3 Liver Dr Fidel Copy

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3 Liver Dr Fidel Copy

  1. 1. LIVER Celso M. Fidel, MD, FPSGS,FPCS Diplomate Philippine Board of Surgery
  2. 2. Embryogenesis of the Liver <ul><li>Liver premordium appear early in 4 th week at the </li></ul><ul><li>Anterior intestinal portal growing to Caudal side </li></ul><ul><li>of the transverse septum. The septum contains: </li></ul><ul><li> Vitelline veins </li></ul><ul><li> Umbilical veins </li></ul><ul><li>Series of inductions ; </li></ul><ul><li>Mesodern of T Septum is associated w/ developing </li></ul><ul><li>Liver caudally. </li></ul><ul><li>Hepatic mesenchyme stimulates endodermal cord </li></ul><ul><li>growth and differentiation to hepatic cells. </li></ul><ul><li>Primitive endodermal plate becomes diverticulum. </li></ul><ul><li>Hepatic diverticulum develops 2 outpocketings. </li></ul>
  3. 3. Embryogenesis of the Liver <ul><li>Proximal =ventral primordium of pancreas </li></ul><ul><li>Distal = cystic duct and gall bladder </li></ul><ul><li>Terminal = Intrahepatic ducts, liver parenchyma </li></ul><ul><li>Liver parenchyma appears first as solid cord of </li></ul><ul><li>cells from the end of the hepatic diverticulum </li></ul><ul><li>that grows into the transverse Septum. </li></ul><ul><li>These hepatic cords invest first the vitelline </li></ul><ul><li>veins in the fifth week and part of the left </li></ul><ul><li>umbilical vein later. These vessels break-up to </li></ul><ul><li>plexus of thin-walled vessels = liver sinusoids </li></ul>
  4. 6. ANATOMY <ul><li> Largest, Heaviest, Intra-abdominal organ ,2% </li></ul><ul><li>of total body weight </li></ul><ul><li> Composed of 2 lobes (right & left) and each </li></ul><ul><li>lobe has 2 segments </li></ul><ul><li> Segmentation </li></ul><ul><li>1. Morphologic Surface features </li></ul><ul><li> These lobes are divided by the Interlobar </li></ul><ul><li>fissure, an invisible line between the gall </li></ul><ul><li>bladder fossa anteriorly and the inferior </li></ul><ul><li>vena cava Posteriorly </li></ul>
  5. 7. ANATOMY <ul><li> Segmentation </li></ul><ul><li>1. Morphologic Surface features </li></ul><ul><li> Falciform ligament , the only externally </li></ul><ul><li>visible boundary, marks the segmental </li></ul><ul><li>fissure between median & lateral </li></ul><ul><li>segment of the left lobe </li></ul><ul><li> Right lobe segmental fissure has no </li></ul><ul><li>external landmarks </li></ul><ul><li>2. Functional vascular anatomy </li></ul><ul><li> Liver is divided into segments supplied </li></ul><ul><li>by the portal triad , and drained by the </li></ul><ul><li>hepatic veins </li></ul>
  6. 8. ANATOMY <ul><li> Segments of the liver </li></ul><ul><li>I. Caudate lobe – located posteriorly between </li></ul><ul><li>right and left hepatic lobe </li></ul><ul><li>II. Left </li></ul><ul><li>III. lateral segment </li></ul><ul><li>IV. Left median segment </li></ul><ul><li>V. Anterior inferior ,Right </li></ul><ul><li>VI. Posterior inferior, Right </li></ul><ul><li>VII. Posterior superior, Right </li></ul><ul><li>VIII. Anterior superior, Right </li></ul>
  7. 10. Segments of the Liver
