1. ADVANCES IN HEPATO-BILIARYADVANCES IN HEPATO-BILIARY
& PANCREATIC SURGERY:& PANCREATIC SURGERY:
WHERE ARE WE TODAY?WHERE ARE WE TODAY?
Dr. Harshal Rajekar MS MRCS DNB
Consultant hepatobiliary, GI and transplant Surgeon,
Pune

2.  J Am Coll Surg. 2010 Oct;211(4):443-9. Epub 2010 Aug 8.
Perioperative management of hepatic resection toward zero mortality
and morbidity: analysis of 793 consecutive cases in a single institution.
Kamiyama T, et al.
Hokkaido University , Sapporo, Japan.
 CONCLUSIONS: Shorter operative times and reduced blood loss:
- improved surgical technique
- using new surgical devices and
- intraoperative management, including anesthesia.
Additionally, decision making using our algorithm and perioperative
management according to CDC guidelines reduced the morbidity and
mortality associated with hepatectomy.

3.  High volume hepatobiliary centre
 Major resection (sectionectomy, hemihepatectomy, and extended
hemihepatectomy), was performed in 535 patients (67.5%) and re-resection
in 81 patients (10.2%).
 Only a small percentage were colorectal metastasis.
 Liver functional reserve and liver remnant volume

4.  Torzilli Arch Surg, 1999, no mortality after 107 consecutive resections (first
report).
 Ascites, serum bilirubin, ICG 15 <14%
 Precise delineation of vascular relations using CT angiography and volumetry
 The independent relative risk for morbidity was influenced by an operative
time of more than 360 minutes, blood loss of more than 400 mL, and serum
albumin levels of less than 3.5 g/dL, as determined using multivariate logistic
regression analysis.

5.  Assessment of liver reserve
 Child-Pugh scoring, Class B and above
 ICG clearance at 15 minutes, retention > 14% bad risk
- 99m-Tc-galactosyl human serum albumin
- Functional scintigraphy
Hepatic resection can be undertaken safely, and
increasing experience as a hepatic surgeon is
associated with greater utilisation of parenchymal
sparing and extended resections.
 - Low CVP.
 - Vascular inflow occlusion,
 - Ischaemic preconditioning (Clavien Ann Surg 2003) may be useful.
 - Equipment:- CUSA, harmonic scalpel (laparoscopic resection), bipolar drip
diathermy, Argon beam coagulator

6. Zentralbl Chir. 2010 Jun;130(3):238-45.
Surgical treatment of portal hypertension.
Wolff M, Hirner A. Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax-
und Gefässchirurgie, Rheinische Friedrich-Wilhelms Universität, Bonn.
Surgical shunt procedures continue to be safe, highly effective and durable
procedures to control variceal bleeding in patients with low operative
risk and good liver function.
For patients with noncirrhotic portal hypertension, in particular with
extrahepatic portal vein thrombosis, portosystemic shunt surgery
represents the only effective therapy which leads to freedom of
recurrent bleeding and repeated endoscopies for many years, and
improves hypersplenism without deteriorating liver function or
encephalopathy.

7. CONCLUSIONS:
 Operative portal decompression is more effective, more durable, and
less costly than TIPS in Child-Pugh class A and B cirrhotic patients with
variceal bleeding. Good-risk patients with portal hypertensive bleeding
should be referred for surgical shunt.
 Shunt surgery is an important treatment for noncompliant patients or
patients living in areas where access to TIPS, repeated hospitalization
and liver transplantation, is limited. It is safe and effective.

8.  CONCLUSIONS:
 In patients with high-risk esophagogastric varices or symptomatic
splenomegaly and hypersplenism, patients had high-risk
esophagogastric varices or symptomatic splenomegaly and
hypersplenism.

9. Conclusions: RFA is a safe and effective treatment of small HCC in
cirrhotics awaiting OLT, although tumor size (>3 cm) and time
from treatment (>1 year) predict a high risk of tumor persistence
in the targeted nodule. RFA should not be considered an
independent therapy for HCC.
ROLE OF INTERVENTIONAL RADIOLOGY -
RFA/ TACE

10. One- and 3-year survival were 78 and 33%; 1- and 3-year disease-free
survival were 60 and 20%. The advantage of surgery was more
evident for Child-Pugh class A patients and for single tumors of more
than 3 cm in diameter.
Conclusions: RFA has still to be confirmed as an alternative to
surgery for potentially-resectable HCCs.

11.  Is RFA stand alone treatment for HCC?
 Complete response rate only 55% (63% for <3 cm)
 > 3 cm in size and > 1 year wait for OLTx
 High rate of recurrence in explanted liver
 Child’s B group, RFA and surgical resection similar
survival, therefore they should be transplanted
 Not an independent therapy for HCC!

