Advances in Hepatobiliary Surgery

1. Advances in Hepatobiliary Surgery Jack Matyas, MD, FACS & Keith Nichols, MD, FACS

5. Presenting Symptoms • Jaundice • Weight Loss • Pruritus • Steatorrhea • Clay-Colored Stool

6. Work-up 1980

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

9. CT Criteria for Unresectability • Absolute • Liver mets – Bx proven • Portal vein thrombosis • SMA or coeliac encasement • Necrotic lymph nodes – Bx proven

10. Unresectable • Bypass • Biliary stent • 5 FU/XRT– locally advanced • Gemzar (Gemcitabine) - systemic

11. CT Scan • Relative contraindications • Ascites • Loss of portal vein fat plane • Enlarged L. nodes • Liver lesions not classic for metastasis

12. Ascites • Laparoscopy with cytology and biopsy suspicious lesions • Omentum - Liver

13. Liver Lesions • CT guided biopsy • MRI • Laparoscopy

14. CT Scan • Relative contraindications • Ascites • Loss of portal vein fat plane • Enlarged L. nodes • Liver lesions not classic for metastasis

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19. Summary • Adenocarcinoma involving the distal bile duct continues to have an overall poor prognosis. • Through aggressive “high tech” preoperative work-up, a select group of patients will enjoy surgical benefit. • High volume institutions like Riverside maintain an acceptable <5% mortality. Low volume institutions have 5-6x greater morbidity and mortality. • Transduodenal/Transhepatic wall stents have replaced cumbersome unsatisfactory internal bypass.

20. Summary (cont.) • 5FU/XRT provides reasonable palliation for locally advanced tumors avoiding unnecessary laparotomy. • Gemcitibine has low toxicity and can provide short term palliation in cases of systemic metastasis. • EVS has opened new doors for pre-op staging and better direction for cystic pancreatic neoplasms.

22. 2007 • History • Physical • Ultrasound – dilated vs. non-dilated • CT scan – pancreatic protocol • ~ 60% unresectable by CT scan • 40% further studies

23. Summary • 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

24. Summary • 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.

25. Enlarged Lymph Nodes • EV5 endoscopic ultrasound with biopsy

26. Loss of Portal Vein Fat Plane • EV5 • MRI • Angiogram with venous phase

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