The liver, gallbladder, bile duct, and pancreas are essential in ensuring our day-to-day survival. It helps facilitate bodily functions and ensures that we remain healthy and active at all times. However, these organs are also susceptible to a wide range of health conditions. If you suspect any related disorders, you should immediately seek medical attention to prevent more damages. 

Good digestion requires a functioning pancreas and biliary tract. Because pancreatic and biliary tract problems can cause severe conditions that need a fast, precise diagnosis and treatment.

Hepatobiliary and pancreatic surgery is an effective treatment option for complex diseases of the pancreas, liver, gallbladder, and bile duct. It’s mainly recommended if other treatment options, including medication and other non-surgical options, fail to address the issue. 

The Anatomy

The pancreas is a solid organ that sits just beneath the stomach. It contains two cells that are important in how you digest food and manage your body's metabolism. One type of cell produces enzymes that break down proteins, lipids, and carbs, allowing you to obtain nourishment from the foods you eat. The other produces hormones, most notably insulin, which regulates how your body stores and consumes sugar.

The biliary system consists of the organs and ducts that produce, store, and supply bile, a viscous fluid that aids in the breakdown and absorption of lipids and the removal of waste products into the small intestine for improved digestion. The gallbladder absorbs and stores bile produced by the liver, and then releases the stored bile throughout a meal to aid digestion.

Hepatobiliary and Pancreatic Conditions 

Hepatobiliary and pancreatic health conditions often affect the liver, bile ducts, pancreas, and gallbladder. These disorders typically come with long-term damage to the affected organ and the surrounding organs and tissues.  

Diseases of the Pancreas and Biliary System include:

1. Acute Pancreatitis

Acute pancreatitis is a condition in which the pancreas gets inflamed quickly. During an assault, enzymes can exit from the pancreas.

2. Alcohol-Related Pancreatitis

Individuals who are prone to alcohol pancreas damage might suffer from iterative inflammation of the pancreas with severe long-term repercussions.

3. Cholangitis

Cholangitis is an inflammation of the bile ducts in which gallbladder stones become stuck, impeding bile passage from the liver to the gut.

4. Cholecystitis

Cholecystitis is a gallbladder inflammation that can be transient or persistent. Upper-right abdomen discomfort might last anywhere from minutes to days.

5. Chronic Pancreatitis

Chronic pancreatitis occurs gradually and can worsen over time when the pancreas loses its capacity to produce adequate digestive enzymes and insulin.

6. Gallstone Pancreatitis

Small gallstones may move from the gallbladder to the main bile duct, obstructing the pancreatic duct and causing severe pancreatitis.

7. Gallstones & Bile Duct Stones

Gallstones are formed in the gallbladder by the condensation of hard, crystal-like bile substances. These stones can migrate from the gallbladder to the bile ducts and can get stuck there.

8. Hereditary Pancreatitis

Hereditary pancreatitis is uncommon, affecting less than one in a million persons. It is a genetic anomaly that can be inherited or developed on its own.

9. Pancreas Divisum

Pancreas divisum is a congenital condition in which the normal outflow of pancreatic secretions is disrupted, potentially leading to pancreatitis and/or high duct pressures.

Most of these hepatobiliary and pancreatic diseases are genetically predetermined, while others are acquired. Minor conditions are not usually associated with any sign or symptom. However, severe symptoms can arise if the condition is more intense and can as well trigger other issues silently. 

These symptoms can include;

• Skin itchiness 
• Nausea and vomiting
• Abdominal swelling 
• Diarrhea associated with fat droplets in the stool 
• Jaundice (this is where the skin and the whites of the eyes turns yellowish)
• Dark-colored urine 
• Hiccups, gas, and belching 
• Pale colored and sometimes bloody stool
• Loss of appetite 
• Unexplainable weight loss 
• Pain in the upper abdomen that usually travels to the mid-back part

Diagnosing Hepatobiliary and Pancreatic Diseases 

Just like other diagnosis steps, the first step of diagnosing hepatobiliary and pancreatic conditions is a physical examination. It includes looking at medical history as well as the symptoms. The doctor can as well inquire about your history and your family’s to determine if you are at a high risk of suffering from a particular condition. 

