Hepatobiliary surgery - role in liver diseases.pptx

Gian Luca Grazi
Hepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
Hepatobiliary surgery: role in liver diseases

Hepatobiliary surgery: role in liver disease
1980 - 1990 1990 - 2000 2000 - 2010 2010 - 2020
• Pioneering time
• Early days of
ultrasonography
• Poor CT scans
• No RMI
• First
introduction of
liver
transplantation
• Few indications
for surgery
• High mortality
rates
• Better
radiological
planning
• Improved
insights of
consequences of
hepatic surgery
• Expansion of
surgical
indications
• Improved early
results
• Sophisticated
radiological
planning
• The concept of
“Failure to
rescue”
• Revision of
surgical
indications
• Further
improvements
of early results
Evolution of
hepato-biliary
surgery toward
the
transformation
into an
autonomous
and specialized
branch of
surgery
The growth of biliary hepatic surgery
v

https://www.chirurgiadelfegato.it/storia-della-chirurgia-del-fegato/

• Primary Liver Tumors
• Secondary Liver Tumors
• Benign neoplasms
• Acute biliary diseases
• Chronic biliary diseases
Conventional Liver Resections
 Minor/Extended
 ALPPS
 Laparoscopic
 Robotic
Liver Transplantation
Biliary diversions
Indication for Hepatobiliary Surgery

Hepatocellular Carcinoma

Reig M. et al., J Hepatol. 2022 Mar;76(3):681-693

877 Liver Resections
(June 2010 – September 2022)
HCC
195
Intrahepatic
Cholangiocarcinoma
79
CRLM
402
Perihilar
Cholangiocarcinoma
36
Others
93
Gallbladder
29

195 Liver Resections for Hepatocellular Carcinoma
(June 2010 – September 2022)

195 Liver Resections for Hepatocellular Carcinoma
Actuarial Survival

Distribution of median survival estimates according to the different therapies in each stage
Vitale A, Liver Int. 2019;39:1478-1489
CPS, Child Pugh score; PST, performance status; VI, vascular invasion; Meta, extra‐hepatic metastases; LT, liver transplantation; LR, liver
resection; ABL, ablation; IAT, intra‐arterial therapy; SOR, Sorafenib; BSC, best supportive care

The proposed simplified ITA.LI.CA treatment algorithm based on the concept of therapeutic hierarchy
LT, liver transplantation; LR, liver resection; LRT, loco‐regional therapy; ST, systematic therapy
Vitale A, Liver Int. 2019;39:1478-1489

Overall survival
among the 2
groups before
the weighting.
Hepatectomy Versus Sorafenib in Advanced Nonmetastatic Hepatocellular Carcinoma
A Real-life Multicentric Weighted Comparison
Famularo S, Ann Surg. 2022;275:743-752
Overall survival
among the 2
groups after the
weighting.

EASL, J Hepatol. 2018; 69: 182-236
Impact of mini-invasive technology in surgery for HCC

Impact of robotic technology in surgery for HCC

Benign Hepatic Neoplasms

Pompili M, Dig Liver Dis, 2022, doi:10.1016/j.dld.2022.08.030

Giant Liver Hemangioma: Follow-up

Clinical Picture Reccomandation
Asymptomatic hemangioma < 10 No follow-up
Symptomatic patients or with hemangiomas > 10 cm Follow-up, due to possible complications
Symptomatic hemangiomas (Kasabach-Merritt syndrome
or bulk symptoms) or pedunculated hemangiomas or
hemangiomas with a diameter of 10 cm or more
Surgical treatment
Symptomatic hemangiomas less than 10 cm Locoregional ablation techniques
Unfavorable clinical evolution or volume increase after
treatment
Resection with radical intent
Symptomatic patients with unresectable giant hepatic
hemangioma or multiple hemangiomas
Liver transplantation as a feasible
treatment
Liver Hemangioma

• Hepatic haemangioma was diagnosed in 2071 patients (2.5% prevalence).
• In 226 patients (10.9%), haemangioma had diameter of 4 cm or more
(giant haemangioma).
• Spontaneous bleeding occurred in 5/1067 patients (0.47%).
 All 5 patients had giant haemangioma: 4 had exophytic lesions and presented with
haemoperitoneum; 1 with centrally located tumour experienced intrahepatic bleeding.
• Giant haemangiomas have a low but relevant risk of rupture (3.2% in this
series), particularly when peripherally located and exophytic.
• Surgery might be considered in these cases.
Mocchegiani F, Dig Liver Dis. 2016;48:309-14
Prevalence and clinical outcome of hepatic haemangioma with specific reference to the risk of rupture:
A large retrospective cross-sectional study

Risk of rupture and symptoms related to the size of haemangioma.
*Symptoms: Abdominal pain not responsive to medical therapy; nausea, vomiting, early satiety related to gastric compression.
Mocchegiani F, Dig Liver Dis. 2016;48:309-14

Giant Liver Hemangioma: Surgery

Focal Nodular Hyperplasia

Recommendation
Asymptomatic adults with focal nodular hyperplasia not
localized in the subcapsular or pericaval region
Not performing imaging surveillance
Symptomatic patients with pain or compression
symptoms, refusing treatment, and in patients with
lesions located in the subcapsular or pericaval region
Ultrasound or magnetic resonance surveillance
Lesions undefined by imaging techniques as focal
nodular hyperplasia
Referring patients to a tertiary reference center
Female patients with focal nodular hyperplasia Not discontinuing oral contraceptives, that show no role
in the development and evolution
Symptomatic adults with focal nodular hyperplasia Surgical treatment of the lesion, as it might improve the
quality of life. However, follow-up does not appear
associated with the occurrence of major complications.
Focal Nodular Hyperplasia

Intrahepatic rupture of hepatic adenoma

Nault JC, J Hepatol. 2017;67:1074-1083.

