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SpringerWienNewYork
Constantine Ch. Karaliotas Christoph E. Broelsch Nagy A. Habib (Eds.)
Liver and Biliary Tract Surgery
Embryological Anatomy to 3D-Imaging and Transplant Innovations
SpringerWienNewYork
Constantine Ch. Karaliotas, MD, PhD Chairman of 2nd Surgical Department and Surgical Oncology Unit in Red Cross Hospital, Athens, Greece
Christoph E. Broelsch, MD, FACS Professor and Chairman, Department of General Surgery and Transplantation, University Clinic Essen, Germany
Nagy A. Habib, ChM, FRCS Professor of Hepatobiliary Surgery, Imperial College, Hammersmith Hospital, London, UK
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© 2006 Springer-Verlag/Wien Printed in Greece
SpringerWienNewYork is part of Springer Science + Business Media springer.com
Printing: I. Sideris Publishing, Athens, Greece
Printed on acid-free and chlorine-free bleached paper SPIN: 11778318
With more than 430 figures, 250 in colour
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ISBN-10 3-211-49275-5 SpringerWienNewYork ISBN-13 978-3211-49275-8 SpringerWienNewYork
This Book is Dedicated to
Evangelos Papaevangelou
MD, PhD Professor of Surgery- University of Athens
Former Chairman of Surgery in Red Cross Hospital, Athens - Greece
Former President of the Hellenic Surgical Society
and 23 d Panhellenic Surgical Congress
"In admiration for his scholarship in many fields, for his zeal as teacher, surgeon, and administrator"
"In the judicious discharge of these interdependent functions he has unfailingly strengthened the natural alliance
between humanism and surgery"
We are like dwarfs seated on the shoulders of giants.
If we see more and further than they,
it is not due to our own clear eyes or tall bodies,
but because we are raised on high
and upborne by their gigantic bigness.
Bernard of Chartres
Chancellor in 1119
PREFACE
The 25th Panhellenic Surgical Congress is offering the present textbook of surgery to all participants on one of the hot surgical topics: hepatobiliary surgery: "I wonder what the young surgeon learn when they attend a national surgical congress?" It is well known that delegates and young surgeons attend sessions on surgical topics of great interest, such as round table discussions, lectures on specific issues by distinguished Greek and foreign guests, postgraduate courses, follow live operations transmitted from operating rooms, meet experts describing their own techniques, debate scientific problems and ideas with well known pioneers in the field, and go home to review the scientific programme and their notes from the sessions attended.
Pioneers from both the international and Greek Hepatobiliary Club, present their combined experience, describe techniques for hepatic and biliary surgery and explore future trends. It is important for all of us to know
what is really "innovative" in hepatobiliary surgery. New thinking is both an initiation and a "nouveaute" that pushes at the frontiers in surgery. This book addresses all the main topics in Hepatobiliary surgery including living related and conventional cadaveric transplantation, new trends in hepatic surgery, new applications for laparosco- pic surgery, especially laparoscopic exploration of the biliary tree, the changing face of biliary reoperation and iatrogenic biliary stenoses and strictures, etc.
The book also covers cutting-edge research and technological advances that will shape the surgery of to- morrow. There is little doubt that technological advances in preoperative imaging, such as 3-D reconstruction, preoperative preparation with portal vein embolisation and operative techniques using bloodless RF resection methods, are already changing the nature of liver surgery.
It will be interesting to see how surgery will benefit from advances in stem cell research, gene therapy, geno- mics, proteomics and miRNA. I hope that this book will inspire young surgeons to invent, to dream and believe in their imagination.
As a surgeon who has participated in the evolutionary steps of biliary and hepatic surgery over the last deca- des, I want to express my enthusiasm for this book, and my deep appreciation to the Organising Committee and especially the President of the Congress, my friend Constantine Karaliotas, and the hope that this book will be appreciated by all members of the 2006 Congress.
Evangelos J. Papaevangelou Professor of Surgery
Former President of Hellenic Surgical Society
PREFACE
With the coming of 2007, we are celebrating seventy nine years since the institution of the Hellenic Surgical
Society.
These years have proven very productive for surgery in Greece, mainly because the founders of our Society,
as well as all the great scientists of the Executive Committees that followed, offered all their knowledge in an
effort to upgrading surgery in Greece, so that it is now considered as worthy as surgery worldwide.
Wishing to honour the 79th anniversary of our Society and at the same time holding the 25th Panhellenic Congress of Surgery, the present Executive Committee decided, among other, to publish a book titled "Liver and Biliary Tract Surgery".
The aforementioned book, written in English so as to be read by doctors beyond Greek frontiers, is the result of a very successful team work of some of the most significant scientists of our days. The President of the congress
and elect President of the Hellenic Surgical Society, Dr C. Karaliotas, Chairman of the Surgery and Surgical Onco-
logy Department of Red Cross Hospital in Greece, Professor Chistoph Broelsch, Chairman of the Transplantation
Center of Essen University in Germany and Professor Nagy Habib Chairman of the Hepatobiliary Department of
the Hammersmith Hospital in United Kingdom, are the editors of the present book.
The catalogue of authors includes 68 scientists very well known for their work, knowledge and literature
contribution, worldwide, from Greece, Germany, United Kingdom, United States and France.
SpringerWienNewYork, the Publisher is one of the highest reputed publishing Houses, and an additional gua- rantee of the book's high quality.
Being the representative of the Hellenic Surgical Society, I wish to thank the editors, Doctors Karaliotas, Broelsch and Habib for their hard work, all the authors for their valuable contribution and Springer publishers who gave us the opportunity for that great edition. We look forward to a future cooperation.
It is our wish, this very special work of so many remarkable authors to receive the welcome it deserves.