  8. 11. ANATOMY <ul><li> Vascular Supply ( Hepatic artery and portal </li></ul><ul><li>vein) </li></ul><ul><li>1. Arterial Supply </li></ul><ul><li> 25% of the liver blood flow </li></ul><ul><li> Common Artery enters the porta hepatis </li></ul><ul><li>medially to the CBD, gives up the gastro- </li></ul><ul><li>duodenal artery to be Hepatic Artery proper </li></ul><ul><li> Cystic Artery from the right hepatic artery </li></ul><ul><li> Left hepatic artery comes from the gastric </li></ul><ul><li>artery in 25% of the population </li></ul>
  9. 12. ANATOMY <ul><li> Vascular Supply ( Hepatic artery and portal </li></ul><ul><li>vein) </li></ul><ul><li> Right Hepatic Artery arises as a branch of the </li></ul><ul><li>Superior Mesenteric A in 20% of population </li></ul><ul><li>2. Venous supply </li></ul><ul><li> Portal vein </li></ul><ul><li> Lies posteriorly in the porta hepatis </li></ul><ul><li> Formed by Superior Mesenteric, Inferior </li></ul><ul><li>mesenteric and coronary veins </li></ul><ul><li> R and L branches supplies right and left </li></ul><ul><li>hepatic lobes, provides 75% of blood flow </li></ul>
  10. 13. ANATOMY <ul><li> Venous drainage </li></ul><ul><li> Hepatic vein courses between segments and drains </li></ul><ul><li>into the inferior vena cava </li></ul><ul><li> Hepatic Resections </li></ul><ul><li> Right Hepatic Lobectomy –transects liver thru </li></ul><ul><li>Interlobar fissure between gallbladder fossa and </li></ul><ul><li>inferior vena cava </li></ul><ul><li> Left hepatic Lobectomy </li></ul><ul><li> Trisegmentectomy- R lobectomy & median segment </li></ul><ul><li>of the left, leaving L lateral segment </li></ul><ul><li> L lateral Segmentectomy- Left lateral segment to </li></ul><ul><li>the left of the Falciform ligament </li></ul><ul><li> Wedge resection </li></ul>
  11. 14. Studies of the Liver <ul><li> Liver function test (Synthesis) </li></ul><ul><li> Serum protein </li></ul><ul><li> Clotting factors </li></ul><ul><li> Cholesterol </li></ul><ul><li> Blood Glucose </li></ul><ul><li> Clearance functions </li></ul><ul><li> Ammonia </li></ul><ul><li> Indirect Bilirubin </li></ul><ul><li> Excretory function </li></ul><ul><li> Direct Bilirubin </li></ul><ul><li> Enzyme level( Alk.Phos.,Gamma glutamyl transferase) </li></ul>
  12. 15. Studies of the Liver <ul><li> Extent of Injury </li></ul><ul><li> SGOT </li></ul><ul><li> SGPT </li></ul><ul><li> Imaging Modalities of the Liver </li></ul><ul><li> Ultrasound </li></ul><ul><li> CT Scan and MRI </li></ul><ul><li> Arteriography </li></ul><ul><li> Angioportography </li></ul><ul><li> Hepatobiliary Scanning </li></ul><ul><li> Intraoperative Ultrasonography </li></ul>
  13. 16. Studies of the Liver <ul><li> Imaging Modalities of the Liver’s Sensitivity </li></ul><ul><li>in detecting Hepatocellular Carcinoma </li></ul><ul><li> Intraoperative Ultrasonography > 99% </li></ul><ul><li> CT Scan > 89% </li></ul><ul><li> Preoperative Sonography > 88% </li></ul><ul><li> Angioportography > 82% </li></ul>
  14. 17. Surgical Conditions of the Liver <ul><li> Hepatic Abscess and Cysts </li></ul><ul><li> Nonviral Liver Infections </li></ul><ul><li>1. Bacterial, Protozoal and Parasitic </li></ul><ul><li>2. Environmental factors, particularly geogra- </li></ul><ul><li>phic location and presence of endemic </li></ul><ul><li>parasites </li></ul><ul><li>3. Abscess and Cysts- few localizing signs </li></ul><ul><li>4. Similar test as used for liver tumors </li></ul>
