HEPATIC, BILE DUCTS, AND PANCREATIC SURGERY
HEPATOPANCREATOBILARY SURGERY
- Hepatic Cysts
- Hepatic Tumors
- Diseases of the Gallbladder and Bile Ducts (Calculus, Cyst, and Tumor)
- Pancreatitis and pseudocysts
- Pancreatic Cystic Diseases
- Pancreas Cancer
Liver is the largest gland of our digestive system and our body. Being a central biochemical laboratory for all tissues, the liver has many functions. It contributes to almost every function of the body. It produces, stores, and functions as: Bile, a protein that is used as fuel for the body, glucose, cholesterol, vitamins, hormones, etc. Moreover, almost everything (including toxic materials) that enter the body is cleared and inactivated in the liver.
Hepatic Cysts
A benign, thin-walled structure with fluid content in hepatic tissue is known as a simple cyst. They are usually small in size and do not require treatment; however, if there are numerous and large and cause pain, although rare, surgery may be required. Deroofing or in some cases, draining cyst content (recurrence may occur) may be considered for treatment.
In Turkey, fluid cysts are mostly caused by a parasite known as Echinococcus granulosus (known as hydatid disease) and are detected most frequently in the liver and other organs. These types of cysts definitely require surgery in the parasite in which the cyst is alive. Included among treatments are PAIR (cleaning and aspiration of cyst content via a thin tube placed on the cyst) performed by Interventional Radiology and closed or open surgery. Before and after every interventional treatment, medical treatment with albendazole should be administered.
Hepatic Abscess
Severe infections in other parts of the body may cause the formation of a structure filled with pus in the liver. These structures are called an abscess. Some of the abscesses may directly develop in the liver. This disease mostly affects people with weak immune systems; however, it should be kept in mind that it may also develop secondary to severe inflammation in other organs. In this case, the only treatment option is surgery under intravenous administration of a strong antibiotic. Nowadays, it may be treated by placement of a catheter by Interventional Radiology without the requirement of surgery in most of medium- and large-sized medical centers.
Hepatic Tumors
Benign Hepatic Tumors (most common types)
Hemangioma is one of the most common benign tumors that may be observed in the liver and other organs and tissues. It is a tumor composed of a hereditary cluster of blood vessels. Most of the time, it cannot be treated; however, surgical treatment may be considered if it causes notable pain or blood destruction (as in Kasabach–Merritt syndrome, also known as hemangioma with thrombocytopenia).
Hepatic adenoma is a benign and well-contoured tumor, which is mostly detected incidentally during investigations for another reason. It is more commonly observed in people using contraceptive medications (or steroid hormones) for any reason compared to those who are not. Upon discontinuation of the medication, it may regress in some of the patients. Surgical treatment may be considered for tumors that are larger than five centimeters due to hemorrhage or risk of conversion into a malignant tumor.
Focal nodular hyperplasia is the second most common benign hepatic tumor. Surgery is not recommended for this type of tumor if it is detected incidentally or in case of definitive diagnosis with radiological imaging (the central scar is observed in 80% of the cases). Its potential to convert into a malignant tumor has not yet been reported in the literature. There is no risk of hemorrhage as in a hemangioma or hepatic adenoma. However, surgical treatment may be recommended in case of notable and otherwise untreatable abdominal pain or if a definitive diagnosis cannot be achieved.
Malignant Hepatic Tumors
Hepatocellular carcinoma is the most common malignant hepatic tumor. It may develop due to chronic liver disease that developed on the background of hepatitis B and C and cirrhosis due to various reasons and some hereditary diseases. The incidence rate of this disease is five percent in a hundred thousand in developed countries whereas it is around 70-80 percent in a hundred thousand in most of African countries and Southeast Asia countries. Among the investigations required for diagnosis are mostly computed tomography (CT), magnetic resonance tomography (MRI), and the marker known as alpha-fetoprotein (AFP) in the blood. Unfortunately, only 10%-20% of the patients may undergo surgery for this disease due to accompanying chronic liver disease. Liver transplantation may be an option for some of the patients if certain criteria are met.
