Hepatobiliary surgery includes surgery of the liver, bile ducts, gallbladder and pancreas. Hepatobiliary surgeons work in close cooperation with gastroenterologists, oncologists and radiologists to evaluate and treat diseases involving these organs. Surgery related to gallstones and discussed separately under "Gallbladder". Liver surgery is often indicated for resection (excisiton) of benign or malignant tumors.
The most common benign (non-cancerous) lesions are cysts, hemangiomas, focal nodular hyperplasia and peatic adenomas. Simple cysts, hemangiomas and focal nodular hyperplasia seldom require surgery unless they are very large or symptomatic. Hepatic adenomas occur predominatly in women, especially those who have taken birth control piulls for a prolonged period of time. A small percentage can repture and result in life-threatening hemorrhage and also have a small risk of becoming malignant (cancerous) after several years. Because of these risks, resection of hepatic adenomas may be recommended.
Malignant (cancerous) tumors can be either primary (arising in the liver) or metastatic (spread from a cancer which started in another organ).
The most common primary liver cancers are hepatocellular carcinoma and cholangiocarcinoma. Surgery to resect or remove the tumor offer the only potential for cure. Hepatocellular carcinoma usually occurs in patients with cirrhosis who may not have enough reserve function to tollerate resection of a large part of the liver. In these patients, liver transplantation may be considered.
Metastatic tumors are far more common than primary liver cancers, and have most frequently spread from tumors in the color, pancreas, stomach or breast. The presence of metastatic cancer in the liver is usually a sign of widespread disease and surgery is often not an option. However, patients with tumors that originated from primary colon, rectal, or neuroendocrine (carcinoid) cancers, and are confined to a portion of the liver, may benefit from resection. It may be only necessary to remove a small portion of the liver, or resection of the entire left or right lobe (half) may be needed. Up to 75% of the liver can be removed, as long as 25% of functioning liver, free of tumor, remains. The best results are seen in patients with one or two tumors, less than 5cm in size, confined to one lobe of the liver with no evidence of spread outside of the liver. A liver resection is a major operation with significant risks and a 2-3% risk of dying as a result of the surgery. The 5 and 10 year survival after liver resection for metastatic colon and rectal cancer is approximately 30% and 20% respectively, and is significantly better than with chemotherapy alone. Resection is usually combined with chemotherapy before and/or after surgery. Other options that may be considered for liver tumors include radiofrequency ablation (RFA) in which an electric heater probe is inserted into the tumor to destroy it, chemoembolization (performed by a Radiologist) or focused radiation therapy. These techniques are not as effective as surgical removal and are reserved for patients who are not candidates for surgical resection.
Cancers of the gallbladder may also require extensive surgical resection. Gallbladder cancers are often discovered incidentally in the gallbladder after laparoscopic cholecystectomy and depending on the size and spread of the tumor may require another operation to resect the liver surrounding where the gallbladder was attached, the bile duct and nearby lymph nodes. Gallbladder cancer frequently spreads early, even when the primary tumor is small.
Bile Duct and pancreatic cancers often present with jaundice (yellow skin), dull abdominal pain and rapid weight loss, and may be considered for surgical resection if they are localized. The operation performed will depend on the location of the tumor and may include resection of the duodenum and a portion of hte stomach (Whipple procedure). These are usually extensive, complex operations with multiple anastomoses (connections), and may be combined with post-operative radiation and/or chemotherapy.