  15. 18. Surgical Conditions of the Liver <ul><li> Hepatic Abscess and Cysts </li></ul><ul><li> Bacterial Abscesses </li></ul><ul><li>1. Most common hepatic abscess in the </li></ul><ul><li>western World </li></ul><ul><li>2. Abdominal Infections, Appendicitis, Cholan- </li></ul><ul><li>gitis, Diverticulitis </li></ul><ul><li>3. Distant source= endocarditis </li></ul><ul><li>4. In 10-50% of cases no identifiable source </li></ul><ul><li>5. Infecting organism related to primary source </li></ul>
  16. 19. Surgical Conditions of the Liver <ul><li> Hepatic Abscess and Cysts </li></ul><ul><li> Bacterial Abscesses </li></ul><ul><li>6. In Abdominal; common organisms are gram </li></ul><ul><li>negative rods, anaerobic streptococcus </li></ul><ul><li>7. Extra Abdominal; gram + organisms </li></ul><ul><li>8. Clinical picture includes: </li></ul><ul><li> Right upper quadrant pain </li></ul><ul><li> Liver tender or enlarged </li></ul><ul><li> Sepsis may be overwhelming </li></ul><ul><li> Hemobilia- due to erosion of abscess into </li></ul><ul><li>biliary tree </li></ul>
  17. 20. Surgical Conditions of the Liver <ul><li> Hepatic Abscess and Cysts </li></ul><ul><li> Bacterial Abscesses </li></ul><ul><li>9. Management includes : </li></ul><ul><li> Percutaneous drainage </li></ul><ul><li> Operative Surgical Drainage, Antibiotics </li></ul><ul><li> Amoebic Abscess </li></ul><ul><li>1. 2 nd most common hepatic abscess in the </li></ul><ul><li>western world and common than bacterial </li></ul><ul><li>abscess in the 3 rd world </li></ul><ul><li>2. Solitary abscess ; 90% in right lobe </li></ul>
  18. 21. Surgical Conditions of the Liver <ul><li> Hepatic Abscess and Cysts </li></ul><ul><li> Amoebic Abscess </li></ul><ul><li>3. Entamoeba histolytica from intestinal amoe- </li></ul><ul><li>biasis through portal vein </li></ul><ul><li>4. Clinical Picture includes: </li></ul><ul><li> fever; hepatomegaly; R upper quadrant </li></ul><ul><li>pain; Leukocytosis;  liver enzymes </li></ul><ul><li>5. Management includes: </li></ul><ul><li> Aspiration of Abscess </li></ul><ul><li> Parenteral Metronidazole </li></ul>
  19. 22. Surgical Conditions of the Liver <ul><li> Hepatic Abscess and Cysts </li></ul><ul><li> Hydatid Cyst of the liver </li></ul><ul><li>1. Dogs are definitive host </li></ul><ul><li>2. Echinococcus granulosus </li></ul><ul><li>3. 2/3 occurs in the liver </li></ul><ul><li>4. Clinical picture includes: </li></ul><ul><li> Patient exposure in an endemic area </li></ul><ul><li> Liver enlargement and R upper Q pain </li></ul><ul><li> Eosinophilia present in 40% of patients </li></ul><ul><li> Serum test for parasite antigen is diagnostic </li></ul>
  20. 23. Surgical Conditions of the Liver <ul><li> Hepatic Abscess and Cysts </li></ul><ul><li> Hydatid Cyst of the liver </li></ul><ul><li>4. Clinical picture includes: </li></ul><ul><li> Progressive Liver enlargement =Rupture: </li></ul><ul><li> into Hepatic parenchyma ( daughter Cysts) </li></ul><ul><li> into the bile ducts </li></ul><ul><li> into free peritoneal cavity </li></ul><ul><li> Pericystic calcification on abdominal X ray </li></ul><ul><li>(condition requires no further treatment) </li></ul>
