver Cancer also end up being diagnosed with Cirrhosis of the liver- a condition where the liver is scarred. In many cases, liver scarring results from the consumption of too much alcohol over a long period of time but it may be caused by Hepatitis infections (Hepatitis B, C or D).  A Cirrhosis or Hepatitis diagnosis will increase the risk of liver cancer in the future, but fortunately, not everyone who ends up with Cirrhosis of the liver will be diagnosed with liver cancer.

Secondary liver cancers

In the western hemisphere, the most common type of liver cancer is secondary liver cancer. Almost any cancer can spread to the liver but the types that are more likely to do so originate from the stomach, breast, and bowel. When cancer has spread from one area to another, the term used to describe it is metastasis. As a result, if the cancer has spread from the breast to the liver, it will be called metastatic breast cancer. Hence, secondary liver cancer is named based on where it originated (primary cancer).

In some cases, it is only after the secondary cancer has been diagnosed that the primary cancer is recognised.

Symptoms

Liver cancer usually has no symptoms in the early stages but can include:

  • Pain in the upper right side of the abdomen
  • Fever
  • Yellowing of the skin and eyes (jaundice)
  • Nausea
  • Weakness
  • Weight loss
  • Loss of appetite
  • Swelling of the abdomen

Diagnosis methods

Liver cancer is usually diagnosed with a number of different tests, which may include:

  • CT (Computed Tomography) scan: special x-ray images are taken at different angles so a 3D image of the body can be analysed.
  • MRI (Magnetic Resonance Imaging): it is similar to the CT scan but it uses magnetism instead of x-rays.
  • Blood Test: the blood is analysed for a chemical known as AFP. If the levels are high, it is an indication that there is liver cancer.
  • Liver biopsy: a needle is used to remove a small piece of liver tissue, which is then tested for cancer cells.
  • Laparoscopy: a small incision is made in the abdomen so a laparoscope can be used to look at the liver and take a sample of the liver tissue for testing. If you are diagnosed with secondary cancer because of this test, you may have to endure more tests in order to determine the origin of the cancer.

Treatment options

Treatment for liver cancer will depend on whether it is a primary or secondary cancer. Treatment options may include:

  • Surgery – to remove the cancer and as much damaged tissue as possible. This is the main treatment for primary liver cancer. It is only useful for secondary liver cancer if the cancer cells only affect one part of the liver.
  • Chemotherapy – either tablets or injections of anti-cancer drugs. Sometimes they are injected directly into the artery that feeds the tumour in the liver (hepatic arterial infusion). It is the main treatment for secondary liver cancer and sometimes used for primary liver cancer.
  • Radiotherapy – x-rays are used to target and kill cancer cells. It may help in treating some types of primary liver cancers and may be used to relieve symptoms of pain and discomfort from secondary liver cancer.

HEPATITIS

Please see our gastrointestinal surgery page for information on Hepatitis.

GALLBLADDER

Located just below the liver, the gall bladder is a small sac that is mostly known for its function of storing bile. It also delivers the bile to the small intestine so it can participate in the digestive process. As the bile mixes with the food that has been partially digested, it emulsifies the fat to aid in its absorption. Additionally, it assists in the absorption of the vitamins that are dissolved in these fats.

GALLSTONES

Please see our gastrointestinal surgery page for information on Gall Stones.

CHOLESCYSTITIS

Please see our gastrointestinal surgery page for information on Gall Stones.

PANCREAS

The pancreas is a relatively small gland/organ that is located behind the stomach in the abdomen. It has two essential roles in the body. It plays a part in the digestive system by producing enzymes needed for digestion and it produces hormones that help to regulate the glucose levels in the blood.

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PANCREATITIS

Please see our gastrointestinal surgery page for information on Gall Stones.

PANCREATIC CANCER

The primary causes of Pancreatic Cancer are not yet known. However, what is known is that this type of cancer generally begins in the pancreatic ducts and then spreads to the pancreas. The blood vessels and nerves that surround this area may also become affected. Without treatment, Pancreatic Cancer can easily spread to other abdominal organs and eventually to other parts of the body. Although it is a mystery how this form of cancer develops, there are factors that may increase the chances of Pancreatic Cancer. These include:

  • Smoking
  • Chronic pancreatitis
  • Being aged over 65

Symptoms

As is the case with many illnesses, the symptoms of Pancreatic Cancer are similar to other illnesses. This tends to lead to a late diagnosis of Pancreatic Cancer. Some symptoms are:

  • Persistent and consistent pain in the abdomen
  • Appetite loss
  • Loss of weight
  • Jaundice, if the bile duct is blocked
  • Back pain (in some cases)

Diagnosis

For an accurate diagnosis, your doctor may have to perform one or more of the following tests.

