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Hepatic Transplantation

Liver transplantation has now been the accepted standard of care for the treatment of end-stage liver disease and related conditions for more than 25 years. Although it was in 1963 that Thomas Starzl and his team performed the first successful human liver transplant, it was not until 1967 that the first 1-year survival was celebrated. Indeed, acceptable and reliable outcomes came significantly later. Starzl and others…

Ablative Therapies for Hepatic Neoplasms

The liver is a common site for both primary and metastatic oncologic disease. Primary hepatocellular carcinoma (HCC) has an annual incidence of 6 per 100,000 in the United States. Worldwide HCC is the second leading cause of cancer-related death in men and sixth leading cause in women. Furthermore, the worldwide incidence and number of deaths per year for HCC are nearly identical, highlighting the aggressive nature…

Minimally Invasive Techniques of Hepatic Resection

The field of hepatobiliary surgery has evolved dramatically in the past few decades, with improved understanding of the anatomic segments of the liver, advancements in modern imaging techniques, better operative instrumentation, and improved anesthesia care, as well as postoperative management. At the same time, minimally invasive surgery has become an integral part of each surgical subspecialty. However, the application of minimally invasive techniques to liver surgery…

Diagnostic Operation of the Liver and Techniques of Hepatic Resection

Liver Biopsy Percutaneous and Transjugular Liver Biopsy Liver biopsy was originally described by Ehrlich in 1883 to determine glycogen stores in patients with diabetes. A variety of approaches and techniques have been described for performing liver biopsy, including percutaneous, transjugular, laparoscopic, and open techniques. For focal lesions, percutaneous liver biopsies are often conducted under image guidance either with the use of ultrasound, computed tomography (CT), or…

Management of Hepatobiliary Trauma

Despite improvements in motor vehicle safety and altered patterns in trauma epidemiology over the past 20 years, the liver remains the most commonly injured intraabdominal organ. While the treatment of hepatic injuries has evolved over the past 100 years, areas of controversy remain. Improved resuscitation strategies, critical care, and abdominal imaging modalities have placed the primary focus of the surgeon on selection of appropriate patients for…

Liver Abscess

Liver abscess is an uncommon entity that over the past 100 years has seen fairly dramatic changes in demographics, etiology, diagnosis, and treatment. Although the mortality from liver abscess has decreased significantly since the early 20th century, the incidence appears to be increasing. Traditionally, it has been useful to think of hepatic abscesses in two broad categories: those of bacterial origin, otherwise known as pyogenic liver…

Hepatic Cysts

Hepatic cysts are a diverse group of lesions, ranging from developmental to infectious to neoplastic in etiology. The clinical implications of these lesions also vary widely. The increased use and sensitivity of abdominal imaging have led to the increasingly common incidental diagnosis of cystic lesions of the liver. The majority of these are simple cysts, usually of little clinical consequence. In contrast, echinococcal cysts remain a…

Perioperative Management and Nutritional Support in Patients With Liver and Biliary Tract Disease

Even the most straightforward surgical procedure can become exceptionally challenging when performed on a patient with an underlying hepatobiliary disorder. Hepatic dysfunction, as manifest by portal hypertension, synthetic impairment, and cholestasis may be present to varying degrees, and can have a profound influence on the physiology of other organ systems. Depending on the severity of the underlying dysfunction and the nature of the operation, even seemingly…

Laboratory Measurement of Hepatic Function

Liver function tests or a hepatic function panel consists of serum biochemical tests that include serum albumin, bilirubin, alkaline phosphatase, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). These terms, however, are misleading because only the serum albumin truly measures the liver's synthetic function. Hence this group of tests is better named as liver chemistry tests . Elevations in liver chemistry tests usually reflect pathology in the…

Anatomy and Physiology of the Liver

Our understanding of functional surgical hepatic anatomy evolved significantly through technical advances in repair of hepatobiliary injury, liver transplantation, hepatic resection, and radiologically guided intervention. This evolution was essential to the development of live-donor and deceased-donor segmental liver transplantation. Molmenti described this reconception of hepatic anatomy as derived from an anatomic-physiologic inside-out approach, as opposed to the purely topographic outside-in view of the past ( Fig.…