12. Indian J Crit Care Med. 2012 Jan;16(1):1-7.
Structured approach to treat patients with acute liver failure: A
hepatic emergency.
Kumar R, Bhatia V. Department of Hepatology, ILBS Delhi.
Acute liver failure (ALF) is a condition of acute hepatic emergency
where rapid deterioration of hepatocyte function leads to
hepatic encephalopathy, coagulopathy, cerebral edema (CE),
infection and multi-organ dysfunction syndrome resulting in a
high mortality rate. Urgent liver transplantation is the standard
of care for most of these patients.

13.  Acute liver failure (ALF) is a disease with a high mortality
 Standard therapy at present is liver transplantation.
 Liver transplantation is hampered by the increasing shortage of organ
donors,
 BAL / liver dialysis therapy is marked as the most promising solution
to bridge ALF patients to liver transplantation or to liver
regeneration,
 Bioartificial liver therapy for bridging patients with ALF to liver
transplantation or liver regeneration is promising. Its clinical value
awaits further improvement of BAL devices, replacement of
hepatocytes of animal origin by human hepatocytes, and assessment
in controlled clinical trials.

14.  Ann Surg. 2004 Sep;240(3):438-47;
Five-year survival after resection of hepatic metastases from colorectal
cancer in patients screened by positron emission tomography with F-18
fluorodeoxyglucose (FDG-PET).
Fernandez FG, Drebin JA, Linehan DC, Dehdashti F, Siegel BA, Strasberg
SM.
Washington University School of Medicine, St. Louis, Missouri, USA.
RESULTS: One hundred patients (56 men, 44 women) were studied.
Resections were major (>3 segments) in 75 and resection margins were >
or = 1 cm in 52. Median follow up was 31 months, with 12 actual greater
than 5-year survivors. The actuarial 5-year overall survival was 58% (95%
confidence interval, 46-72%). Primary tumor grade was the only
prognostic variable significantly correlated with overall survival.

15.  19 studies (6070 patients)
 >40% median 5-year survival
 Results not improved in recent studies
 Operative mortality <2%
 FDG-PET scan detects 25% extrahepatic disease
 Primary tumor grade was the only prognostic variable significantly
correlated with overall survival
 A resection margin which was often less than 1cm but
microscopically negative
 PET Scan is poor for HCC and false negative for patients on
chemotherapy

16. Annals of Surgery. 240(6):1002-1012, December 2004.
One Hundred Thirty-Two Consecutive Pediatric Liver Transplants
Without Hospital Mortality: Lessons Learned and Outlook for the
Future. University Hospital Eppendorf, University of Hamburg,
Hamburg, Germany.
Conclusions: Progress during the past 15 years has enabled us to
perform pediatric liver transplantation with near perfect patient
survival.
The long-term treatment of the transplanted patient, with the aim of
avoiding late graft loss and achieving optimal quality of life, is easily
achieved with minimal effort.
PEDIATRIC LIVER FAILURE

17.  Most important prognostic factor after multivariate
analysis - the year of transplantation
 Only 3 recipients (2%) died during further follow-up
 Sixteen children (12%) had to undergo retransplantation
 This paper marks a turning point at which immediate
survival after transplantation will be considered the norm!

18.  Ann Surg. 2013 Apr;257(4):737-50.
 Predictors of surgery in patients with severe acute pancreatitis managed by
the step-up approach.
 Babu RY, Gupta R, Kang M, Bhasin DK, Rana SS, Singh R.
 PGIMER, Chandigarh
 RESULTS: Of the 70 consecutive patients with SAP, 14 were managed
medically, 29 managed with PCD alone, whereas 27 required surgery after
initial PCD.
 CONCLUSIONS:
 PCD reversed sepsis in 62% and avoided surgery in 48% of the patients.
Reversal of sepsis within a week of PCD, APACHE II score at first intervention
(PCD), and organ failure within a week of the onset of disease could predict
the need for surgery in the early course of disease.

19.  Cochrane Database Syst Rev. 2012 May.
 Early routine endoscopic retrograde cholangiopancreatography strategy
versus early conservative management strategy in acute gallstone pancreatitis.
 Tse F, Yuan Y.
 Department of Medicine, Division of Gastroenterology, McMaster University,
Hamilton, Canada
 Early ERCP should be considered in patients with co-existing cholangitis or
biliary obstruction. However, in patients with acute gallstone pancreatitis,
there is no evidence that early routine ERCP significantly affects mortality,
and local or systemic complications of pancreatitis, regardless of predicted
severity.

