Advances in Hepatobiliary SurgeryAdvances in Hepatobiliary Surgery

Jack Matyas, MD, FACS

&

Keith Nichols, MD, FACS

Presenting SymptomsPresenting Symptoms

• Jaundice

• Weight Loss

• Pruritus

• Steatorrhea

• Clay-Colored Stool

Work-up 1980Work-up 1980

Dilated Ducts on Ultrasound

Surgery

80% Unresectable

CT Criterion for ResectabilityCT Criterion for Resectability• Mass < 2cm• No mass• No stone• “Double duct sign”• No enlarged nodes• No ascites• No vessel involvement• No liver lesions

CT Criteria for UnresectabilityCT Criteria for Unresectability

• Absolute– Liver mets – Bx

proven

– Portal vein thrombosis

– SMA or coeliac encasement

– Necrotic lymph nodes – Bx proven

UnresectableUnresectable

• Bypass

• Biliary stent

• 5 FU/XRT– locally advanced

• Gemzar (Gemcitabine) - systemic

CT ScanCT Scan

• Relative contraindications– Ascites

– Loss of portal vein fat plane

– Enlarged L. nodes

– Liver lesions not classic for metastasis

AscitesAscites

• Laparoscopy with cytology and biopsy suspicious lesions

• Omentum - Liver

Liver LesionsLiver Lesions

• CT guided biopsy

• MRI

• Laparoscopy

CT ScanCT Scan

• Relative contraindications– Ascites

– Loss of portal vein fat plane

– Enlarged L. nodes

– Liver lesions not classic for metastasis

SummarySummary

1. Adenocarcinoma involving the distal bile duct continues to have an overall poor prognosis.

2. Through aggressive “high tech” preoperative work-up, a select group of patients will enjoy surgical benefit.

3. High volume institutions like Riverside maintain an acceptable <5% mortality. Low volume institutions have 5-6x greater morbidity and mortality.

4. Transduodenal/Transhepatic wall stents have replaced cumbersome unsatisfactory internal bypass.

Summary (cont.)Summary (cont.)

5. 5FU/XRT provides reasonable palliation for locally advanced tumors avoiding unnecessary laparotomy.

6. Gemcitibine has low toxicity and can provide short term palliation in cases of systemic metastasis.

7. EVS has opened new doors for pre-op staging and better direction for cystic pancreatic neoplasms.

20072007

• History

• Physical

• Ultrasound – dilated vs. non-dilated

• CT scan – pancreatic protocol

• ~ 60% unresectable by CT scan

• 40% further studies

SummarySummary

• 80% of distal bile duct obstructions are surgically incurable

• Technology & proper staging has significantly decreased unnecessary laparoscopy

• Almost all patients that are properly staged undergo definitive surgery

SummarySummary

• High volume institutions like Riverside have an acceptable morality such that even “palliative” whipple provides a good quality of life

• 5 FU/XRT for locally advanced, Gemzar for systemic mets & wall stents are far superior to open biliary bypass.

Enlarged Lymph NodesEnlarged Lymph Nodes

• EV5 endoscopic ultrasound with biopsy

Loss of Portal Vein Fat PlaneLoss of Portal Vein Fat Plane

• EV5

• MRI

• Angiogram with venous phase