eMentorSurgery

Dear students, This is only for your revision and NOT A FULL TEXT.

Liver

LARGEST VISCERAL ORGAN.

SITUATION : Rt. HYPOCHONDRIUM

DUAL BLOOD SUPPLY

80% PORTAL  VEIN

20%  HEPATIC ARTERY

LOBES OF LIVER

RIGHT. AND LEFT ANATOMICAL

RIGHT AND LEFT SURGICAL

TOTAL 8 SEGMENTS

LIVER  FUNCTION  TESTS

•        BILURIBIN

            DIRECT

            INDIRECT

•        ALKALINE PHOSPHATASE

•        ASPARTATE TRANSAMINASE

•        ALANINE TRANSAMINASE

•        GAMMA-GLUTAMYL TRANSPEPTIDASE

•        ALBUMIN

•        PROTHROMBIN TIME

INVESTIGATIONS -  IMAGING

•        ULTRASOUND ABDOMEN

•        SPIRAL  CT SCAN

•        M.R.I.&M.R.C.P.

•        E.R.C.P.

•        P.T.C.

•        HEPATIC ANGIOGRAPHY

•        RADIO-ISOTOPE SCAN

•        LAPAROCOPY & LAPAROSCOPIC     ULTRASOUND

•        FLUORODEOXYGLUCOSE- POSITION EMISSION TOMOGRAPHY (FDG—PET)

Ultrasound

•        The first-line test owing to its safetyand availability.

•        Useful for determining bile ductdilatation, the presence of gallstones and the presence of liver tumours.

•        Doppler ultrasound allows flow inthe hepatic artery, portal vein and hepatic veins to be assessed.

•         Insome countries - a screening test for the development of primary liver tumours in a high-risk population.

•        Useful in guiding the percutaneous biopsy of a liver lesion and draining the liver abscess(therapeutic).

Computerised tomography (CT)

•        The current ‘gold standard’ for liver imaging is triple-phase spiral CT.

•        Provides fine detail of liver lesionsdown to less than 1 cm in diameter.

•         Oral contrast enhancement allowsvisualisation of the stomach and duodenum in relation to the liver hilum.

•        The early arterial phase of the intravenous contrast vascular enhancement is particularly useful for detecting small liver tumours owing to their preferential arterial blood supply.

•        With intravenous contrast, whereas thecommon haemangioma characteristically shows late venous enhancement.

•        The density-the presence of a cysticlesion. 

Magnetic resonance imaging (MRI)

•        Effective an imaging modality.

•        Advantages. -iodine-containing -historyof allergy. -offered MRI rather than contrast CT.

•        MRCP -excellent quality imaging -noninvasively.

•        Quality is currently below that availablefrom ERCP or PTC 

•        But rapidly improving. -where ERCP has failed

•        Magnetic resonance angiography (MRA)-images of the hepatic artery and portal vein.

•        Alternative to selective hepatic angiography for diagnosis.

•        Useful in patients with chronic liverdisease and a coagulopathy in whom the patency of the portal vein and its branches is in question. 

Endoscopic                 E

Retrograde                 R

Cholangio                   C

Pancreatogram           P

Now, it is more used in therapeutic rather thandiagnostic.

•        By using this technique with aside-viewing fibreoptic duodenoscope the ampulla of Vater can be clearly seen.

•         Images of contrast injected into the biliaryand pancreatic ducts can display the anatomy and pathology of these ducts.

•        Changes seen in chronic pancreatitisinclude pancreatic duct strictures, dilatation of the main pancreatic duct withstones abnormalities of pancreatic duct side branches, communication of the pancreatic duct with cysts and bile-duct strictures.

•        In pancreatic carcinoma, the main pancreatic duct may be narrowed or completely obstructed at the site of the tumour with dilatation upstream but with a normal duct system downstream. This,in conjunction with bile-duct obstruction or a stricture, results in the so-called‘ double duct sign’.

•        Collection of bile or pancreatic juice at endoscopy and brushing of these ducts can yield cells which confirm thesuspected diagnosis of carcinoma .

•        Endoluminal ultrasound of the biliary tract is possible using a ‘baby’ scope, and may provide additionalinformation on the extent of hilar tumours. Therapeutic interventions are alsopossible at the time of ERCP and include stone retrieval, balloon dilatationof strictures.

Percutaneous transhepatic cholangiography (PTC)

•        PTC is indicated where endoscopic cholangiography has failed or is impossible, as in patients with previous Polya gastrectomy.

•        It is often required in patients withhilar bile duct tumours where endoscopic cholangiography fails to visualise the intrahepatic bile ducts.

•        Sometime, preoperative preparationof obstructive jaundiced patient  to drain bile out.

Angiography

•        Selective visceral angiography  may be required both for diagnosticpurposes and for therapeutic intervention.

•        Prior to liver resection it maybe used to visualise the anatomy of the hepatic artery to the right and leftsides of the liver and to confirm patency of the portal vein.

•        It can also provide additionalinformation on the nature of a liver nodule, primary liver turnouts having awell-developed arterial blood supply.

•        Therapeutic interventionsinclude the occlusion of arteriovenous malformations, embolisation ofbleeding sites in the liver and the treatment of liver tumours (chemoembolisation).