20. J Gastrointest Surg. 2000 Jul-Aug;4(4):355-64.
Quality of life and long-term survival after surgery for chronic pancreatitis.
Sohn TA, et al. The Johns Hopkins Medical Institutions, Baltimore
 Patients reported improvements in all aspects of the quality-of-life survey
including enjoyment out of life, satisfaction with life, pain, number of
hospitalizations, feelings of usefulness, and overall health (P < 0.005).
 In addition to improved quality of life after surgery, narcotic use was
decreased (41% vs. 21%, P < 0.01) and alcohol use was decreased (59% vs.
33%.
 These data suggest that surgery for patients with chronic pancreatitis can be
performed safely with minimal morbidity and excellent long-term survival.

21. Br J Surg. 2013 Nov;100(12).
Meta-analysis of randomized clinical trials on safety and efficacy of biliary
drainage before surgery for obstructive jaundice.
Fang Y et al.
 CONCLUSION:
 Pre-op biliary drainage (PBD) in patients undergoing surgery for obstructive
jaundice is associated with similar mortality but increased serious morbidity
compared with no PBD. Therefore, PBD should not be used routinely.

22.  Detailed preoperative reconstruction of biliary anatomy and
 Reliable identification of choledocholithiasis
 Acceptable sensitivity and specificity in a clinical setting.
 Newer software developments may further enhance its accuracy
 Replace more invasive diagnostic measures in the near future.

25. Results: Hospital or 30-day mortality and morbidity rates were 0% and
48%, respectively. The overall 3-year survival rate and median
survival time were 40% and 27 months. Survival of patients with
Bismuth type III or IV tumors or of patients who underwent right
hepatectomy was significantly better. Survival of patients who
underwent concomitant vascular resection was similar to survival of
those who did not. Univariate analysis indicated the type of
hepatectomy, histopathologic grade, Bismuth classification,
concomitant hepatic artery resection, and UICC stage as significant
prognostic factors.

26.  Preoperative biliary decompression
 Portal vein embolization
 No positive ductal margins
 Lymph node metastasis is a powerful, independent prognostic factor in
perihilar cholangiocarcinoma and is better classified based not on location
but on the number of involved nodes. To adequately assess nodal status,
histologic examination of 5 or more nodes is recommended. (Ann Surg. 2013
Apr;257(4):718-25. Assessment of nodal status for hilar cholangiocarcinoma:
location, number, or ratio of involved nodes. Aoba T et al).
 Caudate resection.

27. Acta Gastroenterol Latinoam. 2012 Dec;42(4):291-300.
Surgical resection with curative intent of hilar cholangiocarcinoma. Our
experience.
Vaccarezza H, Ardiles V, et al. Hospital Italiano de Buenos Aires, Argentina.
The association of major hepatectomy with caudate lobe resection and
vascular resection when needed, was associated with 95% tumor-free
margin and morbidity and mortality rate according to the standards of
the international literature.
Associated vascular resection seems to be a feasible and safe option in the
treatment of locally advanced disease.

28. Conclusion: Cholecystectomy should be delayed in patients who
survive an episode of moderate to severe acute biliary pancreatitis
and demonstrate peripancreatic fluid collections or pseudocysts
until the pseudocysts either resolve or persist beyond 6 weeks, at
which time pseudocyst drainage can safely be combined with
cholecystectomy.

29.  Delaying cholecystectomy may aggravate another episode of
pancreatitis
 If pseudocyst does not resolve, may need surgery
 Early ERCP in biliary pancreatitis may improve outcome
 No data was available to guide timing of cholecystectomy
 Complication rates were higher in the early group(5.5% versus
44%)

30. 128 patients underwent extended hepatectomy for colorectal metastases (n
= 86; 67.7%), hepatocellular carcinoma (n =12; 9.4%), cholangiocarcinoma (n
=14; 11.0%), and other malignant diseases (n =15; 11.5%). Synchronous
intraabdominal procedure was the only factor associated with an increased
risk of morbidity (hazard ratio [HR], 4.9; P = 0.02). The median survival was
41.9 months. The overall 5-year survival rate was 25.5%.
Conclusions: Extended hepatectomy can be performed with a near-zero
operative mortality rate and is associated with long-term survival in a subset
of patients with malignant hepatobiliary disease.

31.  128 patients with more than 5 segment resection
 Median survival 42 months
 5 year survival 26%
 Operative mortality 0.8%
 Adverse outcome if combined with any other intraabdominal
procedure
 Behari A, (SGPGI) extended resection for CaGb also showed good long
term results (BJS)