There are various diagnostic types of equipment that doctors utilize. These techniques are less invasive and accurate as compared to traditional tools. They include; 

• Ultrasound: Used to examine the gallbladder if the doctor suspects inflammation or the existence of gallstones. It is a harmless examination that can be carried out at any time.
• Magnetic resonance imaging (MRI): This is the best examination to highlight the existence of even very small stones in the bile ducts, with a good study of the entire biliary tree.
• Endoscopic retrograde cholangiopancreatography (ERCP): It has a double interest: first diagnostic for biopsies of pancreatic and biliary tumors and then therapeutic for the extraction of gallstones to the duodenum.
• Computed tomography (CT): This is an examination used in case of suspicion of malignancy.
• Positron emission tomography (PET): To check for tumor extension outside the hepatobiliary and pancreatic organs.
• Blood work: The doctor orders blood tests to check liver function and pancreatic enzyme levels.
• Upper endoscopy: This technique is used to examine the inner parts of the stomach and gastrointestinal tract in cases of biliary junction tumors.
• Laparoscopy: This is a surgical procedure to assess and diagnose the internal organs of the abdomen. Specialists opt for laparoscopy to check for underlying signs and symptoms of pancreas and gallstone disease.
• Biopsy: This involves the removal of a sample of tissues or cells from the affected organ, which will then be examined under a microscope to check for signs of cancer or other chronic hepatobiliary and pancreatic conditions.

What is Hepatobiliary and Pancreatic Surgery? 

Hepatobiliary and pancreatic surgery are the surgical procedures performed to treat and correct cancer and various disorders of the hepatobiliary and pancreatic systems. Unlike other surgical procedures, surgery of the hepatobiliary and pancreatic organs is more challenging and complex.

Basically, the hepatobiliary and pancreatic system comprises organs such as the liver, gallbladder, bile duct, and pancreas. These organs play a significant role in digestion as well as a range of complex activities that promote vital body functions. As such, any disease and malfunction in these organs can interfere with normal functions, causing serious issues. Such cases may require a professional medical provider for appropriate diagnosis and treatment. 

Generally, hepatobiliary and pancreatic surgery involves resection or removing the primary and secondary (metastatic) tumors. It includes tumors of the pancreas, liver, gallbladder, and bile duct. This procedure is also applied when addressing benign conditions, including cysts, strictures or blockages, bile duct injuries, and portal hypertension.

Sometimes, certain types of tumors that develop in the hepatobiliary and pancreatic organs may require a major resection. This might as well include complex reconstruction of the hepatic artery, bile duct, and portal vein. 

To develop a treatment plan for each patient, hepatobiliary and pancreatic surgery necessitates the collaboration of a multidisciplinary team. Hepatobiliary and transplant surgeons, medical oncologists, interventional radiologists, radiation oncologists, gastroenterologists, and anesthesiologists make up the team. Advanced laparoscopic (keyhole) and endoscopic methods are used in hepatobiliary and pancreatic surgery.

Types of Hepatobiliary and Pancreatic Surgeries

Pancreatic and biliary surgery is often done using minimally invasive techniques, including laparoscopic or robotic. This, however, depends on the patient, the condition, and the affected organ. 

Minimally invasive surgery involves creating small incisions in the affected part rather than making a large opening. The surgeon then inserts small equipment, special cameras, and lights into the cuts. This generates a clear view of the surgical area and enables the surgeon to surgically operate with control and flexibility. 

Most common surgical procedures 

Liver surgical procedures:

The surgical operation of the liver consists of;

Major and minor partial hepatectomy 

Liver resection is the preferred therapy for a variety of primary and secondary hepatic disorders. Advances in anesthesia, surgery, and pre-operative assessment have increased the number of patients examined for liver resections, and the growth in life expectancy has led to an increase in the number of older individuals candidates for curative liver major and minor resection.

Primary liver tumors are among the most frequent solid tumors globally, with Hepatocellular carcinoma (HCC) having the fourth highest incidence of all malignancies. HCC is a common complication of cirrhosis, emerging 20–30 years after the original damage to the liver. However, 25% of individuals have no history of risk factors for cirrhosis development.

The severity of hepatic dysfunction restricts therapy choices, and liver failure kills as many people as tumor development. The peak incidence of HCC during the sixth decade of life, along with global population aging, leads to a substantially expanding geriatric population of HCC patients considered for hepatic resection.

Because it is the only way to cure both the tumor and the underlying cirrhosis, liver transplantation is potentially the best treatment for HCC. In individuals with HCC and cirrhosis, transplantation using the Milan criteria outperforms hepatic resection. When liver transplantation is difficult or impossible, liver resection is the primary therapy, with 5-year survival rates ranging from 40% to 50%.