Theophilos Polymeropoulos President of the Hellenic Surgical Society
FOREWORD
Since in 2006 the art and practice of HPB surgery can be learnt from a variety of sources, which circumstances
did determine and touched the genesis of this book? In spite of the internet and e-learning and the many scientific
and medical meetings, a textbook still has a place in today's world as it provides junior and senior surgeons with a
definite and fundamental source of information to enhance clinical skill and management strategy.
This textbook has three Editors-authors and four sections, each reflective of their own particular perspective.
As each author has chosen different co-authors and topics, the textbook has been enriched with different philoso-
phies and ways of thinking about clinical approaches from which the reader will benefit.
The first and second sections are dedicated to embryology, anatomy and physiology, current diagnostic
techniques in hepatobiliary surgery and management of benign and malignant diseases of the biliary tract. Is one
of the most classical but basic and difficult knowledge for the HPB surgeon. The topics are mainly written by
authors from university centers of Greece and Red Cross Hospital of Athens and Hannover. Invaluable is the offer
of the two famous writers, professors A. Dalley and K.L. Moore from USA and Canada who have written the
chapter I.
The third section, is written from the Hammersmith Hospital doctors. They contributed to chapters covering
three different areas.
The first area reflects the unique activities where HPB department excels. Chapters are dedicated to new
techniques developed at the Hammersmith Hospital, such as radiofrequency assisted liver resection. This concept
was born and developed at the Hammersmith. It is with great pride that on the first anniversary of the launch of
Hammersmith device that one in four of all liver resections in the USA is performed with this technique. The new
technique allows HPB surgeons to perform liver resection with excellent results. In the vast majority of cases liver
resection can be performed without blood transfusion, and without the need to admit patients to intensive care
unit or high dependency unit. The development of the laparoscopic RF resection device is even more significant
as it will finally give the liver surgeon the opportunity to undertake laparoscopic liver resection safely. It will also
significantly reduce the length of hospitalisation and overall cost, rendering liver resection more competitive than
percutaneous tumour ablation and other non-surgical approaches.
The second area describes techniques that were developed by other teams, but adopted recently in Hammer-
smith HPB service. This includes the use of 3D imaging in the pre-operative planning of surgery and the adjuvant
use of SIRTEX for locally delivered radiotherapy.
The third area gives an insight into some of the research undertaken in the department of surgery, such as stem
cell and gene therapy. Several clinical trials have been performed and results, so far, are promising. We believe
that academic research goes hand in hand with modern surgery. Research holds the key for improvements in HPB
surgical outcomes. The up-to-date modern HPB surgeon will have to rely more and more on stem cell biology,
gene therapy, molecular engineering, microarray technology, chemotherapy signatures, genomics, proteomics,
metabonomics, nanotechnology, tissue engineering, medical device engineering and above all his or her creative
surgical handicraft to optimise the management of HPB patients.
The fourth section is dedicated to Liver Transplantations and is written from doctors of Liver Transplantation
Unit of Essen University from Germany. In the past two decades liver transplantation has become the standard
treatment in patients with chronic liver failure. Currently, it also represents the most effective therapy in acute
liver failure and in carefully selected patients with hepatocellular carcinoma. Technical innovations as well as an
i i
Xll Foreword
explosion of basic and clinical knowledge in organ transplantation contributed to the success of liver transplan-
tation. This includes a standardization of operative preservation techniques and in particular new developments in the field of immunosuppression. As a consequence, short term survival has improved tremendously.
Concerning the factors which gained increasing interest are those determining long-term survival, in
particular, recurrence of primary disease. It is one of the major challenges for the future to develop successful strategies for the prevention and therapy of recurrent disease to reduce the risk for recurrence and to increase survival. With increasing success the indication for liver transplantation is more and more broadened, although organ availability will become the limiting factor. To reduce organ shortage, an optimal use of available organs and an extension of the donor pool is inevitable. Split liver transplantation and living-related liver transplantation are the most effective innovations to increase organ availability and to relieve organ shortage.
This textbook comes at a critical time for liver surgery. During the last 3 decades there have been major
advances in liver surgery, such as complex liver surgery and liver transplantation. However, no major break-
through has happened in the last few years, even laparoscopic liver surgery did not gain its expected popularity
because of the technology gap. Unfortunately, liver surgery has been on the defensive. Instead of progressing, the
contrary has happened, and liver surgery is receding from the high ground. Facing the onslaught of major break- throughs in interventional radiology and oncology conventional orthodox liver surgery indications, such as rese- ction of small solitary tumour, were being questioned. Furthermore, major HPB meetings were uninspiring, rich in style, but poor in substance. The major chiefs of liver surgery were repeating old positions with loud voices, but with no convincing arguments.
In all our sections of this textbook we have concentrated on new developments, which Professor Papaevan- gelos alluded to in his preface as "nouveaut6s", in the hope of firing the imagination of HPB surgeons and of attra- cting young talent to this speciality.
HPB surgery and medicine are in dynamic motion propelled by knowledge, discovery and innovation. Curren-
tly, the HPB surgeon has to face the challenge of how to integrate and to work closely with the oncologist, gastro- enterologist, radiologist and pathologist in a multi-disciplinary approach. In the future the challenge will be even greater. In this new era, the HPB surgeon will have to interact with new officers who will make discoveries lead by science and technology. It is in this spirit that this textbook has been designed and prepared.
Finally, we would like to thank our co-authors and all contributors for giving us the privilege to contribute to this textbook and to all our colleagues who assisted with the manuscripts. Lastly, we hope that readers of this book will be inspired by the science, technical surgical handicraft, and spirit of this book which will equip them with new skills to offer optimal management to their patients.
