1. Liver surgery Dr.Muayad Abass Fadhel Surgery department Medical college –Baghdad university No.2 Al-Madena copy1

2.  Ascending cholangitis  Ascending bacterial infection of the biliary tract is usually associated with obstruction and presents with clinical jaundice, rigors and a tender hepatomegaly.  The diagnosis is confirmed by the finding of dilated bile ducts on ultrasound, an obstructive picture of liver function tests and the isolation of an organism from the blood on culture.  The condition is a medical emergency, and delay in appropriate treatment results in organ failure secondary to septicaemia.

3.  Once the diagnosis has been confirmed, the patient should be commenced on a first-line antibiotic (e.g. Third generation cephalosporin) and rehydrated, and arrangement should be made for endoscopic or percutaneous transhepatic drainage of the biliary tree.  Biliary stone disease is a common predisposing factor, and the causative ductal stones may be removed at the time of endoscopic cholangiography by endoscopic sphincterotomy.

4.  The aetiology of a pyogenic liver abscess is unexplained in the majority of patients.  It has an increased incidence in the elderly, diabetics and the immunosuppressed, who usually present with anorexia, fevers and malaise, accompanied by right upper quadrant discomfort.  The diagnosis is suggested by the finding of a multiloculated cystic mass on ultrasound or CT scan.  And is confirmed by aspiration for culture and sensitivity.

5.  The most common organisms are Streptococcus milleri and Escherichia coli, but other enteric organisms such as Streptococcus faecalis, Klebsiella and Proteus vulgaris also occur, and mixed growths are common.  Treatment is with antibiotics and ultrasound- guided aspiration.  First-line antibiotics to be used are a penicillin, aminoglycoside and metronidazole or a cephalosporin and metronidazole.

6.  Percutaneous drainage without ultrasound guidance should be avoided as an empyema may follow drainage through the pleural space.  A source for the liver abscess should be sought, particularly from the colon. 

7.  Entamoeba histolytica is endemic in many parts of the world. It exists in vegetative form outside the body and is spread by the faeco-oral route.  The most common presentation is with dysentery,  but it may also present with an amoebic abscess, the common sites being paracaecal and in the liver. 

8.  The amoebic cyst is ingested and develops into the trophozoite form in the colon, and then passes through the bowel wall and to the liver via the portal blood.  Diagnosis is by isolation of the parasite from the liver lesion or the stool and confirming its nature by microscopy.  often patients with clinical signs of an amoebic abscess will be treated empirically with metronidazole (750 mg t.d.s. for 5–10 days) and investigated further only if they do not respond.

9.  very common condition in countries around the Mediterranean.  The causative tapeworm, Echinococcus granulosus, is present in the dog intestine, and ova are ingested by humans and pass in the portal blood to the liver.  Presentation:  upper abdominal discomfort  acute abdomen after minor abdominal trauma due to rupture of the cyst into the peritoneal cavity.

10.  Active cysts contain a large number of smaller daughter cysts and rupture can result in these implanting and growing within the peritoneal cavity  Liver cysts can also rupture through the diaphragm, producing an empyema, into the biliary tract, producing obstructive jaundice, or into the stomach.

11.  Diagnosis:  on ultrasound multiloculated cyst  CT scan finding of a floating membrane within the cysts.  Clinical and radiological diagnosis can be supported by serology for antibodies to hydatid antigen in the form of an enzyme- linked immunosorbent assay (ELISA).

12.  Treatment:  In the first instance, a course of albendazole or mebendazole may be tried.  Failure to respond to medical treatment usually requires surgical intervention,  percutaneous treatments with hypertonic saline and alcohol have been attempted.  The surgical options :  liver resection or  local excision of the cysts or  de-roofing with evacuation of the contents.

13.  Hydatid cyst of the liver –  treatment  ■ Ideally managed in a tertiary unit by a multidisciplinary  team of hepatobiliary surgeon, physician and  interventional radiologist  ■ Leave asymptomatic and inactive cysts alone – monitor  size by ultrasound  ■ Active cysts should first be treated by a full course of  albendazole  ■ Several procedures are available – PAIR, pericystectomy  with omentoplasty and hepatic segmentectomy; it is  important to choose the most appropriate option  ■ Increasingly, a laparoscopic approach is being tried

14.  active hydatid daughters should be avoided by continuing drug therapy with albendazole and adding peroperative praziquantel.  This should be combined with packing of the peritoneal cavity with hypertonic (20%) saline-soaked packs and instilling into the cyst before it is opened.

