Hepatobiliary Surgery
Hepatobiliary Surgery Hepatobiliary surgery refers to the surgical interventions applied to combat disorders in the liver, pancreas, gallbladder, and bile ducts. The most common issues addressed in hepatobiliary surgery include problems in the gallbladder. Inflammation and the presence of stones in the gallbladder are treated through open and laparoscopic surgical methods. Following laparoscopic surgeries for these diseases, patients can be discharged shortly afterward, returning to their daily lives.
In the battle against pancreatic cancer, which is one of the areas of hepatobiliary surgery, the surgical method applied will vary depending on the location of the cancer in the organ. Liver cancer and soft tissue cancers are also conditions dealt with by hepatobiliary surgery. Additionally, cystic echinococcosis, a disease caused by a parasite and occurring in various parts of the body from the lungs to the brain, is treated through surgical intervention. The treatments involving open or laparoscopic surgeries in these cases constitute the domains of hepatobiliary surgery.
LIVER
Are simple cysts in the liver dangerous?
Simple cysts in the liver are fluid-filled balloon-like lesions with thin walls and no septa, generally considered congenital. They are more common in women and their frequency increases with age. They do not transform into cancer and are not considered dangerous. Most are detected through ultrasound or computed tomography, do not cause symptoms, and do not require treatment.
What are the symptoms of simple liver cysts?
Some cysts can grow large enough to cause pain and a feeling of fullness in the upper right side of the abdomen.
Is treatment necessary for simple liver cysts?
Surgical treatment is necessary for large (>5 cm) cysts causing symptoms and with radiological findings suggestive of neoplasia. The chosen treatment method is to create a wide opening in the cyst wall (unroofing), either through open or laparoscopic surgery. During this procedure, the cyst contents can be aspirated, and the lining of the cyst can be burned using argon coagulation.
Is it possible to aspirate simple liver cysts with a needle from the outside?
It is possible, but aspirating the contents of the cyst in this way results in the cyst refilling in half of the patients. Therefore, it is not preferred as a treatment method. Mucinous Cystic Neoplasm (Cystadenoma)
Are cystadenomas in the liver dangerous?
There is a risk of malignant transformation of approximately 15%. These rare cystic tumors, often reaching large sizes, require surgical treatment.
How is the diagnosis of liver cystadenomas made?
Their general features on ultrasound include being hypoechoic lesions with thick and irregular walls, containing debris and nodular structures extending into the lumen. Tissue evidence is required for a definitive diagnosis.
Can simple liver cysts be confused with cystadenomas?
A simple cyst that has become complicated by bleeding into it may be considered a cystadenoma. However, when cystadenomas are visualized on CT as low-density lesions with thick walls and septations, differentiation from simple liver cysts can easily be made.
What is the treatment for liver cystadenomas?
Due to the risk of malignant transformation, it is recommended to completely remove cystadenomas along with the surrounding liver tissue. Partial removal is not recommended because it poses a risk of recurrence and leaving behind malignant tissue. Polycystic Liver Disease (PLD).
What is polycystic liver disease?
It is a genetic disease affecting the liver and kidneys. Cysts are formed in a grape cluster-like structure, composed of bile epithelium unrelated to the bile ducts. Increased growth and fluid accumulation in the cysts can lead to size enlargement. The disease may be accompanied by aneurysms and arterial dissection in the brain.
What are the symptoms of polycystic liver disease?
In most patients, there are no symptoms and no need for treatment. However, growing cysts can cause pressure on the liver and neighboring organs, leading to complaints in affected individuals.
When is treatment necessary for polycystic liver disease?
Complications such as infection or bleeding into the cyst can occur. In patients with symptoms, there is a wide range of treatment options depending on the severity of the pressure on the cysts, from fenestration to liver transplantation. Fenestration involves creating a window in the cyst wall and can be applied through open or laparoscopic surgical methods. Parasitic Cysts (Hydatid Cysts).
Why do hydatid cysts form, and what is the causative agent?
The causative agent of hydatid cysts is Echinococcus granulosus (EG) and is transmitted by dogs. The disease is common in endemic areas with agriculture and animal husbandry. Poor hygiene facilitates the spread of infection. Echinococcus alveolaris (EA) is another parasite from the same family, but it is found in the liver as a solid mass, not a cyst. EA, more commonly seen in the Central Anatolia region, mimics malignant liver tumors. Biopsy of the mass is diagnostic.
What can be done for the treatment of hydatid cysts?
