Hepato-Pancreato-Biliary Surgery

Last updated date: 03-Mar-2023

Originally Written in English

Hepato-Pancreato-Biliary Surgery

Hepato-Pancreato-Biliary Surgery

What is the Hepato-Pancreato-Biliary Surgery?

The liver, gallbladder, bile ducts, and pancreas make up the hepatobiliary system. This system is necessary for fat digestion and waste removal in the body.

The liver is a major organ on the right side of your stomach. It is divided into two sections: the right lobe and the left lobe.

The gallbladder is a tiny, pear-shaped organ located under your liver that your body utilizes to store bile. The gallbladder also contributes in bile formation and transportation. Bile is produced in the liver and released after you eat to aid in the digestion of fat and certain vitamins.

Bile ducts are tiny tubes that transport bile from the liver and gallbladder to the duodenum, often known as the small intestine. When food needs to be digested, the gallbladder contracts to release greenish-yellow bile into the upper intestine to aid in the digestion of lipids from the food you eat.

The pancreas, like other elements of the hepatobiliary system, is located in the abdominal cavity. More particularly, toward the back of your upper abdomen near your spine. The pancreas cooperates with the liver and bile ducts to aid in digestion.

The pancreas releases pancreatic secretions, which, together with bile from the liver, aid in digestion by breaking down food and allowing nutrients to be absorbed and utilized more easily by your body. This is accomplished by the use of drainage tubes, which, like bile ducts, transport pancreatic juices into the small intestine.

Hepato-pancreato-biliary (HPB) surgery is the broad surgical treatment of conditions involving the liver, pancreas, gallbladder, and bile ducts. These are among the most difficult and complex surgical operations performed in General Surgery, and they need a high level of experience and competence. 


What conditions need Hepatopancreatobiliary surgery?

Hepatopancreatobiliary surgery

  • Hepatobiliary surgery is required when a problem occurs in your hepatobiliary system. This might be caused by illnesses or conditions such as:
    • Blockages
    • Inflammations
    • Cysts
    • Tumors
    • Biliary duct injuries.

These operations can get increasingly difficult and necessitate significant resections. Complicated reconstructions of bile ducts and other components of the hepatobiliary system may be required in these circumstances:

  • Acute and chronic pancreatitis (where the pancreas becomes irritated and swollen) and associated complications.
  • Ampullary cancer (a rare cancer that develops in the ampulla of Vater in the digestive tract) and duodenal malignancies (cancer in the first section of the small intestine).
  • Gallbladder and biliary diseases, including bile duct cancer.
  • Cholangiocarcinoma (Bile duct cancer).
  • Biliary strictures, when the bile duct (the tube that takes bile from the liver to the small bowel) gets smaller or narrower.
  • Gallstones, in the gallbladder or bile ducts.
  • Injuries to the liver, pancreas, or bile duct.
  • Liver abscesses.
  • Liver diseases such as liver cysts (including polycystic disease) and liver tumors (primary and secondary).
  • Liver hemangioma, a non-cancerous tumor in the liver that is made up of clusters of blood-filled cavities.
  • Pancreatic cancer and neuroendocrine tumors, which impact the cells that produce hormones into the circulation.
  • Pancreatic cysts are benign (pseudocysts) or malignant growths in the pancreas (cancerous).


What are the symptoms of Hepatopancreatobiliary diseases?

symptoms of hepatopancreatobiliary diseases

Hepatopancreatobiliary (HPB) disease symptoms might include, but are not limited to:

  • Swelling of the abdomen.
  • Dark urine.
  • Jaundice is characterized by a yellowish discoloration of the skin and the whites of the eyes.
  • Appetite loss or unexplained weight loss.
  • Upper abdominal pain/discomfort.
  • Stool that is pale or bloody.


