Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Techniques of liver replacement

Historic overview The multiple steps by which liver replacement became the treatment of choice for several liver and biliary diseases were summarized in 2002. , The basic operation was developed in dogs during the years 1958 through 1960 and first attempted clinically in 1963 under azathioprine-prednisone immunosuppression. The first humans to have prolonged survival were reported in 1969. However, it was not until the availability of…

Ex vivo and in situ hypothermic hepatic resection

Liver surgery techniques and liver imaging are constantly evolving, allowing for ever more detailed planning of surgical strategy and complex liver resections. The development of living-donor liver transplantation (LDLT; see Chapter 121 ) has led to a comfort and familiarity with a variety of techniques that are immediately applicable to complex, nontransplant liver surgery. The same techniques that are routinely used in LDLT, such as resection…

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): Techniques

Background The liver’s amazing capacity to regenerate is unique in the human body and has captivated mankind since ancient civilizations, as in the Greek myths of the giant villain Tityus and the heroic Titan Prometheus (see Introduction). Twenty-seven centuries later, physicians have achieved the ability to use and manipulate such regenerative capacity, not to torture as it was lucubrated in the past, but to treat and…

Vascular reconstruction techniques in hepato-pancreato-biliary (HPB) surgery

Over the three last decades, advances in liver surgery have included extensive experience in living and deceased donor-liver transplantation (see Chapters 105 and 125 ), induction of liver hypertrophy by interventional radiology (portal vein embolization and radioembolization) (see Chapters 94B and 102C ) or surgical techniques (associating liver partition and portal vein ligation for staged hepatectomy) (see Chapter 102D ), and increased use of neoadjuvant chemotherapeutic…

Resection technique for live donor transplantation

Living-donor hepatectomy is a major surgical operation performed on a healthy person only for the benefit of a recipient who requires liver transplantation (see Chapters 105 , 125 , and 128 ). In 1989 Strong (1999) performed donor left hepatectomy and removed segment IV of the liver on the back table before implantation of segments II and III into a pediatric recipient. In 1990 Tanaka et…

Hepatic resection in cirrhosis

Introduction Local tumor control is still the most important consideration in the treatment of hepatocellular carcinoma (HCC), which is the most common diagnosis associated with hepatic resection in the setting of cirrhosis. Because liver resection can completely remove cancerous tissues, it is theoretically regarded as a curative treatment for HCC (see Chapter 89 ). Patients with HCC often have injured liver tissue or cirrhosis ( Fig.…

Hilar cholangiocarcinoma: Standard and extended resections of perihilar cholangiocarcinoma

Overview Perihilar cholangiocarcinoma , is a devastating disease because the majority of patients are diagnosed with advanced disease at initial presentation. At the present time, surgical resection offers the only possibility of cure for this disease, and achieving tumor-free surgical margins is one of the main goals of resection. Hilar bile duct resection with or without limited hepatectomy has been performed previously but is likely to…

Hepatic resection for biliary tract cancer: Gallbladder cancer

Introduction Although gallbladder cancer is rare, accounting for just 1.2% of all global cancers, it is the most common biliary tract malignancy, making up 80% to 95% of all biliary cancer diagnoses (see Chapter 49 ). Gallbladder cancer occurs most often in patients in their fifth decade of life and has a significant female predominance, with females affected 3 to 4 times as often as males.…

Segmental resection

Introduction Liver resection plays an increasingly important role in the management of benign as well as primary and metastatic liver tumors (see Chapters 50 , 51B , 88 , 89 , and Chapter 90, Chapter 91, Chapter 92, Chapter 93 ). Historically, the high morbidity and mortality of liver resections limited their use. However, over time, the morbidity and mortality of liver resections have decreased due…

Major hepatectomy and extended hepatectomy

Introduction Major hepatectomy is typically defined as a resection of three or more contiguous hepatic segments. Most commonly, this definition encompasses right and left hemihepatectomies and extended left and right hepatectomies. Extended hemihepatectomies can include a small subsegmental portion of the adjacent parenchyma or a more formal “trisectionectomy” where the adjacent segments (i.e., segment IV for a right sided resection, or segments V/VIII for a left…