The primary treatment for hydatid cysts caused by EG is surgery. In cases where surgery is not feasible, drug (albendazole) therapy can be initiated. Additionally, drug administration may be chosen as the initial treatment for small cysts. In large cysts, albendazole treatment has shown a cure rate of 30%, a size reduction in 30-50%, and no change in 20% of cases. In addition, the PAIR method (Puncture, Aspiration, Injection, and Reaspiration) can be used in suitable patients. Patients with Type I and II cysts are suitable candidates for this method. PAIR has a short hospitalization period and is cost-effective.
Which patients are not suitable for PAIR?
Patients with hydatid cysts located on the surface of the liver, honeycomb-like appearance, or cysts associated with the bile ducts are not suitable candidates. There is a risk of cyst content spreading, developing an anaphylactic reaction, and causing bile leaks in such cases.
Are there situations that do not require treatment?
Yes. If radiological examinations show that the cyst wall is calcified (Type V cyst), these cysts do not require treatment. Calcified cysts are considered non-viable.
What problems can hydatid cysts cause as they grow?
As hydatid cysts grow, they can erode the surrounding bile ducts, causing them to open. In this case, the cyst contents can empty into the bile ducts, leading to jaundice. This is a complex situation, and both surgical and endoscopic interventions may be required for treatment.
What are the stages in the surgical treatment of hydatid cysts?
The aim of surgical treatment is to safely remove the infectious cyst content from the body. If there is a risk of the cyst content spreading into the abdomen, there is a risk of both anaphylaxis and the formation and growth of new cysts wherever the fluid contacts. To prevent the spread of cyst fluid to surrounding tissues during surgery, the use of albendazole for 5-7 days before surgery is recommended. Additionally, the area around the cyst is covered with compresses saturated with sclerosing agents (povidone iodine or hypertonic NaCl).
After draining the cyst fluid, the visible cyst wall on the surface of the liver is incised, and the germinal membrane and daughter vesicles inside are cleaned. The cyst walls are examined, and the presence of a connection to the bile ducts is determined. If possible, the cyst cavity is then filled with omentum.
Pyogenic Liver Abscess
What is the cause of a pyogenic liver abscess?
The most common cause is aggressive surgical and interventional procedures in elderly and debilitated patients with bile duct or pancreatic cancer. Those who use drugs intravenously and undergo ablation (RFA) for liver tumors are also at risk. Liver abscess development can also occur through the bloodstream from abdominal microbial foci such as diverticulitis and gangrenous cholecystitis. In most diabetic and immunocompromised patients, the cause cannot be identified in about 20% of cases.
Is a pyogenic liver abscess dangerous?
Yes. The risk of death is approximately 15%. Delay in diagnosis, malnutrition, and the presence of multiple abscesses further increase the risk of death.
What are the symptoms of a pyogenic liver abscess?
Symptoms may include fever, fatigue, chills, jaundice, loss of appetite, weight loss, and nausea.
How is the diagnosis of a pyogenic liver abscess made?
The diagnosis is confirmed by the detection of microbial growth in a sample taken from the abscess or in blood cultures after being identified by ultrasound or computed tomography.
How is a pyogenic liver abscess treated?
Treatment is carried out through intravenous antibiotic use and drainage of the abscess. Additionally, the underlying cause should be investigated and eliminated. The risk of death is approximately 15%. In cases of delayed diagnosis, malnutrition, and the presence of multiple abscesses, the risk of death increases even more.
Amoebic Liver Abscess
What is the cause of an amoebic liver abscess?
It develops as a result of amoebic trophozoites crossing the thick intestinal wall and spreading to the liver through the bloodstream. It is 7-12 times more common in men than women. It is more frequently seen in developing countries (Mexico, India, Central and South America, Asia, and tropical regions of Africa).
How is the diagnosis of an amoebic liver abscess made?
The diagnosis is based on imaging and serological tests in the blood. It is not necessary to take a sample from the abscess fluid to make the diagnosis. Detection of Entamoeba antibodies in the blood sample (EIA) has high sensitivity (>94%) and specificity (>95%) for the diagnosis of amoebic liver abscesses.
How is an amoebic liver abscess treated?
The cornerstone of treatment is antiprotozoal drug therapy. Drainage is generally not necessary. However, drainage may be required if there is a risk of the abscess rupturing, if distinguishing between a pyogenic and an amoebic source is important, or if there is no clinical response after 5-7 days of antiprotozoal treatment.
PANCREAS
Are pancreatic cysts dangerous?