Nuclear medicine scanning

•        Radioisotope scanning can providediagnostic information

•         Iodoida is a technetium-99m (99mTc)labelled radionuclide - administered intravenously, removed from the circulation by the liver, processed by hepatocytes and excreted in thebile.

•        Imaging under a gamma camera allows its uptake and excretion to be monitored in real time.

•         useful where a bile leak or biliary obstructionis suspected and a noninvasive screening test is required.

•        A sulphur colloid liver scanallows the liver’s Kupffer cell activity to be determined.

•        useful to confirm the nature of a liverlesion, adenomas and haemangiomas having a lack of Kupffer cells and hence nouptake of sulphur colloid.

Laparoscopy and laparoscopic ultrasound

•        Useful for the staging of hepatopancreatobiliary cancers.

•        Lesions which have failed to be detected by conventional imaging are mainly peritoneal metastases and superficial liver tumours.

•        Laparoscopic ultrasound  provides additional information with liver tumours on their proximity to the major vessels and bile duct branches.

Fluorodeoxyglucose—position emission tomography (FDG—PET)

•        New imaging modality depends on the aviduptake of glucose by cancerous tissue in comparison to benign or inflammatorytissue.

•        To determine the nature of a mass lesiondemonstrated on another form of imaging.

•        Deoxyglucose is labelled with thepositron emitter fluorine-18 (15FDG) and this is administered to the patientprior to imaging by positron emission tomography (PET).

•        A three-dimensional image of the wholebody is obtained, highlighting areas of increased glucose metabolism

LIVER  -  INJURIES

•        BLUNT TRAUMA

•        PENETRATING TRAUMA

•        CONTUSION

•        LACERATION

•        AVULSION

CLINICAL FEATURES

            SHOCK           

PAIN           

RIGIDITY AND GUARDING

ASSOCIATED INJURIES

            CHEST          

  INTESTINES           

HEAD           

LIMBS 

INVESTIGATIONS

•                    GROUPING

•                    CROSS MATCHING

•                    X- RAY

•                    ULTRASOUND ABDOMEN

•                    C.T.SCAN

•        Radionuclide study withtechnetium-99m iminodiacetic acid (IDA)

•        PARACENTESIS

4 – QUADRANT TAPPING

TREATMENT

INITIAL RESUSCITATION

            BLOODTRANSFUSION

            OBSERVATION

PENETRATING INJURIES

            EXPLORATORYLAPAROTOMY

BLUNT INJURIES

            CONDITIONSTABLE

                        CONSERVATIVETREATMENT

transcatheter embolization of bleeding sites

            DETERIRATION

      OPERATIVETREATMENT

SURGERY

PRINGLE’S MANEUVRE

PACKING

SUTURING

RESECTION

LIVER TUMORS

  • Most common hepatic neoplasm ismetastatic carcinoma (i.e. from Colon)

•Benign tumors

•Hepatic carcinoma

•        • Benign:

    – Cavernoushemangioma (most common; don’t biopsy)

     – Focal nodularhyperplasia (hepatocellular nodules with central fibrous scar)

–       Liver cell adenoma (OCP use; riskof rupture)

–       Cystic disease

–       Infantile polycystic kidneydisease

Polycystic liver disease

Simple cysts

Parasitic cysts

 Benign tumours

–       Pyogenic abscessHaemangioma

Hepatocellular adenoma

Focal nodular hyperplasia

Primary malignant

Hepatocellular carcinoma

hepatoblastoma

cholangiocarcinoma

 Secondary malignant

Colorectal

Pancreas

Stomach

Breast

Lung

Benign tumours

•        Haemangioma is the commonest.

•        asymptomatic --ultrasoundexamination, perhaps for gallstones.

•         liver biopsymay bleed profusely.

•        congenital but may enlargeunder the influence of oral contraceptives. 

•        simple excision of the tumourand a whole lobe of the liver must be removed. A haemangioma usually only 1 or2cm in diameter ..

•        grow during pregnancy andadministration of oestrogens .6

Hepatocellular adenoma

•        asymptomatic .

•        common now because of oralcontraceptives.

•         adenocarcinoma are also associated with use ofanabolic steroids.

Focal nodular hyperplasia

•        benign proliferation of hepatocytes

•        smaller than 5cm in diameter and in thecentre of the nodule is the abnormal artery.

•        No treatment --- asymptomatic,-- notprone to rupture or malignant change.

•        associated with haemangioma

CARCINOMA OF THE LIVER

•        • Hepatocellular carcinoma(HCC) is the

     most common primary liver tumor

•        • Prevalence is associated withHepatitis B

     (early childhood infection)

•        • Repeated cycles of celldeath,

     regeneration, and accumulation ofmutations may transform some hepatocytes

•        • Also an association with Hep C

Clinical:

patients havepre-existing liver disease; new symptoms of rapid liver enlargement, acuteworsening of ascites, fever, and pain call attention to the development of HCC

 • Histologically:

     – Can be unifocal, multifocal, ordiffusely infiltrative.

     – All the subtypes have a propensity forvascular invasion.

 • Prognosis is poor despite maximum therapy

 • Fibrolamellar Carcinoma: distinct variant;young people;

   no association with cirrhosis; betterprognosis

Cholangiocarcinoma

•        arises in the biliary treeanywhere from the small intrahepatic ducts to the distal common bile duct.

Death from:

     – Profound cachexia

     – GI bleed

     – Liver failure