Radiofrequency, microwave ablation, sclerotherapy with ethanol, and transarterial chemoembolization are among other treatment options. A hepatocellular carcinoma patient is primarily followed up by Medical Oncology.
Cholangiocellular carcinoma is the second most common malignant liver tumor that originates from intrahepatic bile ducts. The most common pathological conditions among risk factors required for the disease include primary sclerosing cholangitis, choledochal cysts, and cirrhosis. Usually, a diagnosis is achieved during investigation for another reason or while searching for the source of unknown metastasis. The only radical treatment is the surgical removal of the disease. In cases for which surgery cannot be made, transarterial chemo- and radioembolization or chemotherapy may be administered.
Metastases of the liver are tumoral focuses originating from the digestive system or other system organs. The most common tumor with metastasis of the liver is due to colorectal cancer. If treated, survival rates are gradually increasing with surgical innovations and new medications. Surgical treatment may be used for certain cases of metastasis of colorectal cancer. To achieve the best results, the patients must undergo extended screening for metastasis before the surgery or be in close follow-up for treated disease. In addition to surgical resection, radiofrequency or microwave ablation and other modern methods are among the treatment options.
The gallbladder is the organ that concentrates bile, a fluid produced in the liver. After eating a high-fat meal, concentrated bile is released into the duodenum (“twelve-finger intestine”) and ensures the digestion of food.
Cholelithiasis is the condition where there is calculus (stone) in the gallbladder or bile ducts. Sometimes gallstones cause no symptoms and are detected incidentally. The gallbladder is the main place and source where calculi are produced. Gallstones may rarely cause some chronic bile duct diseases, such as choledochal cysts. In case of pain or other clinical problems, surgical treatment is definitely performed for the calculi. If not surgically treated, the chance of laparoscopic surgery is reduced as the patient has attacks due to severe adhesions and other complications. In the case of “silent” gallstones, sometimes surgery is not recommended due to various risk factors. However, this is a decision taken after a surgeon and patient discuss all the possibilities.
Acute cholecystitis is the most common problem caused by calculi. It causes severe pain due to inflammation of the gallbladder wall and requires surgical treatment. Laparoscopic cholecystectomy (removal of the gallbladder) is usually warranted.
Acute cholangitis is a pathological condition that occurs if calculi move from the gallbladder to the bile ducts and obstruct the bile ducts and causing severe problems (pain, obstructive jaundice, fever, etc.). Inflammation of bile ducts (acute cholangitis) usually requires intravenous admission of antibiotic treatment at a hospital. In case of severe inflammation, treatments involving the removal of calculi from bile ducts are required. Laparoscopic cholecystectomy may be performed as the last resort.
For polyp(s) in the gallbladder, surgical treatment is considered if the polyp measures more than 1 cm or ultrasonography shows size progression during follow-up.
Tumors of Bile Ducts
Gallbladder cancer is usually detected incidentally in the late stage or upon removal of the gallbladder for any reason. If detected in the late stage, treatment is regulated by Medical Oncology. If the case of early-stage gallbladder cancer is detected incidentally, surgical treatment is regulated according to the condition and consists of only liver resection and lymph node dissection.
Cholangiocarcinoma is a group of cancers that begin in the bile ducts. They usually develop together with obstructive jaundice and surgical treatment may consider for some of the patients.
The pancreas is an organ that is located at the back of the stomach and produces essential digestive enzymes and endocrine hormones. Among the most commonly known pancreatic hormones are active molecules such as insulin, glucagon, and somatostatin. Anatomically, the pancreas is in close contact with the stomach, duodenum, bile ducts, and spleen.
Acute pancreatitis is the obstruction of the pancreatic duct for any reason and inflammation of the pancreas. In Turkey, the most common cause of acute pancreatitis is gallstones falling into the common bile duct. The pancreatic duct and bile duct are drained into the same place; therefore, they may be obstructed by the same calculus. For treatment, general medical treatment or possibly ERCP (endoscopic retrograde cholangiopancreatography) may be considered. Afterward, cholecystectomy (removal of the gallbladder) should be performed for gallstones.
