Surgery of the liver including transplantation

Prof Dr Dr Ernst Hanisch Director Department of Surgery Asklepios Hospital Langen Affiliated Teaching Hospital University of Frankfurt/Main

Mangement of major abdominal trauma

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Clinical features of serious liver injury
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Hypovolaemic shock Hypotension Tachycardia Decreased urine outpu Low central venous pressure Abdominal distension

Criteria for non-operative management of liver injuries

Haemodynamically stable following resuscitation No persistent or increasing abdominal pain or tenderness No other peritoneal injuries that require laparotomy <4 units of blood transfusion required

Indications for laparotomy

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Stab or gunshot wounds that have penetrated the abdomen Signs of peritonitis Unexplained shock Evisceration Uncontrolled haemorrhage Clinical deterioration during observation

Liver Trauma – Surgical management
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Stop haemorrhage (Pringle) Remove dead or devitalised liver tissue Ligate or repair damaged blood vessels and bile ducts

Stellate fracture of right lobe of the liver

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Packing of bleeding liver

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Postoperative Complications
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Rebleeding from injury Bile leaks Ischaemic segments of the liver Infected fluid collections

Large intrahepatic haematoma in patient with blunt trauma

Beckingham, I J et al. BMJ 2001;322:783-785

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Liver Trauma - Prognosis
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Overall mortality 10-15 % Mortality after blunt trauma > 20 % If three major organs are injured mortality approaches 70 %

Pyogenic liver abscess – typical features

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Right upper quadrant pain and tenderness Nocturnal fevers and sweats Anorexia and weight Raised right hemidiaphram in chest radiograph Raised white cell count with mild anaemia

Origins and causes of pyogenic liver abscess

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Biliary tract – Gall stones, cholangiocarcinoma, strictures Portal vein – Appendicitis, diverticulitis, Crohn‘s disease Direct extension of: Gallbladder empyema Trauma Iatrogenic – Liver biopsy, blocked biliary stent

Microbiology

E. coli, Klebsiella pneumoniae, bacteroides, enterococci Fungal or opportunistic organisms due to immunosuppression as a result of AIDS, intensive chemotherapy and transplantation

Chest radiograph showing air-fluid level and raised right hemidiaphragm in pyogenic liver abscess

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Treatment

Antibiotics – Penicillin, aminoglycoside (or cephalosporin), metronidazole Treatment for two to four weeks depending on the clinical response

Drainage requirements for liver abscesses

None – multiple small abscesses that respond to antibiotics Percutaneous aspiration – abscesses <6cm Percutaneous catheter drainage – abscesses >6cm

Drainage requirements for liver abscesses – Open surgery
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Failed percutaneous drainage Very large or multilocular abscesses Associated intra-abdominal infection requiring surgery such as bile duct stones

Computed tomogram showing multifocal liver ascess in segment IV. Note drain in segment VII

Krige, J E J et al. BMJ 2001;322:537-540

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Amoebic liver abscess Epidemiology

About 10 % of the world‘s population is chronically infected with Entamoeba histolytica Amoebiasis is the third commonest parasitic cause of death, surpassed only by malaria and schistosomiasis

Symptoms of amoebic liver abscess
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Pain Enlarged liver with maximal tenderness over abscess Intermittent fever with night sweats Weight loss Nausea Vomiting Cough Dyspnoea

Amoebic liver abscess Diagnosis
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Serological tests Stool may contain protozoal cysts Abscess usually solitary – right lobe in 80% of cases Abscess contains sterile pus and reddish-brown liquefied necrotic liver tissue

Amoebic abscess Treatment

95 % resolve with metronidazole alone (800 mg three times a day for five days) After the abscess – diloxanide furate 500 mg, eight hourly for seven days to eliminate intestinal amoebae

Amoebic abscess - Surgery

Surgical drainage is required only if the abscess has ruptured causing amoebic peritonitis

Hydatid disease Presentation
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Liver enlargement Right upper quadrant pain Rupture of the cyst into the peritoneal cavity –urticaria, anaphylactic shock, eosinophilia Erosion into bile duct – jaundice, cholangitis

Lifecycle of Echinococcus granulosus

Krige, J E J et al. BMJ 2001;322:537-540

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Hydatid disease – Diagnosis

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Ultrasonography, computed tomography Serological tests ERCP

Computed tomogram showing hydatid cyst: daughter cysts containing hydatid larvae are visible within the main cyst