What are the types of Hepatopancreatobiliary surgery?

types of hepatopancreatobiliary surgery

Complex hepatic (liver), pancreatic, and biliary surgeries include:

  • Liver resection “hepatectomy”: major and minor.
  • Liver tumor ablation
  • Pancreas resection for benign and malignant disease (including Whipple procedure).
  • Bile duct resection and reconstruction (BDRR).
  • Cholecystectomy.


What is the meaning of hepatectomy?

meaning of hepatectomy

A liver resection, also known as a hepatectomy, is a surgical treatment that removes a portion of your liver.

As long as the remainder of your liver is healthy, you can have up to two-thirds of your liver removed. If you have liver problems a lesser percentage may be eliminated. 

If your remaining liver is healthy, it will regrow to its original size because the liver has the ability to regenerate. In contrast, a total hepatectomy will necessitate a liver transplant.

Primary liver cancer, which includes hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC), is becoming more common and is a significant cause of cancer-related death globally. Even when these tumors are confined, management is difficult because of the relationship between the underlying hepatic illness and the complicated structure of the liver.

Surgical resection is the only potential cure for intrahepatic cholangiocarcinoma (ICC), but in hepatocellular carcinoma (HCC), the risks and benefits of the multiple curative intent options must be considered to individualize treatment based on tumor factors, baseline liver function, and the patient's functional status.

The concepts of surgical resection for both HCC and ICC include margin-negative resections with preservation of remaining liver function. 


Role of liver resection in hepatocellular carcinoma:

hepatocellular carcinoma

Over the last decade, the use of liver resection in the treatment of HCC has increased. In general, individuals with the nonmetastatic illness and normal underlying liver function, or with compensated cirrhosis and no signs of portal hypertension, should be considered for liver resection.

Curative intent options for suitable patients should include ablation (surgical or percutaneous) for smaller tumors less than 2 cm in size, liver resection, and orthotopic liver transplantation (OLT).

Consideration of baseline liver function is paramount when considering hepatectomy for the treatment of HCC; resection should not only follow general oncologic principles (complete margin-negative resection), but it should also be performed in a way to maximize recovery, minimize postoperative complications, and preserve adequate liver function.


Role of liver resection in intrahepatic cholangiocarcinoma:

Surgical excision remains the only treatment option for intrahepatic cholangiocarcinoma (ICC) patients. However, most patients come with advanced illness and are therefore ineligible for resection.

Approximately 75% of resectable patients require a hemi-hepatectomy or extended hepatectomy to remove the tumor, and approximately 80% are resected with negative margins.

Even after resection, the likelihood of a long-term cure remains poor. A population-level analysis utilizing the Surveillance, Epidemiology, and End Results database revealed that survival after resection for ICC has improved in recent years, while 5-year survival remains poor at around 20% to 30%.

The concepts of resectability for ICC are the same as those for HCC. The only curative therapy for ICC is resection, with ablation and orthotopic liver transplantation (OLT) not currently recommended. 


Post-hepatectomy complications:

The management of hepatic resection is difficult. Despite technological breakthroughs and extensive expertise in liver resection at specialist hospitals, it is nevertheless burdened by relatively high rates of postoperative morbidity and mortality.

Common post-hepatectomy complications include:

  • Venous catheter-related infection.
  • Pleural effusion.
  • Incisional infection.
  • Pulmonary collapse or infection.
  • Ascites.
  • Subphrenic infection.
  • Urinary tract infection.
  • Intraperitoneal hemorrhage.
  • Gastrointestinal tract bleeding.
  • Biliary tract hemorrhage.
  • Bile leakage.
  • Liver failure. 


What is liver tumor ablation?

liver tumor ablation

Tumor ablation is broadly described as the direct use of chemicals or radiation to destroy localized tumors.

Tumor ablation procedures are administered by needlelike applicators and are generally classified into systems that use chemical (mainly ethanol and acetic acid) and thermal or nonthermal energy.

Radiofrequency (RF), microwave (MW), laser, cryoablation, and high-intensity focused ultrasonography (US) are the most often employed thermal ablation modalities in the liver.