Constantine Karaliotas Christoph Broelsch
Nagy Habib
Editors
SPECIAL ACKNOWLEDGMENTS
I take special pleasure and satisfaction in acknowledging the assistance of the special and daily contribution of Doctors G. Sgourakis, Th. Christofides, G. Sotiropoulos, Mike Hatzikalis and Ch. Karaliotas during the course of preparation the last 18 months.
I also take matching special pleasure in acknowledging the contribution of Georgina St John in language editing and the contribution of Tania Gaggou in the phototypesetting, giving an excellent result.
Finally I would also like to express my indebtedness for their help to J. Sideris Publishing House, Athens- Greece and to SpringerWienNewYork Publishing House, especially to Raimund Petri-Wieder, Editor-Medicine of Springer in Wien.
My special thanks to Professors Chr. Broelsch and N. Habib, to the President Th. Polymeropoulos and to the members of the Executive Committee of Hellenic Surgical Society. Without the support of all these people I could not have succeeded in this venture.
Constantine Ch. Karaliotas Editor
CONTENTS
SECTION 1
Chapter 1 Embryological and Surgical Anatomy of the Intrahepatic and Extrahepatic Biliary Tree
(A.F. Dalley, K.L. Moore) ..........................................................................................................................................................................
1.1. Embryology ........................................................................................................................................................................................... 3 1.2. Surgical Anatomy ................................................................................................................................................................................ 10 References and Sources of Illustrations ............................................................................................................................................... 16
Chapter 2 Surgical Anatomy of the Liver (P. Kekis, B. Kekis) ........................................................................................................................ 17
2.1. I n t r o d u c t i o n l 7
2.2. E m b r y o l o g y l 7
2.3. Liver Topography and Gross Anatomy ...................................................................................................................................... 19
2.4. Liver Lobes and Segments ............................................................................................................................................................... 25
References ........................................................................................................................................................................................................ 32
Chapter 3 Anatomical Variations and Anomalies of the Biliary Tree, Veins and Arteries
(Con. Ch. Karaliotas, T. Papaconstantinou. Ch. Con. Karaliotas) ............................................................................................. 35
3.1. I n t r o d u c t i o n 3 5
3.2. Aberrant Ducts ..................................................................................................................................................................................... 35
3.3. Anatomical Variations of Vessels ................................................................................................................................................. 41
3.4. Anatomical Variations of CBD Union and the Main Pancreatic Duct ........................................................................... 47
3.5. Conclusion ............................................................................................................................................................................................. 47
References ........................................................................................................................................................................................................ 47
Chapter 4 Ultrasonographical Anatomy for the Surgeon. The Value of Intra-operative Ultrasonography
(S. Mylona, A. Papaevangelou, G. Sgourakis, Con. Ch. karaliotas) .......................................................................................... 49
4.1. Introduction .......................................................................................................................................................................................... 49
4.2. Transabdominal Ultrasound ........................................................................................................................................................... 49
4.3. Intra-Operative Ultrasound ( IOUS)of the Liver .................................................................................................................... 58
References ........................................................................................................................................................................................................ 60
Chapter 5 Elements of the Biliary Tract and Liver Physiology
(Th. Christofides, Ch. Con. Karaliotas, G. Sgourakis, Con. Ch. Karaliotas) .......................................................................... 61
xv i Contents
5.1. Bile Composi t ion ................................................................................................................................................................................ 61
5.2. Mechanism of Emptying of the Gallbladder ............................................................................................................................ 62
5.3. Physiologic Anatomy of the Liver ................................................................................................................................................ 65
5.4. Bilirubin Metabolism and the Enterohepatic Circulation ................................................................................................... 66
References ........................................................................................................................................................................................................ 66
Chapter 6 Conventional Imaging Studies of the biliary Tract
(I. Thanos, S. Mylona) ................................................................................................................................................................................. 69
6.1 Introduction - Abdominal Plain X-Ray 69 6 2 Transabdominal Ultrasonography of the Biliary Tract ..................................................................................................... 69
6 3 Gallbladder Ultrasonographic Imaging ................................................................................................................................... 70
6 4 C o m m o n Bile Duct Imaging ........................................................................................................................................................ 72
6 5 Choledocholithiasis Ultrasonographic Imaging .................................................................................................................. 72
6 6 Cholangiocarcinoma Imaging ..................................................................................................................................................... 72
6 7 Computer ized Tomography (CT) Imaging ............................................................................................................................ 74
6 8 Magnetic Resonance Imaging (MRI) ......................................................................................................................................... 77
6 9 Biliary Scintigraphy ......................................................................................................................................................................... 80
6.10. Percutaneous Transhepatic Cholangiography (PTHC) ..................................................................................................... 81
References ........................................................................................................................................................................................................ 83
Chapter 7 Endoscopic Retrograde Cholangiopancreatography (Kon. Goumas, A. Poulou) .............................................................. 87
7.1. Introduction .......................................................................................................................................................................................... 87
7.2. Technical Features .............................................................................................................................................................................. 87
7.3. Indications ............................................................................................................................................................................................. 89
7.4. Contraindications ................................................................................................................................................................................ 90
7.5. ERCP and Diseases of the Biliary Tract ...................................................................................................................................... 90
7.6. Complications of ERCP ..................................................................................................................................................................... 104
7.7. The Role of ERCP in Biliary Disorders in the Era of MRCP and EUS ............................................................................ 105
References ........................................................................................................................................................................................................ 106
Chapter 8 Endoscopic Ultrasonography on Gallbladder and Biliary Tract (Kon. Goumas, A. Poulou) ........................................ 111
8.1. Equipment and Technique .............................................................................................................................................................. 111 8.2. The Role of EUS in Biliary Diseases ............................................................................................................................................ 112
8.3. Complications of EUS ........................................................................................................................................................................ 115 References ........................................................................................................................................................................................................ 116
SECTION 2
Chapter 9 ': Hepatobil iary Disease and Anaesthesia (P. Georgakis, L. Rizzotti, I. Katsouli-Liapis) .................................................... 121
9.1. Introduction .......................................................................................................................................................................................... 121
Contents xvii
9.2. Clinical Forms of Hepatobil iary Disease ................................................................................................................................... 121
9.3. Pathophysiologic Mechanisms of Hepatocellular Injury .................................................................................................... 122
9.4. Anaesthesia for Hepatobi l iary Disease ....................................................................................................................................... 123