  • CT scan – This is a special x-ray that is taken from several angles, sand used to build a three-dimensional image of the organ. A dye may be injected to further highlight internal organs.
  • Magnetic resonance imaging (MRI) – similar to a CT scan but instead of X-rays, used magnetism to construct the three-dimensional view of the organ
  • Ultrasound – sound waves create a picture of your pancreas
  • Endoscopy – a thin telescopic device is inserted down into your digestive system through the mouth allowing the doctor to better “see” your pancreas
  • Laparoscopy – the internal organs are examined with an instrument inserted into the abdomen through a small cut
  • Tissue biopsy – a small sample of the pancreas is removed with a needle and examined in a laboratory
  • Endoscopic Ultrasound

Treatment

Quite a few factors affect the way Pancreatic Cancer is treated. Treatment will vary based on how healthy you are, your age, the exact location of the cancer and how far it has spread (if it has spread). Usually, the treatment may include:

  • Surgery – This course of action is undertaken when the cancer has not spread beyond the pancreas. During the surgery, the cancer and the damaged part of the pancreas (and a part of the small intestine/bowel) are removed in an operation called ‘Whipple’s resection’. If the situation requires it, some of the stomach, gallbladder and bile ducts may also be removed.
  • Radiotherapy – radiation is used after surgery to destroy any cancer cells that may remain in the body
  • Chemotherapy – Injections of anti-cancer drugs and tablets may be employed post-surgery

INVESTIGATIVE PROCEDURE

LIVER BIOPSY

Many different procedures can be performed in order to carry out a biopsy. However, the principle of a biopsy is fairly simple. A biopsy is a medical procedure where a tissue sample is taken from the body so it can be examined. Once the cells are examined under the microscope, an accurate diagnosis can be made based on what is seen.

A liver biopsy is a more detailed test than the liver blood test and there are three ways that the biopsy can be done- laparoscopic biopsy, percutaneous biopsy and transvenous biopsy. Despite the type of biopsy, they are generally performed in a hospital and overnight stay is not usually required.

Before the test

You may be asked to refrain from eating or drinking at least 8 hours before your biopsy is done. You may also be required to do a blood test because the liver biopsy is considered a minor surgical procedure. Do not forget to tell your doctor about any medications that are currently taking or any other health conditions that you suffer from. An ultrasound or CT (computed tomography) scan of your liver may be done to help doctors locate a particular area of tissue or abnormality from which the sample will be taken.

Talk to your doctor about any medicines you are taking. Some medicines can put you at a higher risk of bleeding. These include non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, and blood thinners such as warfarin (Coumadin). Your doctor should be aware of this and will advise you accordingly.

Percutaneous liver biopsy

For this procedure, you can expect to be placed on your back facing your left. You will be given a sedative through a tube in your arm and a local anaesthetic will be injected close to your rib on the right side to numb the area. Your surgeon will make a small incision over the liver and use the biopsy needle to remove a tissue sample. While this is being done, you have to remain very still and hold your breath for about 5 seconds. Expect to stay in the hospital for a few hours for observation once the procedure is completed. This is very important to ensure that there are no complications from the procedure.

Complications are actually quite rare, but they may include:

Although they are very rare, complications can include:

  • Leaking of bile into the abdomen, which can cause inflammation of the abdominal lining (peritonitis)
  • Bleeding from the place where the biopsy needle goes into the liver. This can occur up to 15 days after the biopsy (doctors advise that, until the 15 days are up, you stay within one hour’s drive of the hospital where the biopsy was conducted)
  • Puncture of the lung or gallbladder during the biopsy itself
  • Infection

You may feel some pain in your upper right abdomen or right shoulder for a while after the biopsy. This pain is usually not serious and can be relieved by paracetamol (don’t take aspirin or over-the-counter non-steroidal anti-inflammatory drugs such as aspirin or ibuprofen because they can cause bleeding). Contact your doctor if the pain becomes worse.

Transvenous liver biopsy

If you have a bleeding problem, this may be the better biopsy method for you. In this procedure, a catheter is placed in your neck and guided to the vein that carries blood from the liver. A needle is then placed in the catheter so the biopsy sample can be taken from your liver.

Laparoscopic liver biopsy

As the name suggests, a laparoscope is used for this procedure. This instrument enables the doctor to see inside the body during the surgical procedure. For the laparoscope to be inserted, a small incision has to be made in the abdomen. For tissue removal, a sharp instrument will be placed at the end of the laparoscope. This method of liver biopsy is very precise so it is best when the tissue sample has to be taken from a very specific part of the liver.

Endoscopic Ultrasound Biopsy (EUS)

A new method performed via a gastroscope.

Endoscopic Retrograde Cholangio Pancreatography (ERCP)

ERCP is a surgical procedure that can diagnose illnesses related to serval organs. It is mainly used to diagnose problems associated with the bile duct (Gall Stones and scars) but it can also diagnose problems with the pancreas and liver.

Things to note about the ERCP:

  • Generally, you are only required to stay in the hospital for a few hours after the surgery for observation. However, if any organ was removed etc., you may need to stay in the hospital overnight
  • The procedure takes anywhere from 30 minutes to 2 hours

Some complications of ERCP are infection, bleeding, and pancreatitis. You may also notice a lump at the injection site but that is normal and it should go down in a few days.

Procedure

ERCP uses a combination of x rays and an endoscopic device – a long, flexible tube that is equipped with a small flashlight. Using these techniques, the surgeon can see the inside of the stomach and duodenum, and inject a coloured dye directly into the ducts within the biliary tree and pancreas so the organ can be seen on x rays and properly diagnosed.

If the examination highlights a narrowing of the ducts or gallstone, the surgeon can insert instruments into the scope and relieve or even attempt to remove the obstruction. Also, biopsies can be taken for further testing for illnesses like cancer.

 

Points of Interest

  • ERCP takes 30 minutes to 2 hours.
  • Usually performed under sedation with a general anaesthetic.  However, pain medicine and sedative should keep you from feeling too much discomfort.
  • After the procedure, it is recommended that you remain in the hospital for 1 to 2 hours until the sedatives are out of your system. The doctor will make sure you exhibit no signs of complications before sending you home
  • If any kind of treatment is done during ERCP, it may be a requirement that you stay in the hospital overnight.