Tumor ablation in the liver has developed into a well-accepted treatment option for increasingly difficult oncologic patients. Ablative treatments can be used alone, with additional ablative therapies, or in conjunction with other oncologic therapeutic techniques (e.g., surgery, chemotherapy, radiotherapy)

Patients with very early and early-stage HCC who are not surgical candidates can undergo image-guided tumor ablation.

Abdominal discomfort/pain, liver infection, fever, and abnormal liver tests are all possible adverse effects of ablation therapy.


What is the meaning of pancreatic resection?

meaning of pancreatic resection

The surgical removal of a portion of the pancreas is known as pancreatic resection. It is sometimes referred to as a "pancreatectomy." The most prevalent reason for undergoing this operation is for the treatment of a pancreatic tumor.


Role of pancreatic resection in acute pancreatitis:

The most prevalent reason for intervention is infected local AP complications (i.e., infected pancreatic and peri-pancreatic necrosis).

The standard of care for the treatment of infected Acute Peripancreatic Fluid Collection and Walled-off necrosis is no longer open necrosectomy (resection of necrotic tissue). Less invasive approaches have been developed and used, thereby reducing the need for open surgeries.

To allow for encapsulation, treatment of infected acute fluid collections and walled-off necrosis should be postponed as long as feasible (by giving optimal critical care support and drainage).

The standard of therapy is a step-up strategy, with initial drainage (percutaneous or endoscopic) followed by minimally invasive necrosectomy (percutaneous or endoscopic) and open necrosectomy only if these procedures fail.

Other reasons for intervention include acute pancreatitis complications (e.g., fistulae, pseudocyst), which may necessitate surgery alone or in combination with other therapy modalities such as interventional radiologic and endoscopic procedures. 


Role of pancreatic resection in chronic pancreatitis:

Patients with chronic pancreatitis that require surgical care include those who are in severe pain, have pancreatitis complications, or cannot distinguish pancreatic cancer from chronic pancreatitis.

The use of endoscopic retrograde cholangiopancreatography (ERCP), CT, and angiography to determine structural anomalies has improved the surgeon's ability to choose an operation that is appropriate for the patient's needs.

In individuals with dilated ducts, a longitudinal pancreatojejunostomy (surgical construction of an artificial tube linking the pancreas to the jejunum) should be done. Pancreatoduodenectomy (removal of the head of the pancreas, the duodenum, a section of the stomach, and other adjacent tissues) has traditionally been the procedure of choice when the pancreas is large and thickened.

Patients whose ducts are too small to allow longitudinal pancreatojejunostomy are candidates for proximal or distal pancreatic resection, depending on the location of pathology.

Surgery relieves pain in around 80% of people with chronic pancreatitis. Many of the late fatalities following surgery for chronic pancreatitis are due to the impact of alcohol rather than the procedure itself. 


Role of pancreatic resection in pancreatic cancer:

pancreatic cancer

Pancreatic resection is performed in the majority of patients for a proven carcinoma or a tumor in the pancreas with clinical characteristics of carcinoma. Preoperative preparation is identical to that for other cancer surgeries, with excellent nutritional state and appropriate clotting factors being critical.

Ductal pancreatic adenocarcinoma, the most common pancreatic cancer, is marked by retroperitoneal and perineural infiltration, early development of numerous metastases, and resistance to the majority of presently available treatment regimens.

Surgical resection, the patient's last hope for a cure, gives a dramatically improved prognosis, with a median survival following resection of 14–20 months and up to 25% 5-year survival rates.

The pancreaticoduodenectomy (Whipple surgery, largely pylorus-preserving) is the conventional operation for cancers of the pancreatic head, while tumors of the body or tail can be removed using a distal pancreatectomy.


Post-pancreatectomy complications:

Patients who have pancreatic resection may encounter both general and specific problems that, if not diagnosed and treated properly, can be fatal.

Unique complications following pancreatectomy include:

  • Pancreatic fistula.
  • Endocrine/ Exocrine pancreatic insufficiency.
  • Biliary reflux.
  • Gastric ileus.