The most common cystic lesions in the pancreas are serous and mucinous cysts. Distinguishing between them is important for determining the appropriate treatment. Serous cysts are completely benign and do not require any treatment, while mucinous cysts, more commonly observed in middle-aged women, carry a risk of cancer development ranging from 10-20%.
What symptoms do mucinous cysts in the pancreas present?
Depending on their size and location in the pancreas, these cysts can cause symptoms such as abdominal pain radiating to the back, nausea, vomiting, and weight loss.
What is the treatment for mucinous cysts in the pancreas?
Due to the risk of cancer development, it is necessary to remove these cysts, which are mostly located in the body and tail of the pancreas and can reach sizes of 5-25 cm.
This procedure is performed through surgical intervention.
Which imaging tests are used to differentiate pancreatic cysts?
Contrast-enhanced CT, endoscopic ultrasound, and MR-MRCP are appropriate imaging methods.
Can a biopsy be performed on pancreatic cysts?
Biopsy can be performed under endoscopic ultrasound. While obtaining tissue samples can be challenging, aspiration of fluid can provide information about whether the fluid is serous or mucinous. Additionally, the levels of tumor markers such as CEA, Ca 19.9 in the fluid, amylase levels, and cytological examination can also provide additional information.
What are pseudocysts of the pancreas?
Pseudocysts of the pancreas occur when a high-amylase content fluid, leaking from disrupted pancreatic tissue integrity in patients with pancreatitis, accumulates in a cystic formation protected by surrounding organs. While small ones may resolve during follow-up, large cysts may intermittently decrease in size during follow-up, reaching dimensions that do not require any intervention. However, if large cysts also exhibit clinical symptoms, drainage may be necessary, either into the stomach or through surgery into the intestine.
What is IPMN in the pancreas?
IPMN stands for 'Intraductal Papillary Mucinous Neoplasia,' involving the secretion ducts inside the pancreas. Bubble-like (papillary) structures grow within these ducts, secreting mucin. Mucin is a sticky, transparent liquid similar to egg white. Most importantly, these structures are pathologically a new tissue formation (neoplasia), meaning they have a tendency to grow anarchically, i.e., towards cancer. They belong to the group of mucinous cysts, and treatment principles are applicable to them as well. The risk of cancer development is more significant in types originating from the main duct (main duct IPMN) than those originating from side branches (branch duct IPMN).
What is the treatment for Pancreatic IPMN?
The surgical removal of the affected portion is required. In some cases, the entire pancreas may need to be removed.
What are the risks of developing pancreatic cancer?
Advanced age, male gender, smoking, Helicobacter pylori infection, excessive alcohol consumption, predominant red meat consumption, low intake of vegetables and fruits, excessive weight, and Type 2 diabetes can be considered as risk factors. Genetic predisposition is also prominent for a group of patients.
Where does pancreatic cancer develop in the pancreas?
It predominantly develops in the head of the pancreas (75%). There is a relatively better chance of early diagnosis in these cases. Since the bile duct is also located in the head of the pancreas, the patient may present with jaundice in the early stages. Pancreatic cancer located in the body and tail may not show symptoms even if it reaches very large sizes, which means the disease may be detected in very advanced stages.
What symptoms does pancreatic cancer present in patients?
Symptoms may include jaundice, abdominal pain, weight loss, greasy stools, the onset or worsening of non-existent diabetes. Sometimes, the tumor grows to a size that causes symptoms related to the obstruction of the duodenum.
What aspects are considered in the radiological images of pancreatic cancer?
The location of the tumor, its size, whether it involves the blood vessels around the pancreas, and whether it metastasizes to local or distant lymph nodes or organs are essential points in treatment planning.
Is a biopsy necessary for pancreatic cancer?
Yes, if it is necessary for a differential diagnosis or to start chemotherapy. However, if surgery is planned, routine biopsy is not required.
What is the treatment for pancreatic cancer?
The most common type of pancreatic cancer is pancreatic ductal adenocarcinoma. Surgical resection without distant metastasis is the gold standard for long-term survival. There are some local situations that can complicate or make surgery impossible. These are often related to the tumor's relationship with major veins and arteries in the vicinity. In some cases, the resection of involved vessel segments and reconstruction is necessary. The contribution of these procedures to survival is still debated. In some cases, starting with chemotherapy first and performing surgery if the tumor shrinks can be an appropriate option.
BILE DUCT
What are bile duct cancers?