15.  A biliary communication should be actively sought and sutured.  The residual cavity may become infected, and this may be reduced, as may bile leakage, by packing the space with pedicled greater omentum (an omentoplasty).

16.  Calcified cysts may well be dead..  Rupture of daughter hydatids into the biliary tract may result in obstructive jaundice or acute cholangitis.  This may be treated by endoscopic clearance of the daughter cysts prior to cyst removal from the liver.

17.  Benign liver tumours  Haemangiomas  most common liver lesions  They consist of an abnormal plexus of vessels, and their nature is usually apparent on ultrasound.  If diagnostic uncertainty exists, CT scanning with delayed contrast enhancement shows the characteristic appearance of slow contrast enhancement due to small vessel uptake in the haemangioma.

18.  Lesions found incidentally require confirmation of their nature and no further treatment.  The management of ‘giant’ haemangiomas  is more controversial Occasional reports of rupture of haemangiomas have led some to consider resection for the large lesions,

19.  They have little if any malignant potential, and this is not indication for surgery.  Percutaneous biopsy of these lesions should be avoided as they are vascular lesions and may bleed profusely into the peritoneal cavity.

20.  Rare benign liver tumours.  Imaging by CT demonstrates a well- circumscribed and vascular solid tumour.  They usually develop in an otherwise normal liver.  Unfortunately, there are no characteristic radiological features to differentiate these lesions from malignant tumours.  Angiography will demonstrate a well developed peripheral arterialisation of the tumour.

21.  Confirmation of the nature of these lesions is required by either percutaneous biopsy or resection with histological confirmation.  These tumours are thought to have malignant potential, and resection is therefore the treatment of choice.  An association with sex hormones (including the oral contraceptive pill) is well recognised, and regression of symptomatic adenomas on withdrawal of hormone stimulation is well documented.

22.  unusual benign condition of unknown aetiology.  there is a focal overgrowth of functioning liver tissue supported by fibrous stroma.  Patients are usually middle-aged females,

23.  Ultrasound shows a solid tumour mass but does not help in discrimination.  Contrast CT may show central scarring and evidence of a well-vascularised lesion.  A sulphur colloid liver scan may be useful. FNH contain both hepatocytes and Kupffer cells. The latter take up the colloid allowing differentiation of FNH from either a benign adenoma or a primary or metastatic cancer, neither of which contains a significant number of Kupffer cells.

24.  Primary liver cancer (HCC) is one of the world’s most common cancers, and its incidence is expected to rise rapidly over the next decade due to the association with chronic liver disease, particularly HBV and HCV.  Many patients known to have chronic liver disease are now being screened for the development of HCC by serial ultrasound scans of the liver or serum measurements of alphafetoprotein (AFP).  Patients often present in middle age, either because of the symptoms of chronic liver disease (malaise,  weakness, jaundice, ascites, variceal bleed,encephalopathy)

25.  Or with the anorexia and weight loss of an advanced cancer.  The surgical treatment options include resection of the tumour and liver transplantation.  Which option is most appropriate for an  individual patient depends on the  -stage of the underlying liver disease,  -the size and site of the tumour,  -the availability of organ transplantation  - the management of the immunosuppressed patient.

26.  In addition to a general assessment of the patient’s fitness for surgery,  crucial information is the severity of the underlying liver disease and the size and site of the tumour.

27.  Extensive liver resections in patients with advanced cirrhosis are associated with a high mortality due to liver failure and sepsis.  In contrast, extensive resections for HCC in a non cirrhotic liver are associated with a low risk of liver failure, and resection rather than transplantation would be the treatment option of choice.

28.  Tumours often metastasise to the lung and bone  and, therefore, a chest CT scan and a bone scan are useful staging investigations.  Evidence of intraperitoneal disease is difficult  to determine by CT scan, and laparoscopy may be useful for this purpose.

29.  The surgical approach should remove the known cancer with a 1-to 2-cm margin of unaffected liver tissue.  In patients with associated chronic liver disease, the volume of liver resected should be minimised to reduce the incidence of postoperative liver failure.  Local or segmental resections are preferred to major resections.

30. The majority of patients diagnosed with HCC will not be amenable to surgical resection because of the advanced stage of the cancer or the severity of the underlying liver disease.  These patients can be offered local ablative treatments such as transarterial embolisation (TAE), transarterial chemoembolisation  (TACE), percutaneous ethanol ablation (PEA) or RFA

31.  There is little evidence that adjuvant chemotherapy will improve the prognosis of patients following resection of HCC, and it may damage the function of the liver in those with underlying chronic liver disease.  AFP is a clinically useful tumour marker for follow-up, although its low sensitivity would suggest that imaging should also be used.