What is Bile duct resection and reconstruction?

Bile duct resection and reconstruction

Bile duct resection and reconstruction (BDRR) is used to treat a number of conditions, including benign and malignant tumors, complications from biliary and gallbladder illness or surgery, and, on rare occasions, traumatic, infectious, or inflammatory diseases involving the biliary tree.

Malignant tumors — BDRR can be done in a variety of cancers, including cholangiocarcinoma (extrahepatic and intrahepatic), hepatocellular carcinoma, and liver metastasis.

Benign tumors — BDRR can also be used to remove premalignant tissue or to repair abnormal bile flow, which can lead to inflammation and later dysplasia or malignancy.

Complicated biliary disease — The vast majority of BDRRs are performed to treat benign biliary illness, such as sequelae of cholelithiasis (stones in the gallbladder) or choledocholithiasis (stones in the bile ducts), and iatrogenic damage following endoscopy, cholecystectomy, or other gastrointestinal operations.

For all conditions, the perioperative mortality and morbidity rates following bile duct resection and reconstruction (BDRR) are 4.2 and 32%, respectively.

Perioperative mortality rates following BDRR for benign and malignant illnesses were 0 to 5% and 5.6 to 8.6%, respectively.

Infection (13 percent) and bleeding (5 percent) are the most prevalent perioperative consequences following BDRR. Another early consequence of BDRR is bile leak, which has been recorded in 3.7 percent of biliary-enteric anastomoses.

Bile duct stricture development is the most prevalent late complication of BDRR, occurring at a rate of 10 to 30%. 


What is Cholecystectomy?


Cholecystectomy (a surgical procedure to remove the gallbladder) is one of the most commonly performed abdominal surgical procedures. and in developed countries, many are performed laparoscopically


Indications of cholecystectomy

The indications for cholecystectomy are the same as for open and laparoscopic cholecystectomy:

  • Symptomatic cholelithiasis (gallbladder stones) with or without complications.
  • Asymptomatic cholelithiasis in patients who are at increased risk for gallbladder carcinoma or gallstone complications.
  • Acalculous cholecystitis.
  • Gallbladder polyps >0.5 cm.
  • Porcelain gallbladder (increased risk for gallbladder cancer).


Laparoscopic Cholecystectomy

The gallbladder is removed during a laparoscopic cholecystectomy by introducing a tiny video camera and specific surgical equipment through four small incisions in the abdominal wall.

90 percent of cholecystectomies in the United States are performed laparoscopically.

The "gold standard" for the surgical treatment of gallstone disease is laparoscopic cholecystectomy. This method produces less postoperative discomfort, better cosmesis, shorter hospital stays, and less job impairment than open cholecystectomy.

Intraoperative complications: Major complications, including vascular injury, bowel perforation, mesenteric injury, and bile duct injuries, often require immediate laparotomy.

Postoperative complications: Bile duct injury, bile leaks, bleeding, and bowel injury.

Other complications, such as residual common bile duct (CBD) stones (incidence of approximately 10%) and postcholecystectomy syndromes, occur at the same rate with both laparoscopic and open cholecystectomy.

Postcholecystectomy syndrome (PCS) is a collection of symptoms that recur and remain following cholecystectomy, including prolonged abdominal pain/discomfort and dyspepsia (difficulty in the digestion process).


Open cholecystectomy

When laparoscopic cholecystectomy is not feasible or cannot be performed safely, open cholecystectomy is recommended.

Open cholecystectomy may also be performed as part of another operation (e.g., pancreaticoduodenectomy) or, if required, as an incidental procedure during another gastrointestinal operation (e.g., colon resection).

To minimize harm to adjacent tissues, laparoscopic cholecystectomy is converted to an open technique in some instances. This indicates solid surgical judgment and should not be seen as a failure or complication of the laparoscopic method. In the United States, a conversion rate of 9.5% of cases was documented.

