surgery of the liver including transplantation
DESCRIPTION
Surgery of the liverTRANSCRIPT
![Page 1: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/1.jpg)
Surgery of the liver including transplantation
Prof Dr Dr Ernst HanischDirector
Department of Surgery
Asklepios Hospital LangenAffiliated Teaching Hospital University of Frankfurt/Main
![Page 2: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/2.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:783-785
Mangement of major abdominal trauma
![Page 3: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/3.jpg)
Clinical features of serious liver injury Hypovolaemic shock Hypotension Tachycardia Decreased urine outpu Low central venous pressure Abdominal distension
![Page 4: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/4.jpg)
Criteria for non-operative management of liver injuries Haemodynamically stable following
resuscitation No persistent or increasing
abdominal pain or tenderness No other peritoneal injuries that
require laparotomy <4 units of blood transfusion
required
![Page 5: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/5.jpg)
Indications for laparotomy Stab or gunshot wounds that have
penetrated the abdomen Signs of peritonitis Unexplained shock Evisceration Uncontrolled haemorrhage Clinical deterioration during
observation
![Page 6: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/6.jpg)
Liver Trauma – Surgical management Stop haemorrhage (Pringle) Remove dead or devitalised liver
tissue Ligate or repair damaged blood
vessels and bile ducts
![Page 7: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/7.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:783-785
Stellate fracture of right lobe of the liver
![Page 8: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/8.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:783-785
Packing of bleeding liver
![Page 9: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/9.jpg)
Postoperative Complications Rebleeding from injury Bile leaks Ischaemic segments of the liver Infected fluid collections
![Page 10: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/10.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:783-785
Large intrahepatic haematoma in patient with blunt trauma
![Page 11: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/11.jpg)
Liver Trauma - Prognosis Overall mortality 10-15 % Mortality after blunt trauma > 20
% If three major organs are injured
mortality approaches 70 %
![Page 12: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/12.jpg)
Pyogenic liver abscess – typical features Right upper quadrant pain and
tenderness Nocturnal fevers and sweats Anorexia and weight Raised right hemidiaphram in
chest radiograph Raised white cell count with mild
anaemia
![Page 13: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/13.jpg)
Origins and causes of pyogenic liver abscess Biliary tract – Gall stones,
cholangiocarcinoma, strictures Portal vein – Appendicitis, diverticulitis,
Crohn‘s disease Direct extension of: Gallbladder empyema Trauma Iatrogenic – Liver biopsy, blocked biliary
stent
![Page 14: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/14.jpg)
Microbiology E. coli, Klebsiella pneumoniae,
bacteroides, enterococci Fungal or opportunistic organisms
due to immunosuppression as a result of AIDS, intensive chemotherapy and transplantation
![Page 15: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/15.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Krige, J E J et al. BMJ 2001;322:537-540
Chest radiograph showing air-fluid level and raised right hemidiaphragm in pyogenic liver abscess
![Page 16: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/16.jpg)
Treatment Antibiotics – Penicillin,
aminoglycoside (or cephalosporin), metronidazole
Treatment for two to four weeks depending on the clinical response
![Page 17: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/17.jpg)
Drainage requirements for liver abscesses None – multiple small abscesses
that respond to antibiotics Percutaneous aspiration –
abscesses <6cm Percutaneous catheter drainage –
abscesses >6cm
![Page 18: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/18.jpg)
Drainage requirements for liver abscesses – Open surgery Failed percutaneous drainage Very large or multilocular
abscesses Associated intra-abdominal
infection requiring surgery such as bile duct stones
![Page 19: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/19.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Krige, J E J et al. BMJ 2001;322:537-540
Computed tomogram showing multifocal liver ascess in segment IV. Note drain in segment VII
![Page 20: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/20.jpg)
Amoebic liver abscess - Epidemiology About 10 % of the world‘s
population is chronically infected with Entamoeba histolytica
Amoebiasis is the third commonest parasitic cause of death, surpassed only by malaria and schistosomiasis
![Page 21: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/21.jpg)
Symptoms of amoebic liver abscess Pain Enlarged liver with maximal tenderness
over abscess Intermittent fever with night sweats Weight loss Nausea Vomiting Cough Dyspnoea
![Page 22: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/22.jpg)
Amoebic liver abscess - Diagnosis Serological tests Stool may contain protozoal cysts Abscess usually solitary – right
lobe in 80% of cases Abscess contains sterile pus and
reddish-brown liquefied necrotic liver tissue
![Page 23: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/23.jpg)
Amoebic abscess - Treatment 95 % resolve with metronidazole
alone (800 mg three times a day for five days)
After the abscess – diloxanide furate 500 mg, eight hourly for seven days to eliminate intestinal amoebae
![Page 24: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/24.jpg)
Amoebic abscess - Surgery Surgical drainage is required only
if the abscess has ruptured causing amoebic peritonitis
![Page 25: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/25.jpg)
Hydatid disease - Presentation Liver enlargement Right upper quadrant pain Rupture of the cyst into the
peritoneal cavity –urticaria, anaphylactic shock, eosinophilia
Erosion into bile duct – jaundice, cholangitis
![Page 26: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/26.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Krige, J E J et al. BMJ 2001;322:537-540
Lifecycle of Echinococcus granulosus
![Page 27: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/27.jpg)
Hydatid disease – Diagnosis Ultrasonography, computed
tomography Serological tests ERCP
![Page 28: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/28.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Krige, J E J et al. BMJ 2001;322:537-540
Computed tomogram showing hydatid cyst: daughter cysts containing hydatid larvae are visible within the main cyst
![Page 29: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/29.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Krige, J E J et al. BMJ 2001;322:537-540