9.5. Anaesthetic Considerat ions for Hepatic Resection Procedures ...................................................................................... 130
9.6. Conclusion ............................................................................................................................................................................................. 131
References ........................................................................................................................................................................................................ 131
Chapter 10 Congenital Malformations in the Extrahepatic biliary Tree in Children Biliary Atresia (D.C. Keramidas) ............ 135
10.1. In t roduct ion ........................................................................................................................................................................................ 135
10.2. E t i o l o g y 1 3 5
10.3. Classification ...................................................................................................................................................................................... 136
10.4. Clinical Manifestation and Diagnosis ....................................................................................................................................... 136
10.5. Surgery in Biliary Atresia .............................................................................................................................................................. 137
10.6. Kasai Hepatic Por toen te ros tomy ............................................................................................................................................... 137
10.7. Complicat ions After Hepatic Po r toen te ros tomy ................................................................................................................. 139
10.8. Results of Hepatic Por toen te ros tomy ...................................................................................................................................... 134
10.9. P r o g n o s i s 1 4 0
R e f e r e n c e s 1 4 0
Chapter 11 Choledochal Cysts of the Biliary Tree in Children (D.C. Keramidas) .................................................................................... 143
11 1. Choledochal Cysts- In t roduct ion .............................................................................................................................................. 143
11 2 E t i o l o g y 1 4 3
11 3 Classification ...................................................................................................................................................................................... 143
11 4 Clinical Presentat ion ....................................................................................................................................................................... 144
11 5 D i a g n o s i s 1 4 4
11 6 Surgica lTrea tment ........................................................................................................................................................................... 145
11 7 Laparoscopic Surgery .................................................................................. . ................................................................................... 146
11 8 Postoperat ive Complicat ions ...................................................................................................................................................... 146
References ................................................................................................................... : .................................................................................... 146
Chapter 12 Gallstone Disease (Kon. N. Birbas, I.G. Kaklamanos, G.N. Bonatsos) ................................................................................... 149
12.1. In t roduct ion - Prevalence and Incidence ................................................................................................................................ 149
12.2. Symptomat ic Gallstones ................................................................................................................................................................ 149
12.3. Preoperat ive Management of Gallstone Disease ......................................................................... : ....................................... 154
R e f e r e n c e s 1 6 6
Chapter 13 Complications in the Per formance of Laparoscopic Cholecystectomy. What Can Go Wrong?
How Do Complicat ions Have to Be Managed? (G. Quast, A. Kuthe) - 169
13.1. Introduct ion ........................................................................................................................................................................................ 169
13.2. The Per ioperat ive Setting 169
13.3. The Use of Per ioperat ive Prophylactic Antibiotics 169
xviii Contents
13.4. The Approach to the A b d o m e n ................................................................................................................................................ 170
13.5. Bile Duct Injuries - Anatomy, Prevent ion Techniques, Trea tment .......................................................................... 170
13.6. Gallbladder Perforat ion and Loss of Stones ........................................................................................................................ 172
13.7. Blood Vessel Injuries .................................................................................................................................................................... 173
13.8. Specific Points for a Successful End to the Laparoscopic Procedure ....................................................................... 174
13.9. Forensic Aspects and Malpractice in Laparoscopic Cholecys tec tomy ..................................................................... 175
13.10. Conclusion ........................................................................................................................................................................................ 176
References ........................................................................................................................................................................................................ 176
Chapter 14 Iatrogenic Injury of the Extrahepatic Bile Ducts. Surgical Reconstruct ion
(I.G. Kaklamanos, Kon. N. Birbas, G.N. Bonatsos) " 179
14.1. Int roduct ion - History .................................................................................................................................................................... 179
14.2. Types of Injury .................................................................................................................................................................................. 179
14.3. Mechanisms of Injury and Risk Factors ................................................................................................................................... 181
14.4. Diagnosis of the Injury ................................................................................................................................................................... 184
14.5. Management of Bile Duct Injuries ............................................................................................................................................. 184
14.6. Repair of Injuries Recognized at the Time of Initial Surgery ................. ........................................................................ 186
14.7. Repair of Biliary Strictures and Injuries Recognized Postoperat ively ........................................................................ 187
14.8. Per ioperat ive and Long-Term Results ..................................................................................................................................... 189
References ........................................................................................................................................................................................................ 190
Chapter 15 Principles of the Surgical Management of the C o m m o n Bile Duct Stones
(Con. Ch. Karaliotas, S. Lanitis, G. Sgourakis) 193
15.1. In t roduct ion .................................................................................................................................................................................... 193
15.2. Incidence of Choledocholi thiasis .......................................................................................................................................... 194
15.3. Pathogenesis of CBD Stones .................................................................................................................................................... 194
15.4. Clinical Findings ............................................................................................................................................................................ 195
15.5. The Surgeon's View in Per ioperat ive Imaging Study of CBD .................................................................................... 196
15.6. Trea tment of Choledocholi thiasis .......................................................................................................................................... 202
15.7. Cholecys tec tomy in Patients with Choledocholi thiasis ................................................................................................ 212
15.8. Postoperat ive Care ....................................................................................................................................................................... 213
15.9. Lithotripsy as a Compl imenta ry Modality for the Management of the C o m m o n Bile Ducts ........................ 213
15.10. Management of Retained Stones After Cholecys tec tomy ............................................................................................ 216
R e f e r e n c e s 2 1 6
Chapter 16 Laparoscopic C o m m o n Bile Duct Exploration
(Con. Ch. Karaliotas, G. Sgourakis, Th. Christofides, S. Lanitis) ............................................................................................... 219
16.1. In t roduct ion ........................................................................................................................................................................................ 219
16.2. Transcholedocal Laparoscopic CBD Exploration ............................................................................................................... 222
16.3. Non-Choledochoscopic Manoeuvres ..... .................................................................................................................................. 222
16.4. Cho ledochoscopy ............................................................................................................................................................................. 223
References ............................................................................. . .......................................................................................................................... 224
Contents xix
Chapter 17 Endoscop ic M a n a g e m e n t of C o m m o n Bile Duct Stones
(Kon. Goumas , A. Poulou) ........................................................................................................................................................................ 227