Chronic pancreatitis develops mostly (70%) due to alcohol misuse. Aside from alcohol, in addition to gallstones, hypercalcemia, sphincter of Oddi dysfunction, and some rare conditions, such as cystic fibrosis, primary sclerosing processes may also be the reason. Being the most common symptom, severe pain is treated with analgesics, pain management, and surgical removal of a certain part of the organ. Rarely, calculi in the pancreatic duct may cause pain that may be treated by longitudinal pancreaticojejunostomy (Puestow procedure), a procedure that connects the pancreatic duct to the small intestine and prevents the repetitive production of calculus.
Pancreatic pseudocysts may be considered significant inflammation residue after acute pancreatitis. Small pseudocysts (measuring less than 6 cm) are taken in follow-up; however, large pseudocysts (measuring above 6 cm and persisting for more than 6 weeks) may require surgical treatment. In addition to laparoscopic and open surgery, endoscopic cystogastrostomy may also be considered.
Pancreatic cystic neoplasms may be divided into two: mucinous and non-mucinous. Serous cystadenomas are benign and non-mucinous tumors. Differentiation from other cystic structures has become easier with current radiological investigations; however, some patients may undergo surgery due to diagnosis hesitancy. Although quite rare, the development of a malignant tumor, known as serous cystadenocarcinoma, from these lesions has been reported.
Mucinous cystic neoplasia is mostly encountered in women and in the pancreatic body and tail. These cystic lesions form approximately 50% of all cystic lesions. The main problem is the release of mucin from abnormal cells in the mucosa of pancreatic duct. These formations are considered as cancer precursors and therefore, surgical treatment is recommended.
Intraductal papillary mucinous neoplasm is a mucinous tumor; however, it has a different course and pathological features in comparison to the previous pathology. It is also known as pancreatic cancer precursor and surgical treatment is recommended. The intraductal papillary mucinous neoplasm may be diagnosed with radiological investigations (CT, MRI) and endoscopic investigations (ERCP, endoscopic ultrasonography).
Pancreatic tumors may be treated with surgical treatments, such as local enucleation, distal pancreatectomy, Whipple procedure, and total pancreatectomy. The surgery in this area requires a specific approach due to its anatomical condition and functions. In some cases, laparoscopic surgery may be safely performed (if the location of the tumor is precisely determined at the pancreatic body/tail) and in others, it may not be possible (in case of advanced local tumors or if the location of the tumor is not definitely known).
Pancreatic cancer constitutes 95% of all malignant tumors of the pancreas. It is an aggressive tumor and only 10-20% of the cases may be early diagnosed and treated with surgery. In most cases, medical treatment is evaluated by Medical Oncology and some palliative surgical treatment may be recommended.
Ampullary cancer is caused by a malignant tumor that originates from the point, where the common bile duct drains into the duodenum. Since it causes obstructive jaundice in the early stage, it may be detected in the early stage and mostly may be treated with surgery.
Pancreatic neuroendocrine tumors may be divided into two groups as active tumors releasing hormones and inactive tumors. The symptoms may vary depending on the released hormone: low blood glucose, diabetes, diarrhea, skin rash, and gastric ulcers are among the most common symptoms. Most neuroendocrine tumors release insulin (insulinoma) and gastrin (gastrinoma). Insulinoma is a benign tumor in 90% of the cases and may be treated with surgery if its location is determined in the pancreas. Gastrinoma (Zollinger-Ellison syndrome) is a tumor that causes resistant gastritis and gastric ulcer and is related to a genetic mutation considered within the scope of MEN1 syndrome in 25% of the cases (hypophyseal, parathyroid gland, and pancreatic tumors develop at the same time). If the location of the tumor in the organ is detected, surgery may be performed. Tumors such as glucagonoma (causes elevated blood glucose, diabetes, skin rash), VIPoma (severe watery diarrhea), and somatostatinoma (causes quite unsteady and various clinical findings) are observed quite rarely. Detection and surgical treatment are quite difficult for these types of tumors, and they require further investigation.