What is hepatobiliary surgery?
The hepato-bilio-pancreatic area is an anatomical and functional area comprising the liver, pancreas, gallbladder and bile ducts, as well as the duodenum. It is a vital area for the functioning of the body but its anatomy is complex and sometimes its anatomical evaluation by radiological and endoscopic tests is difficult. Hepatobiliary surgery is a subspecialty within General and Digestive Surgery.
Hepatobiliary surgery deals with pathologies of the liver, gallbladder and biliary tract, as well as the pancreas.
Why is it performed?
Hepatobiliary surgery is performed to surgically address pathologies affecting the liver, biliary tract and pancreas. It can be used in:
Liver:
- Liver tumors, primary and metastatic. Surgery for primary liver cancer or hepatocarcinoma or cholangiocarcinoma are tumors that usually appear in diseased or cirrhotic livers, although they can also appear in healthy livers. The functional hepatic situation of each patient will determine the treatment to be performed, ranging from surgery to liver transplantation or local treatments such as radiofrequency. Benign liver tumors may also have an indication for surgery, as is the case of adenomas, whose surgery may be indicated due to the risk of malignancy when their size exceeds 5 cm. The evaluation by an expert surgeon is fundamental to establish the correct treatment strategy.
- Liver metastases. Secondary liver tumors or metastases can be operated, integrating it in the context of the global treatment of the primary tumor causing the metastasis. Colon cancer metastases are the most susceptible to surgery. The most frequent cause of liver resection in developed countries is liver metastasis from colorectal cancer. It is estimated that 50% of patients with colorectal cancer will have liver metastases at some point during the course of the disease. Of these, 30% may benefit from surgical treatment.
- Cysts in the liver. Sometimes cysts in the liver require removal, either because of their size, their clinical manifestations, their growth or suspicion of malignancy. Thanks to laparoscopic/robotic techniques surgery is usually minimally invasive.
Gallbladder:
- Laparoscopic surgery of biliary lithiasis.
- Surgery of bile duct tumors. Tumors of the biliary tract and gallbladder are of great complexity, although they are rare. Their removal will require a highly specialized team.
Pancreas:
- Pancreatic cancer surgery. Pancreatic cancer surgery almost always requires total or partial removal of the pancreas. It is a very complex technique, so it must also be performed by a team dedicated to this pathology that performs a minimum number of pancreatic surgeries per year (25) and, therefore, ensures acceptable results in this complex surgery.
- Treatment of pancreatitis. Acute/chronic pancreatitis may require different specialists for its treatment, ranging from gallbladder surgery to pancreas surgery, biliodigestive by-pass or drainage of collections.
- Surgery of endocrine tumors in the pancreas. They are usually treated with surgery, in some cases with partial exeresis of the pancreas.
What does it consist of?
There are various techniques used in hepatobiliary surgery, depending on the pathology suffered by the patient and the extent of the lesion in the liver, gallbladder or pancreas.
Currently, 80% of hepatobiliopancreatic surgeries are performed by minimally invasive surgery, so there is less postoperative pain, less blood loss and shorter hospital stay.
Surgical resection of liver metastases can be performed safely in most patients, with a very low postoperative mortality of 0.2 to 3.5%. Resection in cases of liver metastases will be indicated when integrated into a curative strategy that will require oncologic surgery of the primary tumor and staging to rule out distant disease.
Resection can be:
- Resection of the primary tumor followed by perioperative chemotherapy and subsequent resection of the liver metastasis.
- Simultaneous (or sequential) resection of the primary tumor and liver metastases. Adjuvant chemotherapy will be administered after surgery.
- Neoadjuvant chemotherapy and then simultaneous or sequential resection of the tumor and metastases. If the liver tumor is very important and the primary tumor does not produce symptoms, sequential surgical treatment by liver surgery can be initiated.
Surgery remains the treatment of choice for cancer treatment. However, there are other types of treatment if there are other liver pathologies or if the patient’s situation does not allow surgery:
- Limited hepatectomy: recommended in patients with a diseased liver or compensated cirrhosis whose liver function allows surgery to be supported.
- Liver transplantation: indicated in patients with advanced liver disease or metastases / unresectable tumors and without contraindications to receive the transplant.
- Image-guided tumor destruction. Currently, radiofrequency is recommended for tumors up to 5cm, since its effectiveness decreases with the size of the lesion. It is very useful in tumors up to 2cm. Multifocal tumors can also be used when transplantation is not indicated or as a bridge treatment to transplantation.
Preparation for hepatobiliary surgery
The specialist in General and Digestive Surgery will recommend to the patient which procedures to follow before undergoing any surgery of the liver, gallbladder, biliary tract and pancreas. It is very likely that MRI, PET, blood tests, X-rays and even biopsies will be necessary to know the extent and size of the lesion, as well as exactly which areas are affected.
Care after the operation
Hepatobiliary surgery is performed on vital, very delicate areas and organs, so the patient may have to rest after the interventions. This will be especially important when open surgery or large tumor resections are performed. If the technique used by the specialist is laparoscopy, the rest may be less. In any case, it will be the specialist who will recommend what care to follow and what medication to take in case of discomfort.
Alternatives to this treatment
There is no specific alternative to hepatobiliary surgery. There are different techniques and interventions. The use of one or the other will depend on the extent of the lesion and the involvement of the organ itself and the neighboring organs, as well as their function.