  21. 24. Surgical Conditions of the Liver <ul><li> BENIGN TUMORS OF THE LIVER </li></ul><ul><li> Hemangioma: </li></ul><ul><li>1. Most common benign hepatic tumor </li></ul><ul><li>2. Usually asymptomatic </li></ul><ul><li>3. Can cause symptoms by compression </li></ul><ul><li>4. Discovered as an incidental finding </li></ul><ul><li> Focal Nodular Hyperplasia </li></ul><ul><li>1. Third most common benign liver tumor </li></ul><ul><li>2. Weak association w/ oral contraceptives </li></ul><ul><li>3. Spontaneous rupture is rare </li></ul>
  22. 25. Surgical Conditions of the Liver <ul><li> BENIGN TUMORS OF THE LIVER </li></ul><ul><li> Hepatocellular Adenoma </li></ul><ul><li>1. Uncommon benign tumor </li></ul><ul><li>2. Seen in women taking oral contraceptives </li></ul><ul><li>3. About 25% have abdominal mass or pain </li></ul><ul><li>4. About 30% present w/ spontaneous rupture </li></ul><ul><li>into peritoneal cavity </li></ul><ul><li>5. Suspected when mass is seen on ultrasound </li></ul><ul><li>6. Angiography useful, hypervascularity present </li></ul><ul><li>7. Normal liver function </li></ul><ul><li>8. Biopsy needed to exclude malignancy </li></ul>
  23. 26. Surgical Conditions of the Liver <ul><li> BENIGN TUMORS OF THE LIVER </li></ul><ul><li> Infantile Hemangioendothelioma </li></ul><ul><li>1. Benign liver tumor in children </li></ul><ul><li>2. May present with hepatomegaly and high </li></ul><ul><li>output failure in an infant with a large </li></ul><ul><li>arterio-venous fistula </li></ul><ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Hepatocellular Carcinoma (Hepatoma) </li></ul><ul><li> Clinical Features </li></ul><ul><li>1. 80% of primary liver tumors </li></ul><ul><li>2. Men are affected twice as often as women </li></ul>
  24. 27. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Hepatocellular Carcinoma (Hepatoma) </li></ul><ul><li> Clinical Features </li></ul><ul><li>3. About 10-15% of patients present with </li></ul><ul><li>hemorrhage </li></ul><ul><li>4. Hepatomegaly in 88% of cases </li></ul><ul><li>5. Weight loss in 85% </li></ul><ul><li>6. Tender abdominal mass in 50% </li></ul><ul><li>7. Associated with Cirrhosis in 60% </li></ul>
  25. 28. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Hepatocellular Carcinoma (Hepatoma) </li></ul><ul><li> Risk Factors </li></ul><ul><li>1. Chronic Hepatitis B Virus (HBV) infection </li></ul><ul><li>2. Cirrhosis of the liver </li></ul><ul><li>3. Hemochromatosis with iron overload and </li></ul><ul><li>cirrhosis </li></ul><ul><li>4. Schistosomiasis & other parasitic infestation </li></ul><ul><li>5. Environmental Carcinogens </li></ul><ul><li>6. Chlorinated hydrocarbons such as Carbon </li></ul><ul><li>tetrachloride pesticides </li></ul>
  26. 29. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Hepatocellular Carcinoma (Hepatoma) </li></ul><ul><li> Diagnostics: </li></ul><ul><li>1. Alpha-fetoprotein elevated in 70-90% of cases </li></ul><ul><li>2. Hepatic Ultrasound </li></ul><ul><li>3. Arterioportography </li></ul><ul><li>4. CT Scan </li></ul><ul><li>5. MRI </li></ul><ul><li> Treatment </li></ul><ul><li>Resection of the lesion </li></ul>