Cancers originating from the bile ducts that start as thin channels within the liver, merge, and grow to end in the duodenum. They are divided into two groups based on their location: intrahepatic and extrahepatic bile duct cancers.
What is the treatment for intrahepatic bile duct cancers?
If tumors have not spread outside the liver and can be surgically removed with clean margins, liver resection is the most effective treatment. However, the remaining liver should be sufficient for the patient.
What is the treatment for extrahepatic bile duct cancers?
These patients typically present with jaundice due to the tumor blocking bile flow. If it is possible to surgically remove the tumor with clean margins, surgery is the most effective treatment. During surgery, after removing the tumor tissue, a path for bile flow to the intestine is created.
What can be done if surgery is not possible for advanced-stage bile duct cancers?
Due to the tumor, the bile with blocked flow needs to be removed either to the intestine or outside the body. If this is not done, the patient may experience rising jaundice, liver dysfunction, and overall deterioration. External drainage can be done via PTC or ERCP through the intestinal duct.
What are gallbladder polyps?
The digestive and respiratory systems have a tubular structure. These are lined with a layer of single or multi-layered cells (like a carpet laid on the floor). In this layer, swellings may occur with or without a stalk. Layers of cells that have grown into the gallbladder wall can be seen as polyps. Most of these polyps are benign (95%) and are usually detected during examinations for other reasons.
Which benign polyps are present in the gallbladder?
Most of the polyps developing in the gallbladder wall are benign. For example, there are false polyps (such as cholesterol polyps due to cholesterol accumulation, inflammatory polyps developed as a result of inflammatory attacks, etc.). Additionally, structures like fibroma, lipoma, hemangioma can also appear in a polyp structure. The important thing is to distinguish between benign polyps and polyps prone to cancer or malignancy.
What is the approach to gallbladder polyps?
The recommended treatment depends on the patient's age, the size, and number of polyps. Size assessment is made based on the largest polyp. For polyps with a diameter of 1 cm and above, removal of the gallbladder (cholecystectomy) is recommended due to the risk of malignancy. Sizes between 7-9 mm are considered a gray zone, and follow-up or surgery may be chosen. Generally, for polyps with a diameter less than 7 mm, follow-up is recommended. A single and large polyp detected in the gallbladder is alarming.
Why do gallbladder polyps develop, and what can be done to prevent them?
If no clear cause is identified, it is believed to be related to fat metabolism. Therefore, a low-fat diet is considered to have a preventive effect.
What is the treatment for gallbladder polyps?
For polyps suspected of cancer or malignancy, cholecystectomy is performed using open or closed methods. The definitive diagnosis is made through pathological examination. If cancer is detected in the polyp, further treatment is determined based on its stage.
What is Gallbladder Cancer?
Masses originating from the mucosa (cells) lining the gallbladder and growing from the inside out. The tumor traverses the layers of the gallbladder wall layer by layer. The stage of the disease is determined by this progression.
Is Gallbladder Cancer Detected in the Early Stages?
Very difficult. However, it is incidentally detected when the gallbladder is removed and examined for other reasons such as stones, sludge, or inflammation.
Gallbladder Cancer Treatment Options According to Its Stage:
Is There a Relationship Between Gallbladder Cancer and Gallstones?
There is no scientific data suggesting that gallstones alone cause cancer. However, there is a claim that gallbladder stones (especially those above 2 cm) may create a continuous friction effect on the gallbladder wall, causing disruption in the cells lining the wall from the inside, leading to the development of cancer.
Why is Survival Poor in Gallbladder Cancer?
When diagnosed, it is generally in the advanced stage. Even in the early stages, metastasis to lymph nodes and the depths of the neighboring liver can occur.
Is There a Place for Radiotherapy or Chemotherapy in Gallbladder Cancer?
There are situations where surgery is applied after reducing the tumor size with radiotherapy. Chemotherapy, while not eliminating cancer on its own, can help prevent cancer recurrence after surgical treatment.
What is Gallstone?
Structures ranging from grainy mucous sediment (sludge) to walnut size that should not normally be present in the gallbladder.
Why Does Gallstone (Cholelithiasis) Occur?
Cholesterol and pigment (bilirubin) stones are seen in the gallbladder. Cholesterol stones are the most common. Cholesterol in the body is excreted to the intestine through bile. To be excreted, this cholesterol must be in a liquid state. Lecithin and bile salts, found in appropriate proportions in the content of bile, provide this. For reasons not very clear, the proportions of the trio of cholesterol-lecithin-bile salts in bile are disrupted, and cholesterol begins to solidify and settle by coming out of the liquid state. This forms the nucleus of cholesterol stones.
