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Hepatobiliary procedures

Hepatology

Hepatology is the branch of medicine related to the liver, gallbladder, biliary tree, and pancreas as well as management of their disorders. Although traditionally considered a sub-specialty of gastroenterology, today we have doctors specializing solely on this area, and they are called hepatologists.

Diseases and complications related to viral hepatitis and alcohol are the main reason for seeking specialist advice. More than 2 billion people have been infected with Hepatitis B virus at some point in their life, and approximately 350 million have become persistent carriers. Up to 80% of liver cancers can be attributed to either hepatitis B or Hepatitis C virus. In terms of mortality, the former is second only to smoking among known agents causing cancer. With more widespread implementation of vaccination and strict screening before blood transfusion, lower infection rates are expected in the future. In many countries, though, overall alcohol consumption is increasing, and consequently the number of people with cirrhosis and other related complications is commensurately increasing.

Adult Hepatology and Gastroenterology services

Endoscopic procedures for the care of liver patients are performed by well qualified and trained gastroenterologists. Complex endoscopic procedures like band ligation for bleeding varices in a cirrhotic, ERCP for a variety of biliary problems, sclerotherapy for control of ulcer bleeding etc are done. We also have capsule endoscopy and liver dialysis system (MARS) under the ambit of Hepatoenterology.

Fatty liver clinic

Apollo Hospitals now offers a novel and unique facility, the Apollo Fatty Liver Clinic. This clinic will offer a comprehensive assessment, counseling and therapy for patients with fatty liver. Special packages will be available and patients can seek advice from a liver specialist, dietician and will also be counseled on lifestyle changes, exercise, weight loss etc. Tailored diet charts and exercise programs will be arranged according to each individual's requirement. Patients are also registered for regular follow up to monitor their progress, and will be linked with other specialists like Diabetologist and Cardiologist as necessary.

Dr. N Murugan, Hepatologist, Apollo Hospitals says "Non-alcoholic fatty liver disease is a very common but important problem, as up to 20% can develop serious liver damage. It is important for those with fatty liver to have periodic assessment of risk factors and staging of liver disease, as this is the best way to prevent complications. The key is also in maintaining a healthy lifestyle with proper diet, plenty of exercise and weight management"

Non-Alcoholic Fatty Liver Disease (NAFLD) is a condition where fat builds up in the liver even without alcohol take. When more than 5% - 10% percent of the liver's weight is made up of fat, it is called a fatty liver (Steatosis).

Fatty liver has risen alarmingly owing to genetic predisposition (insulin resistance) coupled with changing lifestyle. Unless problem is addressed in time, it can result in significant liver damage for those affected".

Who is primarily at risk?

Patients who have the following - Type 2 Diabetes, High Blood Pressure, are Overweight or suspected Metabolic syndrome

What is Metabolic Syndrome?

This is a condition that includes the presence of central obesity (fat in the belly area), Hypertension, Diabetes or impaired fasting sugar, high Triglycerides (a type of blood fat) and low HDL (the good cholesterol). Patients with metabolic syndrome have a higher likelihood of fatty liver disease and are at greater risk of having progressive liver disease.

Stages of NAFLD and risks

Fatty liver exists in four stages

Stage 1: Simple fatty liver (simple steatosis) - when the liver has excessive fat of more than 10% without any significant damage or scarring. The majority of people are in this stage, and usually do not develop any serious liver damage.

Stage 2: Non-Alcoholic Steatohepatitis (NASH) - this is a more serious.The liver gets inflamed, followed by liver cell swelling and damage, leading to cell death. This can progress to liver fibrosis, liver cirrhosis, requiring a liver transplant

Stage 3: Fibrosis - some people with NASH can develop scarring of the liver called fibrosis. This gradually replaces healthy liver tissue, and can lead to further liver damage.

Stage 4: Cirrhosis - this is the most severe stage where the entire liver is replaced with bands of scar tissue. The liver becomes hard and may shrink. Over time, this often leads to loss of liver function, cause liver failure, and even liver cancer.

NASH is a serious complication and can occur in up to 20% of patients with fatty liver. NASH is more likely to occur in patients older than 50, women and those with full blown metabolic syndrome. NAFLD increases the risk of liver damage and is associated with an increased risk of cardiac disease and diabetes".

Symptoms and Diagnosis

NAFLD is often silent - which is why it is important to perform the necessary tests regularly to track the conditions of the liver. Patients do not experience any specific complaints in the early period, and even with advancing fibrosis, the disease may not cause any problems. In the later stages, patients may feel non-specific symptoms such as vague right sided abdomen pain, fatigue, tiredness, and some mild weakness.

It is only after developing cirrhosis and liver failure, that patients may experience obvious problems such as swelling of feet or abdomen, blood vomiting, impaired memory and periods of confusion, easy bruising or excessive bleeding after minor injuries, loss of muscle mass, increasing jaundice, frequent infections and eventually coma.