  27. 30. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Hepatoblastoma </li></ul><ul><li> Almost exclusively a childhood tumor </li></ul><ul><li> 66% of malignant hepatic tumor in children </li></ul><ul><li> Occurs in the first 5 years mostly under 2 yrs </li></ul><ul><li> Associated with Wilms’ tumor, Glycogen </li></ul><ul><li>storage disease, Low birth weight, talipes, </li></ul><ul><li>Cleft palate, Down’s syndrome, mutations of </li></ul><ul><li>the Adenomatous polyposis coli (APC) gene. </li></ul><ul><li> Linked to maternal oral contraceptive use & </li></ul><ul><li>total alcohol syndrome </li></ul>
  28. 31. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Hepatoblastoma </li></ul><ul><li> Clinical features </li></ul><ul><li>1. Failure to thrive, weight loss and a rapidly </li></ul><ul><li>enlarging abdominal mass </li></ul><ul><li>2. Serum AFP is invariably high and correlates </li></ul><ul><li>with tumor burden </li></ul><ul><li>3. It is an aggressive neoplasm that invades </li></ul><ul><li>locally & spreads to regional lymph nodes, </li></ul><ul><li>adrenals, Lungs, Brain and Bones </li></ul>
  29. 32. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Hepatoblastoma </li></ul><ul><li> Treatment </li></ul><ul><li>1. Adjuvant and Neo-adjuvant chemotherapy </li></ul><ul><li>and Chemo-embolization has improved the </li></ul><ul><li>resection rate and overall survival </li></ul><ul><li>2. Transplantation in selected cases </li></ul><ul><li> Prognosis </li></ul><ul><li>1. 50-80% long term survival </li></ul><ul><li>2. Patients with pure fetal type have a better </li></ul><ul><li>outcome if completely resected </li></ul>
  30. 33. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Cholangiocarcinoma </li></ul><ul><li> 5-30% of primary Hepatic Malignancy </li></ul><ul><li> The 2 nd most frequent Carcinoma after HCC </li></ul><ul><li> Some arise w/in congenitally dilated ducts, </li></ul><ul><li>1. after thorium dioxide( Thorotrast ) & </li></ul><ul><li>anabolic steroids </li></ul><ul><li>2. in Intrahepatic lithiais </li></ul><ul><li>3. primary sclerosing cholangitis </li></ul><ul><li>4. ulcerative colitis </li></ul>
  31. 34. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Cholangiocarcinoma </li></ul><ul><li>5. Choledochal cyst </li></ul><ul><li>6. parasitic infections w/ Clonorchis and </li></ul><ul><li>opistorchis </li></ul><ul><li> Peripheral type arises from smaller bile ducts </li></ul><ul><li> Hilar type (Klatskin tumors arises from major </li></ul><ul><li>duct in the hepatic Hilar area </li></ul><ul><li> K- ras and p 53 mutations can occur in </li></ul><ul><li>primary sclerosing Cholangitis, </li></ul>
  32. 35. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Cholangiocarcinoma </li></ul><ul><li> Clinical Features </li></ul><ul><li>1. Patients older than 60 in both sexes </li></ul><ul><li>2. Symptoms includes: </li></ul><ul><li> Hepatomegaly </li></ul><ul><li> Abdominal pain </li></ul><ul><li> Weight loss </li></ul><ul><li> Malaise </li></ul><ul><li> Anorexia </li></ul>
  33. 36. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Cholangiocarcinoma </li></ul><ul><li> Clinical Features </li></ul><ul><li>3. Hilar CC presents w/ painless jaundice and </li></ul><ul><li>pruritus </li></ul><ul><li>4. CEA and CA 19-9 are sometimes elevated </li></ul><ul><li>5. Most of Intrahepatic CC are at an advanced </li></ul><ul><li>stage w/ involvement of LN & distant organs </li></ul><ul><li> Prognosis =Poor </li></ul><ul><li> Treatment =Resection when feasible </li></ul>