Transduodenal resection of the papilla of vater

Introduction First described by Samuel Collins in 1685 and later by Abraham Vater in 1720, the ampulla of Vater is a papillary structure in the second portion of the duodenum in which the common bile duct and the pancreatic duct converge just before draining into the duodenal lumen ( Fig. 117D.1 ; see Chapter 2 ). The most common benign neoplasms of the ampulla of Vater…

Total pancreatectomy

Introduction Total pancreatectomy is associated with significant metabolic consequences secondary to the loss of exocrine and endocrine function. Resultant brittle type III diabetes can be difficult to manage and result in severe recurrent hypoglycemia in some patients. Outcomes after total pancreatectomy for pancreatic adenocarcinoma (PDAC) are particularly poor, and this operation is rarely indicated in this setting. More appropriate indications include chronic, recurrent acute, or hereditary…

Distal and central pancreatectomy

Open central (segmental) pancreatectomy is also described in detail and remains an alternative for benign, indolent, or premalignant lesions in the pancreatic neck, when an enucleation is not feasible and a lymphadenectomy not required. This technique preserves normal pancreatic tissue and function and does not include a splenectomy but requires two planes of transection in the pancreas, leading to potential for increased morbidity. We advocate stapled…

Pancreaticoduodenectomy

Operative approach Pancreaticoduodenectomy (PD) is one of the few remaining operations where major morbidity rates hover in the range of 25% and the 90-day mortality rate remains in the 2% to 4% range, even under the care of the highest-volume surgeons at the highest-volume centers. This chapter will describe an approach to the exploration, resection, and reconstruction of patients undergoing PD with the understanding that multiple…

Hemobilia and bilhemia

Introduction Hemobilia and bilhemia are clinical phenomena that arise from admixing of blood and bile due to anomalous connection between the bloodstream and biliary tract. In general terms, a fistula between the hepatic arterial supply and the bile ducts can lead to blood invading the biliary tree, leading to hemobilia. Similarly, aberrant connection between the biliary tract and the portal or hepatic venous supply can result…

Aneurysm and arteriovenous fistula of the liver and pancreatic vasculature

Introduction A wide variety of lesions may affect the liver and pancreatic vasculature. These lesions range from common to exceedingly rare, and they can be acquired or congenital. Some are harmless, whereas others have a high risk of causing morbidity and mortality. In this chapter, we discuss splanchnic artery aneurysms and pseudoaneurysms, arterioportal fistula (APF), hemangiomas, portal vein (PV) anomalies and aneurysms, congenital portosystemic shunts (CPS),…

Pancreatic and duodenal injuries

Introduction Injuries to the pancreas and the duodenum are some of the most feared injuries in trauma. Because of the location of the pancreatoduodenal complex (PDC) and the surrounding structures, even simple injuries are complicated and have the potential of major long-term consequences (see Chapter 2 ). In this chapter, we will review the history of pancreatic and duodenal injuries, as well as current recommendations for…

Injuries to the liver and biliary tract

Introduction The majority of hepatobiliary injuries are managed nonoperatively, supported by tenets of patient selection, appropriately timed adjunct interventions, and careful monitoring. The liver is a well-vascularized solid organ (see Chapter 5 ), making hemorrhage a common cause of mortality in severe trauma. Therefore, in hemodynamically unstable patients or clinically deteriorating patients, timely surgical intervention for hemorrhage control is critical. Hepatobiliary injuries associated with blunt and…

Whole organ pancreas and pancreatic islet transplantation

Type 1 diabetes mellitus (DM), formerly known as “juvenile diabetes,” is characterized by hyperglycemia resulting from the nearly complete destruction of insulin-producing β-cells of the pancreatic islets of Langerhans. The loss of β-cells is the result of a T lymphocyte–mediated autoimmune attack that typically occurs during childhood or early adolescence. Insulin replacement can lead to acceptable control of blood glucose levels; however, affected individuals are subject…

Early and late complications of liver transplantation

Liver transplantation (LT) has evolved from a high-risk procedure with significant morbidity and mortality to a standard treatment for patients with liver failure. Patients who undergo successful liver replacement have 1-year and 5-year survival rates that exceed 85% and 70%, respectively (see Chapter 105, Chapter 106, Chapter 107, Chapter 108, Chapter 109, Chapter 110 ). Despite this dramatic improvement in outcome, a significant percentage of patients…