Absolute indications for open surgery — Although a laparoscopic technique is generally favored, some individuals should not have laparoscopic cholecystectomy:

  • Patients with hemodynamic instability or substantial cardiorespiratory comorbidities are unlikely to tolerate pneumoperitoneum (air used in laparoscopic surgery to enlarge the abdominal cavity for improved view). Pneumoperitoneum in a hemodynamically unstable patient or a patient with poor cardiopulmonary reserve might result in cardiovascular collapse.
  • Patients suffering from refractory coagulopathy. Although coagulopathy should be treated before any procedure if feasible, numerous bleeding spots and diffuse leakage are more easily managed in an open operation.
  • Patients with a significant suspicion of gallbladder cancer. When preoperative imaging indicates a high suspicion of gallbladder cancer, an open approach is indicated to minimize gallbladder perforation and intraperitoneal spread of malignant cells.
  • Patients with additional intra-abdominal disease that necessitates open surgery or who require cholecystectomy as part of another operation (e.g., Whipple procedure). 


What is the outcome after Hepatopancreatobiliary surgery?

Hepatopancreatobiliary surgery outcome

A recently established term, "textbook outcome" (TO), describes the best course of action after surgery that is more in line with patient expectations of "optimal" treatment.

Textbook outcome is based on an "all-or-none" approach in which the ideal or "textbook" outcome is not obtained until patients meet all of the individual factors that comprise a TO.

Textbook outcome is a composite indicator that combines many clinically significant perioperative outcomes that are included in the definition of an "optimal" surgical episode.

In 2018, TO was utilized for the first time to evaluate the results of patients following hepatopancreatobiliary surgery.

Textbook outcome was defined as:

  1. No postoperative complications.
  2. No prolonged length of stay (LOS) (i.e., ≤ 75th percentile).
  3. No 90-day readmission.
  4. No 90-day postoperative mortality.

TO was obtained in 47.8 percent of patients who underwent minor pancreatic resection (i.e., distal pancreatectomy or other partial pancreatectomy) and 24.7 percent of patients who underwent large pancreatic resection (i.e., proximal pancreatectomy, pancreaticoduodenectomy, total pancreatectomy).

Similarly, whereas TO was reached in 46.8 percent of patients after minor hepatectomy, it dropped to 33.3 percent in people treated with extensive liver resection.

These findings underlined the fact that less than half of patients had an ideal or "textbook" result after hepatopancreatic surgery; in particular, TO was much lower for patients receiving major pancreatic or liver resections.



Hepato-Pancreato-Biliary Surgery

Hepato-pancreato-biliary (HPB) surgery is the broad surgical treatment of conditions involving the liver, pancreas, gallbladder, and bile ducts. These are among the most difficult and complex surgical operations performed in General Surgery, and they need a high level of experience and competence. 

hepatobiliary surgery is required when a problem occurs in your hepatobiliary system. This might be caused by illnesses or conditions such as Blockages, inflammations, Cysts, tumors, and Biliary duct injuries.

Symptoms of Hepatopancreatobiliary diseases include:

  • Swelling of the abdomen.
  • Dark urine.
  • Jaundice is characterized by a yellowish discoloration of the skin and the whites of the eyes.
  • Appetite loss or unexplained weight loss.
  • Upper abdominal pain/discomfort.
  • Stool that is pale or bloody.

Types of hepatopancreatobiliary surgery include: 

  • Liver resection “hepatectomy”: major and minor.
  • Liver tumor ablation
  • Pancreas resection for benign and malignant disease (including Whipple procedure).
  • Bile duct resection and reconstruction (BDRR).
  • Cholecystectomy.

The term "textbook outcome" (TO) was used lately to represent the optimum course of action following surgery that is more in line with patient expectations of "optimal" therapy.

Less than half of patients who undergoing hepatopancreatobiliary surgery had an optimal or "textbook" TO; for patients undergoing significant pancreatic or liver resections, TO was substantially lower.