For more information: See Liver Cancer Facts 

Drainage of the liver cysts 

Sometimes, liver cysts, including benign, can be extremely large. Therefore, in such cases, surgery may be recommended to unroof or drain them permanently. This is mostly performed using minimally invasive surgery option.

Liver biopsy 

This is a procedure done in order to check for a liver mass, including tumors. It can also be used to diagnose and test the liver for disorders such as scarring and cirrhosis.

There are 3 types of liver biopsies:

• Percutaneous liver biopsy. The most often used approach. A local anesthetic is administered to you. A tiny needle is inserted into the liver to collect a sample.
• Laparoscopic liver biopsy. A general anesthetic is administered to you. Through a tiny cut or incision, a thin illuminated tube (laparoscope) is inserted into your skin. A small video camera is affixed to the tube. On a computer screen, your provider can view the interior of your stomach. To extract the sample, a needle is passed through another tube.
• Transvenous liver biopsy. If you have blood-clotting issues or fluid in your stomach, this procedure may be employed. A local anesthetic is administered to you. An incision is made on your neck to access a vein. A hollow tube is inserted into your vein and down to your liver. The tube is filled with a contrast dye, and X-rays are taken. The dye allows the vein to be seen more clearly on X-rays. A needle is inserted through the tube into your liver. Tissue samples are extracted using a tube.

Pancreatic surgery

Pancreatic surgery for cancer

Pancreatic cancer is a deadly disease with a dismal prognosis that is the fourth- or fifth-leading cause of cancer mortality in Western countries. Most patients have locally advanced disease and/or distant metastatic lesions at the time of diagnosis, preventing radical resection; the five-year survival rate is around 10–25 percent, even after R0 cancer resection, and it is higher for patients with distal pancreatic duct cancer, ampullary cancer, and duodenal cancer.

The median age at diagnosis is 72 years, and since the senior population has grown in recent decades, individuals over the age of 70 with resectable pancreatic cancer will be encountered increasingly frequently.

As pancreatic resection became safer and accepted as the standard of care, the indications remained narrow, and it was not commonly performed in patients over 70, and only rarely in patients over 80, but the establishment of specialized centers with a high flow of pancreatic cancer patients has resulted in a reduction in the rate of operative complications, prompting surgeons to aggressively approach pancreatic cancer in elderly patients as well.

Pancreaticoduodenectomy (PD) remains the only curative treatment currently available for malignant or potentially malignant tumors of the biliopancreatic junction, and despite advances in surgical skills and technology, it is still associated with a mortality rate of 2–4% and a morbidity rate of more than 30%. 20 It is critical to note that patients undergoing surgery, regardless of their age, should be chosen for their overall health.

Pancreatic surgery types 

Whipple operation or pancreaticoduodenectomy 

This is an operation that involves the removal of the right part of the pancreas, the lower bile duct, and the duodenum, or sometimes a section of the stomach. After the surgery, the remaining parts of the pancreas, stomach, and bile duct are joined to the small intestine. Whipple operation is mostly recommended as an effective treatment option for cancers and pre-cancers affecting these organs. 

See more information about: Pancreatic Cancer Treatment – How to Choose a Treatment Team

• Who is a Candidate for the Whipple Procedure?

The Whipple surgery and subsequent procedures are only available to roughly 20% of pancreatic cancer patients. These are often people whose malignancies are limited to the head of the pancreas and have not migrated to any neighboring major blood arteries, the liver, lungs, or abdominal cavity. Identifying potential Whipple procedure candidates generally necessitates extensive testing.

Some individuals may be candidates for a minimally invasive (laparoscopic) Whipple surgery, which is performed through a series of tiny incisions rather than a single big one. In comparison to the traditional technique, the laparoscopic operation may result in less blood loss, a shorter hospital stay, quicker recovery, and fewer problems. 

For the 40% of newly diagnosed patients whose cancers have expanded (metastasized) outside the pancreas, Whipple surgery is not an option. Only around 40% of patients with a locally advanced illness that has migrated to nearby sites such as the superior mesenteric vein and artery, or those whose tumors have gone to the body or tail of the pancreas, may have this choice, after multidisciplinary consultation.

Pancreatic debridement and drainage 

Pancreatic debridement is a procedure to treat pancreatitis. This is a chronic condition that causes inflammation of the pancreas, and surgery may be a better treatment alternative. Sometimes, this procedure can be done alongside the drainage of the pancreas. 

Pancreatic debridement aims to remove all dead and devitalized pancreatic and peripancreatic tissue while conserving viable working pancreas, managing resulting pancreatic fistulas, and reducing extraneous organ damage.