What Problems Can a Stone Inside the Gallbladder Cause?
A stone or stones in the gallbladder can remain without causing any trouble throughout life, but it can also lead to life-threatening severe pancreatitis.
Treatment for Gallstones Detected in the Gallbladder:
The approach varies depending on whether the patient has symptoms related to the stones.
If the patient experiences complaints such as pain, nausea, bloating, and indigestion related to the stones, the surgical removal of the gallbladder is necessary (laparoscopic cholecystectomy). Pain is typically characterized by a sensation that occurs after meals and radiates from the upper right abdomen to below the shoulder blade.
If there are no symptoms in the patient, and the gallstones in the gallbladder are only incidentally discovered, the treatment approach will be different. These stones are referred to as 'silent gallstones.' When planning the treatment for these patients, the age of the patient and the size of the stone are important factors. Small stones (4-7 mm) have the risk of passing through the cystic duct into the main bile duct.
Since a stone that falls into the main bile duct has the potential to cause problems such as obstructive jaundice and acute pancreatitis, small stones are considered more dangerous compared to large stones. Considering the long years ahead for patients with silently detected stones at a young age, the likelihood of developing symptoms is quite high.
In summary, it is recommended that patients who are young and have small stones undergo surgical removal of the gallbladder even if there are no clinical symptoms. In contrast, for older patients with large stones, follow-up is recommended unless there is the development of discomfort related to the stones.
Benefits and Risks of Laparoscopic Cholecystectomy:
It is advantageous in terms of small incision sizes and a short hospital stay. Almost all procedures are completed in a closed manner. However, in some challenging cases, the surgery may start with an open procedure from the beginning or may switch from a closed method to an open one during the operation.
Will I experience difficulties after the gallbladder is removed due to stones?
The gallbladder is removed as a whole. There is no method that involves only the removal of the stones inside. Most often, the surgery (cholecystectomy) is completed laparoscopically, meaning in a closed manner.
After the gallbladder is removed, the bile produced in the liver continuously drips into the intestine. This situation can lead to clinical conditions ranging from the softening of stools to the development of diarrhea in some individuals. This is referred to as bile acid diarrhea and is generally temporary. In rare cases, it may require medication.
My gallbladder was removed due to stones? What have I lost?
You haven't lost anything. The real question should be, 'Will I experience problems with this gallbladder that has stones?' A gallbladder that has started to form stones or sludge now has the potential to do more harm than good. This risk varies depending on the patient's age, the size, and number of stones.
Can stones in the gallbladder be dissolved?
Some medications taken orally can help dissolve stones over very long periods. However, this does not address the root cause, and since the reason for stone formation is not eliminated, the recurrence of stones in the gallbladder is possible. Trying to increase the risk of stones falling through the gallbladder duct by reducing the size of the stones during this process is not a logical approach. We know that small stones are more dangerous than large stones, hence surgery remains the gold standard.
Can large stones in the gallbladder cause cancer?
There is no scientific evidence that a gallstone alone causes cancer. However, there is a claim that gallbladder stones, especially those larger than 2 cm, may create conditions for the development of cancer by causing continuous friction on the gallbladder wall and disrupting the cells lining the wall due to recurrent inflammatory events.
What causes inflammation of the gallbladder?
In situations where the gallbladder does not empty due to gallstones or sludge, the gallbladder wall becomes tense and edematous, disrupting blood circulation in the wall. Bacteria entering the favorable environment can lead to inflammation. The patient experiences pain, along with complaints of fever, and ultrasound reveals a thickened gallbladder wall. Increased CRP in the blood is also detected, indicating an inflammatory condition.
What is the treatment for gallbladder inflammation (cholecystitis)?
Hospitalization of the patient with pain and fever, discontinuation of oral nutrition, intravenous fluid supplementation, and the administration of antibiotics and pain relievers are necessary. Removal of the gallbladder during the same hospitalization is generally an accepted approach. However, in cases where the duration is prolonged or the patient's general condition is not suitable for surgery, and after the treatment of inflammation and improvement of the general condition, removal of the gallbladder 6 hours later can also be considered.
Can gallbladder inflammation occur without stones?
This condition is generally seen in intensive care patients who have not been fed for a long time and in patients with a compromised general condition. Although attempts are made to suppress it with antibiotics, if the patient is suitable, the gallbladder should be removed.
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