17.1. In t roduc t ion ........................................................................................................................................................................................ 227
17.2. Endoscop ic S p h i n c t e r o t o m y ....................................................................................................................................................... 227
17.3. Bal loon Sph inc te rop las ty .............................................................................................................................................................. 230
17.4. Effect iveness and Technica l Aspects of Endoscop ic Stone Extract ion ...................................................................... 231
17.5. The Role of ERCP in C o m b i n e d Choledocho l i th ias i s and Cholel i thiasis .................................................................. 234
References ........................................................................................................................................................................................................ 235
Chapter 18 Current Changes in Biliary Reopera t ions (E.J. Papaevange lou , A. P a p a e v a n g e l o u - N o m i k o u ) .................................... 239
18.1. I n t roduc t ion ........................................................................................................................................................................................ 239
18.2. Reta ined or Recurrent Stones ...................................................................................................................................................... 239
18.3. Stenosis of the Sphinc ter of O d d i ............................................................................................................................................. 240
18.4. Malfunct ioning "Low" Bil io-Digest ive Anas tomoses ........................................................................................................ 240
18.5. Benign Strictures of the Biliary Tract ....................................................................................................................................... 241
18.6. Reopera t ions for " P o s t c h o l e c y s t e c t o m y S y n d r o m e " . ........................................................................................................ 241
18.7. Reopera t ions for Cases wi th "Cystic Duct S y n d r o m e " . .................................................................................................... 241
18.8. Conclus ion ........................................................................................................................................................................................... 241
References ........................................................................................................................................................................................................ 242
Chapter 19 Othe r Benign Biliary Diseases and Lesions (G. Sgourakis, Th. Mitellas, Con. Ch. Karal iotas) .................................... 243
19 1. Mirizzi 's S y n d r o m e .......................................................................................................................................................................... 243
19 2. Funct ional Disorde rs of the Biliary Tract ............................................................................................................................... 244
19 3. Acalculous Cholecyst i t is ................................................................................................................................................................ 246
19 4. Biliary In t rahepa t ic and C o m m o n Bile Duct Cysts in Adults .......... i .............................................................................. 246
19 5. Biliary Str ictures Mimick ing Mal ignancy ............................................................................................................................... 249
19 6. HIV Cho lang iopa thy (AIDS Cho lang iopa thy ) ...................................................................................................................... 250
References ........................................................................................................................................................................................................ 251
Chapter 20 Cholangi t is (G.P. Fragulidis, A.A. Po lydorou , D.C. Voros) .......................................................................................................... 253
20.1. In t roduc t ion ........................................................................................................................................................................................ 253
20.2. Acute Suppura t ive Cholangi t is .................................................................................................................................................... 253
20.3. Recurrent Pyogen ic Cholangi t is .................................................................... i ............................................................................. 256
20.4. P r imary and S e c o n d a r y Scleros ing Cholangi t is ................................................................................................................... 260
20.5. Fibrosis of Papilla-Papill i t is ............................................................ • ........... ................................................................................... 264
References ............................................................................................................. . ........................................................................................... 265
Chapter 21 Cancer of the Extrahepat ic Biliary Tract ............................................................................................................................................. 267
Cal lb ladder Ca rc inoma (G. Karatzas, E. Misiakos) .............. ........................................................................................................... 267
XX Contents
2 la. 1. Inc idence ........................................................................................................................................................................................ 267
21a.2. Risk Factors .................................................................................................................................................................................... 267
21a.3. Genet ics ........................................................................................................................................................................................... 268
21 a.4. Pa tho logy ........................................................................................................................................................................................ 268
• 21 a.5. Clinical Manifesta t ions ......................................................... : .................................................................................................... 269
21a.6. Diagnost ic Me thods .................................................................................................................................................................... 270
21a.7. Surgical T r e a t m e n t ...................................................................................................................................................................... 270
2 la.8. Inc identa l Finding at C h o l e c y s t e c t o m y ............................................................................................................................. 271
21a.9. Resectable Malignant T u m o r Preopera t ive ly Suspec ted or Co n f i rmed ................................................................ 272
21 a. 10. A d v a n c e d Mal ignancy ............................................................................................................................................................... 273
21 a. 11. Prognosis ........................................................................................................................................................................................ 274
References ........................................................................................................................................................................................................ 275
Bile Duct Cancer (G. Karatzas, E. Misiakos) ...................................................................................................................................... 279
21b.12. Inc idence ........................................................................................................................................................................................ 279
21b.13. His tory ............................................................................................................................................................................................. 279
21b.14. Risk Factors .................................................................................................................................................................................... 279
21 b. 15. Molecular Pa thogenes i s ............................................................................................................................................................ 281
21 b. 16. Locat ion ........................................................................................................................................................................................... 281
2 lb. 17. Pa tho logy and Staging ................................................................................................................................................................ 282
2 lb. 18. Clinical P resen ta t ion .................................................................................................................................................................. 282
21b.19. Invest igat ive Techn iques ......................................................................................................................................................... 283
21b.20. Surgical T r e a t m e n t ...................................................................................................................................................................... 285
References ........................................................................................................................................................................................................ 286
Endoscop ic Pallative M a n a g e m e n t of the Mal ignancies of the Biliary Tract (Kon. Goumas , A. Poulou) ................ 289
2 lc .21. In t roduc t ion .................................................................................................................................................................................. 289
21c.22. Endoscop ic or Surgical Palliative M a n a g e m e n t ? ............................................................................................................ 289
21c.23. Technical Aspects ........................................................................................................................................................................ 290
References ........................................................................................................................................................................................................ 295