Krige, J E J et al. BMJ 2001;322:537-540

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Operative specimen of opened hydatid cyst showing multiple daughter cysts

Krige, J E J et al. BMJ 2001;322:537-540

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Hydatid disease – Treatment I

Surgery – 1. Aspiration of cysts and replacement by a scolicidal agent such as 0.5% sodium hypochlorite Surgery - 2. The cysts are carefully shelled out by peeling the endocyst off the host ectocyst layer along ist cleavage plane

Hydatid disease – Treatment II
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Bile leakages are sutured The cavity is drained and filled with omentum Liver resection seldom necessary Albendazole is given for two weeks postoperatively

Liver tumours
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Cysts Benign tumours – Haemagiomas, liver cell adenoma, focal nodular hyperplasia Malignant tumours – Hepatocellular carcinoma, metastatic tumours

Characteristics of simple cysts
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Thin walled Contain clear fluid Contain no septa or debris Surrounded by normal liver tissue Usually asymptomatic Present in 1 % of population

Liver cysts

Treatment only when symptomatic – usually laparoscopic cyst fenestration NOTE - Thick walled cysts and those containing septa, nodules or echogenic fluid may be cystic tumours Cystic dilatations of the bile ducts (Caroli‘s disease) are premalignant (cholangiocarcinoma)

Polycystic liver disease

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Haemangiomas
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Incidence 3 % Malignant transformation and spontaneous rupture are rare Diagnosis by contrast enhanced computed tomography Resection is indicated only for large symptomatic tumours

T2 weighted magnetic resonance image of large benign haemangioma

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Liver cell adenoma

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Predominantly in women of childbearing age Risk of rupture 10 % Risk of malignant transformation 10 % Liver resection necessary

Focal nodular hyperplasia
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Usually asymptomatic Not premalignant It does not require treatment unless symptomatic Sometimes diagnosis difficult to establish – histology should be determined by surgical resection

Hepatocellular carcinoma

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Commonest malignant tumour worldwide One million new cases a year worldwide 80 % occur with cirrhotic livers Established viral infection – 10 years to develop chronic hepatitis – 20 years to develop cirrhosis – 30 years to develop carcinoma

Distribution of hepatocellular carcinoma

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Hepatocellular carcinoma
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Ultrasonography Alpha fetoprotein >500 ng/ml Surgical resection feasible in less than 20 % of patients Average operative mortality is 12 % in cirrhotic patients 5-year survival 15 %

Hepatocellular carcinoma
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<5 cm tumours – LTX Contraindication to LTX – alcohol injection, radiofrequency ablation Larger tumours – transarterial embolisation with lipiodol and cytotoxic drugs (cisplatin or doxorubicin)

Large hepatocellular carcinoma

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Colorectal liver metastasis

8-10 % of patients undergoing curative resection of colorectal tumours have isolated liver metastasis suitable for liver resection 5-year survival after resection 30 %

Solitary liver metastasis in segment IV

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Inoperable extensive liver metastasis

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Liver resection

A fit patient with a healthy liver will regenerate a 75 % resection within three months Segmental anatomy with each of the eight segments supplied by ist own branch of the hepatic artery, portal vein and bile ducts (Couinaud 1957) Mortality 5 %

Couinaud’s segmental anatomy of the liver

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Intraoperative view after left hepatectomy – raw surfaces of liver are coated with fibrin glue after resection to aid hemostasis and prevent small bile leaks

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Liver transplantation Indications
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Primary biliary cirrhosis Primary sclerosing cholangitis Cryptogenic cirrhosis Chronic active hepatitis (Hep B and C) Alcoholic liver disease (after a period of abstinence)

Timing of LTX – Signs of decompensations
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Tiredness, Ascites, Encephalopathy Peripheral oedema Jaundice Spontaneous bacterial peritonitis Bleeding oesophageal varices Low albumin concentration Raised prothrombin time

Acute liver failure – Paracetamol overdose

Renal failure develops as a hepatorenal syndrome Early deaths result from raised intracranial pressure Death in later stages – multiorgan failure and systemic sepsis Mortality from fulminant liver failure can be as high as 90 %

Implantation of liver transplantation after hepatectomy

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Immunosuppressive drugs
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Cyclosporin Tacrolimus Azothioprine Mycohenolate mofetil Steroids

One year survival after first liver transplant according to primary disease, UK 1985-94

Prasad, K R et al. BMJ 2001;322:845-847

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