Distal or left pancreatectomy 

A distal pancreatectomy is performed to correct lesions in the body and the left part of the pancreas. These lesions can indicate chronic conditions such as cancers, pre-cancers, and other lesions. 

Distal pancreatectomy doesn’t require a reconnection. This is because the procedure doesn’t alter the pancreas' connection to the gastrointestinal tract and the bile ducts. 

A left pancreatectomy can be performed with or without splenectomy. The technique used is determined by the disease process and the features of the lesion.

• Left pancreatectomy with splenectomy: When the underlying pancreatic tumor is aggressive, the spleen, which is positioned near this region of the pancreas and shares some of the same blood arteries, must be removed as part of the treatment. The combination of a left pancreatectomy with a splenectomy allows for the closure of splenic arteries at their origin as well as appropriate lymph node clearance.
• Spleen-preserving left pancreatectomy: This operation is only used to treat benign/borderline pancreatic lesions and cysts, as well as isolated neuroendocrine tumors. There are two methods for preserving the spleen during distal pancreatic dissection. The traditional design involves locating, isolating, and preserving the splenic artery and vein (Kimura procedure). Alternatively, the splenic artery and vein are connected to the pancreas, and the spleen is perfused via the short gastric arteries (Warshaw procedure). Both are considered effective treatments for a mass in the pancreas' tail.

Biliary surgical procedures

Bile duct resection 

Bile duct resection is a procedure to remove the bile ducts, especially if the patient has cancer or pre-cancer. Bile ducts are the passage that the bile goes through from the liver towards the intestines. So after the removal of the bile duct, the bile flow is redirected to the intestines. 

Cholecystectomy 

A cholecystectomy is a gallbladder removal procedure. The gallbladder is located in the right upper region of the stomach, beneath the liver. The liver produces bile, which is stored in the gallbladder. When bile is required, it is discharged via the common bile duct. Bile is a digestive fluid that aids in the digestion of fat. The gallbladder and liver are connected to the first section of the small intestine via the common bile duct.

A cholecystectomy may be used to treat some cases of: 

1. Gallbladder cancer. 
2. Cholelithiasis (gallstones within the gallbladder). 
3. Choledocholithiasis (gallstones within the bile duct). 
4. Cholecystitis (inflammation of the gallbladder). 
5. Pancreatitis (inflammation of the pancreas).

• Simple cholecystectomy 

Simple cholecystectomy is done to remove the gallbladder, especially if the patient is suffering from a gallstone condition. It’s mainly performed with minimally invasive surgery and can sometimes require the open surgery technique. 

The procedure can be done open or laparoscopically:

1. Open Cholecystectomy: The gallbladder is removed by a big (about 6 inch) abdominal incision (cut). When cancer is known or suspected, this is the ideal technique.
2. Laparoscopic Cholecystectomy: In the abdomen, several small incisions (cuts) are made. The gallbladder is removed using a laparoscope (lighted tube) inserted via the incisions. When gallbladder cancer is known or suspected, this procedure is not employed.

See for more information: Gallstones – definition

• Extended cholecystectomy 

This is a procedure to treat cancer of the gallbladder. The gallbladder is usually connected to the liver, and sometimes the cancer cells can invade the liver and spread towards the gallbladder. In such situations, a liver extended cholecystectomy is recommended over simple cholecystectomy to avoid leaving behind the cancer cells after the procedure.

Generally, extended cholecystectomy involves the removal of a small section of the liver connected to the gallbladder. This is to clear all the cancerous cells and prevent them from spreading and multiplying further. 

Complications of Hepatobiliary and Pancreatic Surgery 

Any surgery carries varying risks and complications, ranging from mild to chronic and serious problems. This, however, depends on the surgical area, the severity of the condition, and the associated organs, blood vessels, and nerves.

Overall, these are the common risks that might arise after the surgery;

• Infection inside the belly or on the incision part
• Bleeding, especially on the surgical sections
• Leakage on the connected region of the bile duct or the pancreas 
• Difficulties and delays in emptying the stomach, making it hard to eat 
• Temporary or permanent diabetes 
• Anesthesia reactions

Conclusion 

Hepatobiliary and pancreatic surgery is a modern surgical procedure that most medical specialists recommend. It helps treat and repair a wide range of conditions affecting the liver, gallbladder, bile ducts, and pancreas. 

Nowadays, with the improvement of surgical skills and new technologies available, HPB major surgery can be considered safe and feasible even in carefully selected elderly patients.