Chapter 22 Opera t ions of the Biliary Tract. Tecnical Aspects (J. Bramis, I.P. Gomatos , M.M. Kons tandou lak i s ) ...: .................. 297
22.1 In t roduc t ion .................................................................................................................................................................................... 297
22.2 P reopera t ive Evaluation ............................................................................................................................................................. 297
22.3 To Stent or Not to Stent ............................................................................................................................................................. 297
22.4 Genera l P r inc ip l e s - Exposure ................................................................................................................................................. 298
22.5 Hilar Dissec t ion ............................................................................................................................................................................. 299
22.6 Bi l ia ryTrac t Recons t ruc t ion ..................................................................................................................................................... 300
22.7. Pa renchymal liver t ransec t ion ................................................................................................................................................. 301
22.8. Ope ra t i ons of the Biliary Tract ............................................................................................................................................... 3 0 2
22.9. C h o l e d o c h o d u o d e n o s t o m y - Indica t ions ........................................................................................................................... 304
22.10. Ope ra t i ve Bile Duct Dra inage Via Segmen t III - " T h e Round Ligament Approach" . ...................................... 306
22.11. The R o d n e y - Smith P rocedu re ............................................................................................................................................... 307
22.12. The Longmi re P rocedu re ................... ....................................................................................................................................... 308
22.13. Specific Condi t ions ...................................................................................................................................................................... 308
References ....................................................... : ................................................................................................................................................ 312
Contents xxi
SECTION 3
Chapter 23 Imaging Studies of the Liver (L. Thanos, S. Mylona) ..................................................................................................................... 317
23.1. Introduct ion - Plain X-Ray ............................................................................................................................................................ 317
23.2. Ultrasonography ............................................................................................................................................................................... 317
23.3. Computed Tomography ................................................................................................................................................................ 319
23.4. MRI of the Liver ................................................................................................................................................................................ 322
23.5. Scintigrams - PET Scanning ......................................................................................................................................................... 324
23.6. Angiography ....................................................................................................................................................................................... 325
23.7. Needle Biopsy of the Liver ........................................................................................................................................................... 327
References ........................................................................................................................................................................................................ 329
Chapter 24 Three Dimensional (3D) Computed Tomography Images Reconstruction in Liver Surgery
(O. Damrah, R. Canelo, D. Zacharoulis, P. Tait, L.R. Jiao, N. Habib) ...................................................................................... 333
24.1. Introduct ion .................................................................................................................................................................................... 333
24.2. Liver Anatomy ................................................................................................................................................................................ 333
24.3. Clinical Application of 3-D Reconstruction of the Liver: 3-D Imaging
and Liver Transplantation ......................................................................................................................................................... 334
24.4. Oncologic Resections ................................................................................ . ................................................................................. 334
24.5. 3-D and Training ........................................................................................................................................................................... 335
24.6. Technique ........................................................................................................................................................................................ 336
24.7. Segmentat ion .................................................................................................................................................................................. 336
24.8. Data Processing ............................................................................................................................................................................. 336
24.9. Visualization .................................................................................................................................................................................... 336
24.10. A n a l y s i s 3 3 6
24.11. Softwares for 3-D CT Reconstruction ................................................................................................................................... 337
24.12. 3-D CT and Navigation ............................................................................................................................................................... 338
References ........................................................................................................................................................................................................ 338
Chapter 25 Preoprative Assessment of Liver Function
(G. Sgourakis, Th. Christofides, Ch. Con. Karaliotas, Con. Ch. Karaliotas) ............................. i ............................................ 339
25.1. Introduction .................................................................................................................................................................................... 339
25.2. Indocyanine Green Retention ................................................................................................................................................. 340
25.3. 99m-Tc-Galactosyl-Human Serum Albumin Scintigraphy ........................................................................................... 343
25.4. Hippurate Ratio .............................................................................................................................................................................. 347
25.5. Amino Acid Clearance Test ............................................................................................................ : ......................................... 347
25.6. Aminopyr ine and Phenylalanine Breath Test ................................................................................................................... 347
25.7. Monoethylglycinexylidide Test .............................................................................................................................................. 348
25.8. Measurement of Liver Volume ................................................................................................................................................ 348
25.9. D-Sorbitol ......................................................................................................................................................................................... 348
25.10. Clearance of Galactose ............................................................................................................................................................... 349
25.11. Other Tests ...................................................................................................................................................................................... 349
xxi i Contents
25.12. Patient Selection, Scoring Systems and Resection Outcomes ................................................................................... 349
References ........................................................................................................................................................................................................ 351
Chapter 26 Indications for Liver Resection (A. Healy, J. Tracey, N.A. Habib, L.R. Jiao) ....................................................................... 357
26.1. Int roduct ion 357
26.2. Indications ........................................................................................................................................................................................... 357
26.3. Preoperat ive Management ............................................................................................................................................................ 360
26.4. Standard Resect ions-Segmentectomies " 361
References ........................................................................................................................................................................................................ 362
Chapter 27 Liver Resection and Stapling Devices - Laparoscopic Resection (A. Healy, J. Tracey, N.A. Habib, L.R. Jiao) ...... 363
27.1. Int roduct ion ........................................................................................................................................................................................ 363
27.2. Techniques for Liver Parenchymal Transect ion .................................................................................................................. 363
27.3. Laparoscopic Liver Resection ..................................................................................................................................................... 364
References ........................................................................................................................................................................................................ 366
Chapter 28 Liver Resection Assisted with the Radiofrequency Technique (A. Healy, J. Tracey, N.A. Habib, L.R. Jiao) .......... 367
