3  Liver Dr Fidel   Copy
Upcoming SlideShare
Loading in...5
×
 

3 Liver Dr Fidel Copy

on

  • 2,336 views

 

Statistics

Views

Total Views
2,336
Views on SlideShare
2,334
Embed Views
2

Actions

Likes
1
Downloads
145
Comments
0

1 Embed 2

http://www.slideshare.net 2

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

3  Liver Dr Fidel   Copy 3 Liver Dr Fidel Copy Presentation Transcript

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