Surgical Treatment of Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is a chronic, cholestatic liver disease of unknown cause characterized by diffuse inflammation and fibrosis of intrahepatic and/or extrahepatic bile ducts and is strongly associated with inflammatory bowel disease (IBD). PSC is ultimately progressive, leading to obliteration of the biliary tree and subsequently to biliary cirrhosis. To date, the etiology of PSC remains unknown and effective medical therapy is not currently available.…

Cystic Disorders of the Bile Ducts

Classification of Cystic Disorders of the Bile Ducts In 1959 Alonso-Lej first classified extrahepatic bile duct cystic dilatation into the following three types: type I is congenital cystic dilatation of the common bile duct in which the intrahepatic tree is usually normal; type II is congenital diverticulum of the common bile duct and is extremely rare; type III is choledochocele, a cystic dilatation of the distal…

Biliary Atresia and Biliary Hypoplasia

Biliary atresia is a disease characterized by progressive obliterative destruction of intrahepatic and extrahepatic biliary structures. It is the most common cause of direct hyperbilirubinemia in infancy and must be quickly and effectively differentiated from the numerous other causes of jaundice. Early surgical intervention and appropriate postoperative medical management are necessary to prolong native liver function. Ultimately liver transplantation is required in most cases. However, the…

Operative Management of Bile Duct Strictures

Bile duct strictures can result from a myriad of conditions, both benign and malignant. These strictures represent a significant clinical problem and if not managed correctly can result in major morbidity, both short and long term, and possible mortality. Complications of untreated or improperly treated strictures include cholangitis, biliary cirrhosis, portal hypertension, and end-stage liver disease. The goal of treatment is to reestablish unobstructed biliary flow…

Prevention and Management of Bile Duct Injury

Bile duct injuries most commonly occur after primary operations on the gallbladder or biliary tree. Biliary injuries themselves are also among the most difficult challenges that a surgeon will face. Although numerous technologic developments have facilitated diagnosis and management, bile duct injuries remain a significant clinical problem. If they go unrecognized or are managed improperly, life-threatening early complications such as sepsis and multisystem organ failure or…

Biliary Tract Tumors

Benign Gallbladder Tumors Benign tumors of the gallbladder are relatively common, with up to 5% of patients undergoing abdominal ultrasonography being found to harbor gallbladder polyps. Benign gallbladder tumors can be broadly categorized as epithelial (adenomas), mesenchymal (fibromas, lipomas, hemangiomas), or as pseudotumors (cholesterol polyps, inflammatory polyps, and adenomyomas). Cholesterol polyps are the most common of the benign tumors, accounting for approximately 60% of all gallbladder…

Endoscopic Evaluation and Management of Pancreaticobiliary Disease

Since the first endoscopic visualization and cannulation of the major papilla with cholangiopancreatogram was completed in 1968, rapid advances in the field of endoscopy have increased the capabilities of physicians to detect, classify, and more recently, provide therapy to disease involving the pancreaticobiliary system. The development of side-viewing endoscopes and introduction of endoscopic sphincterotomy (ES) permitted less invasive diagnostic and therapeutic maneuvers in the pancreatic and…

Biliary Dyskinesia and Sphincter of Oddi Dysfunction

Biliary dyskinesia and sphincter of Oddi dysfunction (SOD) are functional disorders of the pancreas and biliary tract that challenge the practicing surgeon. Both disease entities are characterized by pancreatobiliary pain syndromes and are fraught with controversy over their definition, diagnosis, and management. In addition, both disorders have been the subject of recent important study, potentially affecting management. Biliary Dyskinesia Acalculous gallbladder disease has been recognized by…

Management of Common Bile Duct Stones

Choledocholithiasis is a common condition that often requires a procedural intervention in order to treat. There are a number of different treatment strategies used when managing patients who present with common bile duct (CBD) stones. As such, the debate about the optimal management of patients with choledocholithiasis has persisted for many years. The currently available options include surgical intervention, most commonly with laparoscopic common bile duct…

Operative Management of Cholecystitis and Cholelithiasis

With an annual rate of greater than a quarter of a million hospital admissions and an associated cost of greater than two billion dollars, cholelithiasis and cholecystitis have a tremendous impact on the health care system. Their diagnosis and associated symptoms are one of the most common reasons for clinic visits and the second most common reason for gastrointestinal-related hospital admissions in the United States. Minimally…