28.1. In t roduct ion ..................................................................................................................................................................................... 367
28.2. Background ...................................................................................................................................................................................... 367
28.3. Monopolar Electrodes .................................................................................................................................................................. 367
28.4. Bipolar Electrodes ......................................................................................................................................................................... 367
28.5. General Considerat ions ................................................................................................................................................................ 368
28.6. Design of the Habib ® 4X ............................................................................................................................................................ 368
28.7. Application ............................................................................................................................ : .......................................................... 369
28.8. Results ................................................................................................................................................................................................. 370
28.9. The InLine T M (ILRFA/ILRFC) ................................................................................................................................................... 370
28.10. Laparoscopic Hepatic Resection with RF ............................................................................................................................. 371
28.11. Trans-metastasis Hepa tec tomy Using RF ............................................................................................................................. 371
28.12. Conclusion ........................................................................................................................................................................................ 372
References ........................................................................................................................................................................................................ 372
Chapter 29 Liver Resection for Cholangiocarc inoma (G.C. Sotiropoulos, H. Lang, Ch.E. Broelsch) .............................................. 373
29.1. Resection of Hilar Bifurcation and Biliary Reconstructions ........................................................................................... 373
29.2. Vascular Reconstructions .............................................................................................................................................................. 375
29.3. Vascular Occlusion ........................................................................................................................................................................... 376
29.4. Non-convent ional Liver Resections (In Situ-Ante Situm and Ex-Situ) ....................................................................... 377
29.5. L y m p h a d e n e c t o m y by Liver Resection ................................................................................................................................... 377
29.6. Intraoperat ive Management During Liver Resection ........................................................................................................ 378
29.7. Repeated Hepa tec tomy for Reccurent Malignant Tumor ................................................................................................. 378
References ........................................................................................................................................................................................................ 379
Contents xxiii
Chapter 30 Portal Vein Embo l i s a t i on (O. Damrah , R. Canelo, L. Jiao, N.A. Habib) ................................................................................. 381
30.1. I n t roduc t i on .................................................................................................................................................................................... 381
30.2. B a c k g r o u n d ..................................................................................................................................................................................... 381
30.3. Liver Regene ra t i on ....................................................................................................................................................................... 382
30.4. Clinical Rat ionale for PVE Before Major Liver Resec t ion ............................................................................................ 383
30.5. M e a s u r e m e n t of FLR V o l u m e and Pred ic t ing Func t ion after PVE ........................................................................... 383
30.6. A n a t o m i c Cons ide ra t i ons .......................................................................................................................................................... 385
30.7. Portal Venous A n a t o m y .............................................................................................................................................................. 385
30.8. Portal Venous Variants ............................................................................................................................................................... 386
30.9. M e c h a n i s m of PVE ........................................................................................................................................................................ 387
30.10. Embol i c Material ........................................................................................................................................................................... 389
30.11. P o s t e m b o l i s a t i o n Course ............................................................................................................................................................ 389
30 12. Ind ica t ions for PVE ...................................................................................................................................................................... 389
30 13. Con t r a ind i ca t i ons ......................................................................................................................................................................... 390
30 14. O u t c o m e s After PVE and H e p a t e c t o m y .............................................................................................................................. 390
30 15. PVE in Pat ients wi th Chron ic Liver Disease ...................................................................................................................... 391
30 16. PVE in the Absence of Chron ic Liyer Disease .................................................................................................................. 391
30 17. C o m p l i c a t i o n s ................................................................................................................................................................................ 392
30 18. F u t u r e 3 9 2
Refe rences ........................................................................... ~. ........................................................................................................................... 393
Chapter 31 Hepat ic C h e m o e m b o l i z a t i o n (Paul Tait) ............................................................................................................................................ 397
31.1. I n t r o d u c t i o n ........................................................................................................................................................................................ 397
31.2. Theore t i ca l Aspects ......................................................................................................................................................................... 398
31.3. Pat ient Se lec t ion ............................................................................................................................................................................... 398
31.4. T e c h n i q u e ............................................................................................................................................................................................ 399
31.5. Post P r o c e d u r e .................................................................................................................................................................................. 403
31.6. Compl i ca t i ons ....................................................................................................................................................................... ........... .. 404
31.7. C o n c l u s i o n 4 0 5
Refe rences ........................................................................................................................................................................................................ 406
Chapter 32 Select ive In te rna l Radia t ion T h e r a p y (SIRT) in the M a n a g e m e n t of Liver T u m o u r s ........................................... i ........... 409
32a. Select ive In terna l Radia t ion t h e r a p y (A. A1-Nahhas, T. Szyszko, P. Tait, O. Damrah , R. Cane lo) ................... 409
32a. 1. I n t r o d u c t i o n ........................................................................................................................................................................ 409
32a.2. Select ive In te rna l Radia t ion T h e r a p y ....................................................................................................................... 410
32a.3. Ind ica t ions for SIR-Spheres T h e r a p y ....................................................................................................................... 410
32a.4. Con t r a ind i ca t i ons ........................................................................................................................................................... .. 411
32a.5. Pat ient Se lec t ion ............................................................................................................................................................... 411
32a.6. Diagnos t ic A n g i o g r a p h y ................................................................................................................................................ 411
32a.7. Asses smen t of H e p a t o p u l m o n a r y Shunt ................................................................................................................. 412
32a.8. Dose Calcula t ion and De l ive ry ................................................................................................................................... 412
32a.9. Adver se React ions ..................................................................................................... .- ...................................................... 413
xx iv Contents
32a. 10. Clinical Experience with SIRT .................................................................................................................................... 414