Clinical Picture Recommendations
Adults with hepatocellular adenoma and histological subtype
not classifiable with imaging techniques
Biopsying the lesion to identify the β-catenin mutated adenoma (exon 3), the
subtype with highest risk of malignant transformation, and the sonic hedgehog
adenoma subtype associated with a high risk of spontaneous bleeding. The risk
of complications of percutaneous biopsy of adenomas is considered low.
In women with adenoma in follow-up who discontinued oral
contraceptives
MR re-evaluation at 6 months. If the adenoma is unchanged or is reduced to
less than 5 cm, we suggest a re-evaluation at 1 year. After the first 18 months of
follow-up, if the adenoma is unchanged, we suggest continuing the follow-up
with annual ultrasound examination
Female patients with hepatocellular adenomas that, 6
months after discontinuation of oral contraceptives, remain
equal to or greater than 5 cm, or with malignant features on
imaging or with histologically proven β-catenin mutation
Surgical resection
Male patients with hepatocellular adenoma Surgical resection regardless of the size of the lesion
Female patients with hepatocellular adenoma on follow-up Discontinuing oral contraceptives
Adults with multiple hepatocellular adenomas Resection in case of malignant degeneration or bleeding of 1 or more lesions
Adults with multiple hepatocellular adenomas ( ≥10) Liver transplantation is suggested in case of malignant degeneration, and might
be considered in patients at high risk of liver functional decompensation after
resection and in symptomatic massive forms.
Liver Adenoma

Liver Cysts

Acute Biliary Diseases

Acute Suppurative Cholangitis
Stenosis of the left bile duct
Bile duct dilatation

Left Bile Duct Fibrosis
Stenosis of the left bile duct Bile duct dilatation

Biliary complications during follow-up
Cumulative incidence of biliary complications.
Yasuda I, Gastrointest Endosc. 2010;72:1185-91

Bektaş H, Wideochir Inne Tech Maloinwazyjne. 2017;12:231-237
Multiple plastic biliary stent placement
in the management of large and multiple choledochal stones

The main causes of cholangitis following Roux-en-
Y hepaticojejunostomy in healthy liver, namely,
(i) stenosis of the biliary anastomosis and
(ii) ascending cholangitis favored by a bowel loop
that is too short

Cholangitis after Roux-en-Y hepaticojejunostomy

Chronic Biliary Diseases

Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis
(PSC) are progressive cholestatic liver diseases of supposed auto-
immune etiology.
The clinical course is unpredictable and, in many patients, leads to
end-stage liver disease or a poor quality of life.
Conservative therapy only has a limited effect on the natural
history, but orthotopic liver transplantation (OLT) offers a definitive
therapeutic option.

Primary Sclerosing Cholangitis (1)
Non-transplant surgery
Surgery is performed to improve bile flow,
reduce jaundice and prevent further episodes
of cholangitis.
Non-transplant surgical approaches include
resecting the part of the hepatic bile duct that
is outside the liver, called the extrahepatic bile
ducts.

• Although PSC involves both intrahepatic and extrahepatic bile ducts in most patients, the hepatic duct bifurcation is often the
most severely involved region.
• The surgical approach which is used in some centers involves resection of the hepatic duct bifurcation, intraoperative dilation of
the intrahepatic biliary tree, reconstruction with a hepaticojejunostomy and insertion of long-term transhepatic stents to prevent
restricturing of the intrahepatic bile ducts.
• This approach is reported to improve jaundice and overall transplant-free survival in a select group of patients without cirrhosis.
• The absence of prospective controlled data makes it difficult to accurately assess the beneficial effects that operative biliary
drainage may have on the natural history of PSC.
• Because PSC is progressive in most patients, operative biliary drainage is still regarded as a palliative procedure used to relieve
obstructive jaundice, infective cholangitis and intractable pruritus.
• There is general consensus that operative biliary drainage provides no benefit in patients with PSC who have cirrhosis or advanced
diffuse intrahepatic biliary disease.
• Surgical treatment of extrahepatic strictures is now used infrequently because of concern that operations in the vicinity of the
porta hepatis may hamper future liver transplantation.

Endoscopic dilatation and stenting is the optimal treatment of
symptomatic dominant biliary strictures
Operative biliary drainage may alleviate symptoms, but it appears to
have no effect on the natural history of the disease.
Conventional biliary surgery should be avoided, if possible, because
it may interfere with subsequent liver transplantation, which is the
only effective life-saving procedure for patients with advanced PSC.

ASSOCIATED INFLAMMATORY
BOWEL DISEASE
IBD is seen in approximately 70% to 80% of patients with PSC and ulcerative colitis
accounts for approximately 85%to 90% of those patients.
Conventional treatment of IBD does not alter the course of PSC, and severity of the
former does not affect the disease seriousness of the latter.
Proctocolectomy, the most aggressive treatment for CUC, has had no effect on PSC
natural history.
PSC patients with CUC have increased risk of colorectal dysplasia and neoplasia after
OLT.
In PSC patients who undergo OLT, annual colonoscopy with surveillance biopsies is
recommended.
GALLBLADDER POLYPS In PSC patients with gallbladder polyps is much higher than that for the general
population.
In patients with PSC and the presence of a gallbladder polyp may benefit from
cholecystectomy, regardless of the size of the polyp.

Gian Luca Grazi
Hepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
gianluca.grazi@ifo.it
www.chirurgiadelfegato.it

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Hepatobiliary surgery - role in liver diseases.pptx