Operative specimen of opened hydatid cyst showing multiple daughter cysts
![Page 30: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/30.jpg)
Hydatid disease – Treatment I Surgery – 1. Aspiration of cysts and
replacement by a scolicidal agent such as 0.5% sodium hypochlorite
Surgery - 2. The cysts are carefully shelled out by peeling the endocyst off the host ectocyst layer along ist cleavage plane
![Page 31: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/31.jpg)
Hydatid disease –Treatment II Bile leakages are sutured The cavity is drained and filled
with omentum Liver resection seldom necessary Albendazole is given for two weeks
postoperatively
![Page 32: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/32.jpg)
Liver tumours Cysts Benign tumours – Haemagiomas,
liver cell adenoma, focal nodular hyperplasia
Malignant tumours – Hepatocellular carcinoma, metastatic tumours
![Page 33: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/33.jpg)
Characteristics of simple cysts Thin walled Contain clear fluid Contain no septa or debris Surrounded by normal liver tissue Usually asymptomatic Present in 1 % of population
![Page 34: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/34.jpg)
Liver cysts Treatment only when symptomatic –
usually laparoscopic cyst fenestration NOTE - Thick walled cysts and those
containing septa, nodules or echogenic fluid may be cystic tumours
Cystic dilatations of the bile ducts (Caroli‘s disease) are premalignant (cholangiocarcinoma)
![Page 35: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/35.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:477-480
Polycystic liver disease
![Page 36: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/36.jpg)
Haemangiomas Incidence 3 % Malignant transformation and
spontaneous rupture are rare Diagnosis by contrast enhanced
computed tomography Resection is indicated only for
large symptomatic tumours
![Page 37: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/37.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:477-480
T2 weighted magnetic resonance image of large benign haemangioma
![Page 38: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/38.jpg)
Liver cell adenoma Predominantly in women of
childbearing age Risk of rupture 10 % Risk of malignant transformation
10 % Liver resection necessary
![Page 39: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/39.jpg)
Focal nodular hyperplasia Usually asymptomatic Not premalignant It does not require treatment
unless symptomatic Sometimes diagnosis difficult to
establish – histology should be determined by surgical resection
![Page 40: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/40.jpg)
Hepatocellular carcinoma Commonest malignant tumour
worldwide One million new cases a year
worldwide 80 % occur with cirrhotic livers Established viral infection – 10 years
to develop chronic hepatitis – 20 years to develop cirrhosis – 30 years to develop carcinoma
![Page 41: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/41.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:477-480
Distribution of hepatocellular carcinoma
![Page 42: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/42.jpg)
Hepatocellular carcinoma Ultrasonography Alpha fetoprotein >500 ng/ml Surgical resection feasible in less
than 20 % of patients Average operative mortality is 12
% in cirrhotic patients 5-year survival 15 %
![Page 43: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/43.jpg)
Hepatocellular carcinoma <5 cm tumours – LTX Contraindication to LTX – alcohol
injection, radiofrequency ablation Larger tumours – transarterial
embolisation with lipiodol and cytotoxic drugs (cisplatin or doxorubicin)
![Page 44: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/44.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:477-480
Large hepatocellular carcinoma
![Page 45: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/45.jpg)
Colorectal liver metastasis 8-10 % of patients undergoing
curative resection of colorectal tumours have isolated liver metastasis suitable for liver resection
5-year survival after resection 30 %
![Page 46: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/46.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:477-480
Solitary liver metastasis in segment IV
![Page 47: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/47.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:477-480
Inoperable extensive liver metastasis
![Page 48: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/48.jpg)
Liver resection A fit patient with a healthy liver will
regenerate a 75 % resection within three months
Segmental anatomy with each of the eight segments supplied by ist own branch of the hepatic artery, portal vein and bile ducts (Couinaud 1957)
Mortality 5 %
![Page 49: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/49.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:477-480
Couinaud’s segmental anatomy of the liver
![Page 50: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/50.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Beckingham, I J et al. BMJ 2001;322:477-480
Intraoperative view after left hepatectomy – raw surfaces of liver are coated with fibrin glue after resection to aid hemostasis and
prevent small bile leaks
![Page 51: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/51.jpg)
Liver transplantation - Indications Primary biliary cirrhosis Primary sclerosing cholangitis Cryptogenic cirrhosis Chronic active hepatitis (Hep B and
C) Alcoholic liver disease (after a
period of abstinence)
![Page 52: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/52.jpg)
Timing of LTX – Signs of decompensations Tiredness, Ascites, Encephalopathy Peripheral oedema Jaundice Spontaneous bacterial peritonitis Bleeding oesophageal varices Low albumin concentration Raised prothrombin time
![Page 53: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/53.jpg)
Acute liver failure – Paracetamol overdose Renal failure develops as a
hepatorenal syndrome Early deaths result from raised
intracranial pressure Death in later stages – multiorgan
failure and systemic sepsis Mortality from fulminant liver
failure can be as high as 90 %
![Page 54: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/54.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Prasad, K R et al. BMJ 2001;322:845-847
Implantation of liver transplantation after hepatectomy
![Page 55: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/55.jpg)
Immunosuppressive drugs Cyclosporin Tacrolimus Azothioprine Mycohenolate mofetil Steroids
![Page 56: Surgery of the liver including transplantation](https://reader033.vdocuments.mx/reader033/viewer/2022061105/543e0dc4b1af9f272b8b45ff/html5/thumbnails/56.jpg)
Copyright ©2001 BMJ Publishing Group Ltd.
Prasad, K R et al. BMJ 2001;322:845-847
One year survival after first liver transplant according to primary disease, UK 1985-94