32a. 11. Follow up after 9°y-mic rosphere Therapy ............................................................................................................ 415
32a.12. Conclusion .......................................................................................................................................................................... 417
R e f e r e n c e s 4 1 7
32b. The Use of Sirtex in Inoperable Liver Tumours. A Surgeon's View
(D. Zacharoulis, N.A. Habib, R. Jiao) ......................................................................................................................................... 419
32b. 1. In t roduct ion .......................................................................................................................................................................... 419
32b.2. Results ...................................................................................................................................................................................... 420
References ........................................................................................................................................................................................................ 420
Chapter 33 Radiofrequency Ablation (RFA) of Liver Tumours ......................................................................................................................... 421
33a. Basics of Radiofrequency Tissue Ablation (L.R. Jiao, D. Zacharoulis, N.A. Habib) ................................................ 421
33a.1. In t roduct ion .......................................................................................................................................................................... 421
33a.2. Indications for Radiofrequency Ablation of Primary and Metastatic Liver Cancer ................................ 421
References ........................................................................................................................................................................................................ 422
33b. Radiofrequency Ablation of Liver Colorectal Metastases
(J. Tracey, J. Dimarakis, D. Zacharoulis, J. Anderson, P. Tait, L. Jiao, N. Habib) .................................................. 423
33b.3. Background ....................................................................................................................................................................... 423
33b.4. In t roduct ion ...................................................................................................................................................................... 423
33b.5. Basic Science of Radiofrequency Ablation .......................................................................................................... 423
33b.6. Colorectal Carcinoma ................................................................................................................................................... 425
33b.7. Lung Metastasis ............................................................................................................................................................... 427
33b.8. Liver and Lung Metastases .......................................................................................................................................... 427
33b.9. Improving Local Ablation Efficacy ......................................................................................................................... 428
33b.10. Complicat ions .................................................................................................................................................................. 428
33b.11. Local Recurrence ............................................ i ............................................................................................................... 429
33b.12. Technical Recommenda t ions .................................................................................................................................... 429
33b.13. Poor Prognostic Indicators ......................................................................................................................................... 429
33b.14. Conclusion ......................................................................................................................................................................... 429
References ........................................................................................................................................................................................................ 429
Chapter 34 Stem Cell Therapy in Liver Disease (M. Pai, N.A. Habib) ............................................................................................................ 433
34.1. In t roduct ion - Incidence ............................................................................................................................................................... 433
34.2. Causes .................................................................................................................................................................................................... 433
34.3. Current Trea tment and Recent Advances .............................................................................................................................. 433
34.. 4. General Concepts about Stem Cells .......................................................................................................................................... 434
34.5. Stem Cell Plasticity ................................................................................................................................................................... . ...... 436
34.6. Liver and Stem Cells ....................................................................................................................................................................... 436
References ........................................................................................................................................................................................................ 438
Chapter 3 5 Liver Gene Therapy: Will Gene Therapy Deliver to the Liver Patient? (N. Levicar, L. Jiao, Ph. Bachellier,
D. Zaharoulis, D. Jaeck, S. Helmy, H.Salama, J. Nicholls, S. Jensen, N.A. Habib) ............................................................. 441
Contents x x v
35.1. Introduct ion ........................................................................................................................................................................................ 441
35.2. Gene Therapy Vectors .................................................................................................................................................................... 443
35.3. Gene Therapy for Liver Tumours .............................................................................................................................................. 444
35.4. Gene Therapy for Hepatitis B and C ........................................................................................................................................ 446
35.5. Gene Therapy for Liver Cirrhosis .............................................................................................................................................. 446
References ........................................................................................................................................................................................................ 447
Chapter 36 Liver Trauma (Con. Vagianos, D.A. Tsiftsis, D. Siablis) ................................................................................................................ 451
36.1. In t roduct ion ..................................................................................................................................................................................... 451
36.2. Historical Evolution ...................................................................................................................................................................... 451
36.3. Anatomy of the Liver and Physiology of Liver Injury .................................................................................................... 451
36.4. Classification .................................................................................................................................................................................... 452
36.5. Diagnosis ........................................................................................................................................................................................... 457
36.7. Decision Making ............................................................................................................................................................................ 457
36.8. Non-Surgical Management ........................................................................................................................................................ 458
36.9. Opera t ive Management .............................................................................................................................................................. 461
36.10. Conclusion ........................................................................................................................................................................................ 466
References ........................................................................................................................................................................................................ 466
Chapter 37 Hydatid Cyst of the Liver (S. Lanitis, G. Sgourakis, Con. Ch. Karaliotas) ............................................................................. 471
37.1. In t roduc t ion - Life-Cycle, Species, Distribution ............................................................................................................... 471
37.2. Anatomy of the Paras i te- Egg .................................................................................................................................................. 472
37.3. Lodging in the Liver-Cyst Structure and Ferti l i ty-Daughter Cyst - Secondary Cyst .......................................... 472
37.4. Clinical Presentat ion .................................................................................................................................................................... 473
37.5. Diagnosis ........................................................................................................................................................................................... 473
37.6. Classification .................................................................................................................................................................................... 474
37.7. Trea tment of Liver Hydat id Cyst ............................................................................................................................................ 474
37.8. Surgical Managemen t /Genera l Principles ........................................................................................................................... 475
37.9. Radical Approach ........................................................................................................................................................................... 475
37.10. Conservat ive Approach ...............
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