Hepatobiliary Pancreatic Surgery

Hepatobiliary Pancreatic surgery is established as a subspecialty of Surgical Gastroenterology, especially with the growth of liver transplantation. Good results in complex hepatobiliary pancreatic surgery are dependent not only on expert surgical skills, but also on an experienced multidisciplinary team of specialists working together to ensure the best outcome for the patient. The process begins preoperatively with diagnosis and staging of disease and planning extent of resection with high resolution, multislice, 4-phase contrast enhanced CT angiography and liver volumetry. Intraoperatively, low central venous pressure anesthesia reduces blood loss during liver parenchymal transection thereby avoiding blood transfusions. The use of technically advanced equipment for transection such as Hydrojet (ERBE) and CUSA has enabled precise dissection reducing intraoperative blood loss and the incidence of postoperative bleeding or bile leakage. The process of ERAS continues into the postoperative period with liberal use of epidural analgesia to manage pain and facilitate early ambulation with emphasis on early resumption of oral intake.

The development of technology and multidisciplinary team approach has enabled us to undertake complex resections in patients with early cirrhosis. Tumor ablation using Radiofrequency and Microwave energy (RFA and MWA) is another addition to our armamentarium in the management of liver tumors in cirrhotic patients. It is performed as a standalone procedure in patients with small lesions (<3 cm) or in patients who are not fit to undergo surgery or transplantation. It is also used as an adjunct to surgery in patients with multiple tumors in both lobes of the liver.

Trans Arterial Chemo Embolization (TACE) or Trans Arterial Radio Embolization (TARE) is another technique that involves superselective infusion of chemotherapeutic drugs or radiation in close proximity to the tumor thereby avoiding systemic side effects from these agents. They are used in patients with large tumors as an adjunct to reduce tumor size (downstaging) prior to surgery or transplant or with a palliative intent in patients not fit for surgery.

1. Liver cysts

2. Traumatic liver injury

3. Liver abscess

4. Liver cancer (Primary and metastatic)

5. Liver cirrhosis

6. Fatty liver

Gallbladder cancers and Cholangiocarcinomas are tumors arising from the gallbladder or bile ducts. They may cause jaundice due to narrowing of the bile duct. Preoperative biliary drainage by endoscopy (ERCP) or percutaneous route (PBD) prior to surgery, is used to restore flow of bile and reduce jaundice making it safer to perform major liver resection. For patients where the volume of liver left behind after surgery is <30%, preoperative portal vein embolization is used to cause hypertrophy (increase in size) of the future remnant liver enabling a safe resection and avoiding post hepatectomy liver failure. Our experience in handling small bile ducts in the living donor liver transplant setting makes us comfortable offering surgery in patients with bile duct cancers and strictures where small segmental ducts need to be anastomosed. Stenting of biliary or bilioenteric anastomoses is no longer performed, thereby reducing postoperative morbidity.

Gallbladder and biliary tract diseases treated at ILC

1. Gallstones

2. Bile duct stones

3. Choledochal cyst

4. Gallbladder cancer

5. Cholangiocarcinoma or bile duct cancer

6. Jaundice

Pancreatic cancer is an aggressive disease associated with high morbidity and mortality. Tumors can originate in the head or body/tail region of the pancreas. Tumors in the head present with jaundice early in the course of their disease due to blockage of the lower end of bile duct. A Whipple’s pancreatoduodenectomy is performed to remove the tumor along with the areas it can potentially spread to including lymphatic ducts, lymph nodes and nerves. In patients with locally advanced or borderline resectable cancer, preoperative chemotherapy is given to shrink the tumor and render it suitable for resection. For lesions located in the body or tail region, a distal pancreatectomy is performed. For low grade cancers such as IPMN, a spleen preserving distal pancreatectomy can be performed rather than the conventional pancreatosplenectomy, thereby preserving immune function of the spleen.

Pancreatic diseases treated at ILC

1. Acute pancreatitis

2. Pseudocyst

3. Infected pancreatic necrosis

4. Chronic pancreatitis

5. Pancreatic cancer

6. Cystic tumors of the pancreas