  34. 37. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Angiosarcoma </li></ul><ul><li> Clinical Features </li></ul><ul><li>1. Most common primary Mesenchymal liver </li></ul><ul><li>tumor in Adults </li></ul><ul><li>2. 1% of Liver tumors found in men in their </li></ul><ul><li>5 th and 6 th decade of life </li></ul><ul><li>3. Latency period of 20-35 years </li></ul><ul><li>4. Local spread to the spleen in 80% of cases </li></ul>
  35. 38. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Angiosarcoma </li></ul><ul><li> Clinical Features </li></ul><ul><li>5. Related to exposure to: </li></ul><ul><li> Thorotrast  Vinyl Chloride </li></ul><ul><li> Arsenic  Androgenic Steroids </li></ul><ul><li> Copper Sulfate  Estrogen </li></ul><ul><li> Radiotherapy  Chemotherapy </li></ul><ul><li>6. Hemochromatosis </li></ul>
  36. 39. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Angiosarcoma </li></ul><ul><li> Clinical Features </li></ul><ul><li>7. Symptoms includes: </li></ul><ul><li> Abdominal pain  Anorexia </li></ul><ul><li> weight loss  Fatigue </li></ul><ul><li>8. PE findings </li></ul><ul><li> Hepatomegaly w/ or w/o splenomegaly </li></ul><ul><li> Thrombocytopenia </li></ul>
  37. 40. Surgical Conditions of the Liver <ul><li> PRIMARY MALIGNANT TUMORS OF LIVER </li></ul><ul><li> Angiosarcoma </li></ul><ul><li> Diagnostic tool- Angiography and contrast </li></ul><ul><li>enhanced CT scan of the liver </li></ul><ul><li> Prognosis- Grave ; Most patients die within </li></ul><ul><li>6 months </li></ul><ul><li>Deaths are due to Hepatic failure and </li></ul><ul><li>intra abdominal bleeding </li></ul>
  38. 41. Surgical Conditions of the Liver <ul><li> METASTATIC TUMORS OF LIVER </li></ul><ul><li> Overview </li></ul><ul><li> Liver is the 2 nd most common site of mets. </li></ul><ul><li> Over 2/3 of all colorectal cancer ultimately </li></ul><ul><li>involve the liver </li></ul><ul><li> Up to 50% of cancers outside the abdomen </li></ul><ul><li>metastasize into the liver </li></ul><ul><li> May be difficult to detect because liver </li></ul><ul><li>metastasis are asymptomatic </li></ul>
  39. 42. Surgical Conditions of the Liver <ul><li> METASTATIC TUMORS OF LIVER </li></ul><ul><li> Overview </li></ul><ul><li> Metastatic disease to the liver depends on </li></ul><ul><li>type of primary tumor . </li></ul><ul><li> Chemotherapy for liver metastasis from </li></ul><ul><li>colorectal cancer </li></ul><ul><li> Radiation therapy is poorly tolerated by the </li></ul><ul><li>liver but may be palliative for painful liver </li></ul><ul><li>metastasis </li></ul><ul><li> Hepatic Artery ligation </li></ul><ul><li> Surgical resection </li></ul>
  40. 43. Surgical Conditions of the Liver <ul><li> TRAUMA </li></ul><ul><li> Liver is 2 nd commonly injured organ </li></ul><ul><li> High blood flow and in proximity to IVC </li></ul><ul><li> Vital structure and propensity to develop </li></ul><ul><li>infection </li></ul><ul><li> The overall mortality of liver trauma remains </li></ul><ul><li>about 10-20 % </li></ul><ul><li> Abdominal pain and symptoms of shock </li></ul><ul><li> Abdominal paracentesis for blunt abdominal </li></ul><ul><li>trauma </li></ul><ul><li> Packing and Pringle’s maneuver ( porta hepatis) </li></ul>
  41. 44. THANK YOU!!!

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