Liver Pancreatic Surgery

The institution offers a range of treatment facilities for hepatobiliary and pancreatic. The following is a sample list of common procedures that are done here

Liver:
Liver resection for primary and secondary tumors

Hydatid nucleation

Biliary:
Laparoscopic cholecystectomy

ERCP

Pancreatic surgeries:
Whipples operation

Pancreatic resections

Endoscopic drainage of pancreatic pseudo cysts

Pancreatic stenting

 

Liver metastasis is the culmination of spread of cancer from distant primary sites. While the outlook is still poor, there is a ray of hope for selected patients. Surgery is possible in a minority of patients, depending on the type and location of the cancer metastasis.

Anatomy: Liver is the largest abdominal organ. Blood draining from the abdominal organs such as the stomach, bowel and pancreas drain into the portal vein. This subsequently enters into the liver and bathes the liver cells. This arrangement allows the liver to extract nutrients, flowing after digestion from the gut. It also unfortunately makes the liver vulnerable to spread of infections and cancers of the abdominal viscera.  For example amoebiasis can enter the liver and form abscesses following a primary infection in the large intestine. Similarly pyogenic abscesses from severe diverticulitis or appendicitis can occur.

History of liver surgery: Liver is a difficult organ from a surgical perspective. It has a very rich dual blood supply. The venous drainage is into the inferior vena cava, via the hepatic veins, only centimetres away from the heart! There are very few external landmarks over the liver. Its soft tissue is very friable and does not easily accept sutures like other tissues like skin or bowel.  However progress came with better understanding of the segmental anatomy of the liver. It was realised that complications were less once liver was treated as an aggregate of several segments of liver. Each segment has distinct inflow (portal and hepatic) and outflow (hepatic veins). When surgery is done respecting these divisions, it is possible to excise offending lesions along segmental lines. The excision also satisfies oncological standards  with minimal morbidity. Liver is unique amongst internal organs due to its capability to regenerate back to original size. This allows us to remove up to 80% of the liver in selected patients.  Regeneration  depends on the both quantity and quality of the remnant liver.

Anaesthetic considerations: Bleeding is the major concern during liver resections. There are some useful manoeuvres such as low CVP and aiming for a low urine output such as 25ml/hr. These run counter to most anaestheists’ reflexes. Hence it is important to have an anaesthetist who understands and is experienced with these issues.

Surgery: The decision to remove metastatic deposit in the liver in depends on the following factors

Number of metastatic deposits

Extent of deposit

The primary pathology – has it been completely excised?

The gap between removal of the primary cancer and the appearance of metastasis – longer the interval, better the outlook

Nature of the primary cancer – colorectal cancers remain the major primary, for which experience and evidence exists. Other metastatic cancers can be resected, provided there is no other metastasis and the lesion is stable. A PET scan is valuable in excluding occult distant metastasis before embarking on liver surgery. The decision is individualised.

Currently as a general rule, if a lesion is technically amenable for segmental excision, with a reasonable liver remnant and the cancer is a stable slow growing cancer with no evidence of any other spread, then liver resection is a reasonable option. Segmental resection has changed the scene by extending resection options and the ability to conserve more functional parenchyma.

The following is an illustration of liver resection applied to a suspected gallbladder cancer which was done at Dr Kamakshi Memorial Hospital, which illustrates the principles.