Liver cancer too can develop silently, and many times diagnosed only on routine scans such as ultrasound.

Diagnosis

NAFLD is initially diagnosed by ultrasound and blood tests may show high levels of liver enzymes (liver function tests). Additional tests are often done to rule out other liver diseases.

How can NAFLD be assessed?

Ultrasound picks up fat when it is more than 30%. Once fatty liver has been diagnosed the key is to determine whether the patient may have any serious liver disease. Liver biopsy is sometimes used to diagnose these advanced stages of the disease.

The level of fibrosis can now be assessed by noninvasive tests, including blood tests and scans such as Fibroscan. This is a novel method, now available at Apollo Hospitals to accurately diagnose the level of fibrosis and early stages of cirrhosis.

Hepatobiliary surgery

Our centers of excellence in Hepatology and Hepatobiliary surgery consists of teams of hepatologists and hepatobiliary surgeons addressing all medical and surgical diseases related to the hepatobiliary system. With the use of advanced technology and surgical methods, patients now have more options than ever for the treatment of Hepatobiliary disease.

For patients requiring hospitalization, we have a dedicated Hepatobiliary critical care unit, a Hepatobiliary physician on-call, anesthetists and a specialized O.R. nursing team. Our focus is on providing experienced, personalized care for all our patients. Our doctors are trained at the world's most renowned centers in Hepatobiliary surgery and Liver Transplantation and are actively involved in clinical research.

Our team of surgeons, interventional endoscopists, radiologists and hepatologists work together to provide surgical treatment for the following disorders:

Biliary disorders

The biliary tract includes the liver, gall bladder and bile ducts. They work together to make, store and secrete bile. Bile consists of water, electrolytes, bile acids, cholesterol, phospholipids and conjugated bilirubin. Bile is secreted by the liver into small ducts that join to form the common hepatic duct. Between meals, secreted bile is stored in the gall bladder, where 80%-90% of the water and electrolytes can be absorbed, leaving the bile acids and cholesterol. During a meal, the smooth muscles in the gallbladder wall contract, leading to the bile being secreted into the duodenum.

Common disorders include:

  • Carcinoma of the gallbladder - malignant tumors involving the gall bladder
  • Malignant tumors of the bile duct - cancers of the bile duct
  • Bile duct injuries and strictures - trauma to the bile duct and post inflammatory narrowing and strictures
  • Choledochal cysts - (aka bile duct cyst) are congenital conditions involving cystic dilatation of bile ducts.
  • Recurrent pyogenic cholangitis - infective disorders of the biliary tract

Disorders of the Pancreas

The pancreas -- a spongy, tadpole-shaped organ located behind the stomach -- makes enzymes our bodies need to digest food and hormones to regulate blood sugar levels.

Common disorders include:

  • Pancreatitis - is a disease in which the pancreas becomes inflamed. Acute pancreatitis is a sudden inflammation and may range from mild discomfort to a severe, life-threatening illness. Chronic pancreatitis is long-lasting inflammation of the pancreas. It most often happens after an episode of acute pancreatitis. Heavy alcohol drinking is another big cause.
  • Pancreatic pseudocyst - If the pancreas is injured, its ducts, which carry enzyme-containing juices, can become blocked. This can lead to the development of a fluid-filled sac called a pancreatic pseudocyst
  • Malignant neoplasms of the pancreas - cancers of the pancreas

These make up the vast majority of all pancreatic cancers (around 90%) and come from the cells that line the ducts in the pancreas which carry digestive juices into the intestine. These are called pancreatic ductal adenocarcinomas.

  • Pancreatic islet cell tumors -These are known as neuroendocrine tumours, and are much less common.

Liver disorders

  • Hepatic trauma - this refers to some form of trauma sustained to the liver. This can occur through either a blunt force such as a car accident, or a penetrating foreign object such as a knife. Liver injuries constitute 5% of all traumas, making it the most common abdominal injury.
  • Primary cancers like hepatocellular carcinoma as well as metastatic cancers of the liver (Cancer originated elsewhere & spread to liver)

Benign (Non cancerous) tumors and cysts of the liver. Each cellular component of the liver (e.g., hepatocyte, biliary, endothelial, or other mesenchymal cells) can undergo benign proliferation, but only four lesions have common clinical relevance: hemangioma, focal nodular hyperplasia, hepatocellular adenoma, and hepatic cysts.

  • Portal hypertension this is an increase in the blood pressure within a system of veins called the portal venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver. If the vessels in the liver are blocked due to liver damage, blood cannot flow properly through the liver. As a result, high pressure in the portal system develops. This increased pressure in the portal vein may lead to the development of large, swollen veins (varices) within the esophagus, stomach, rectum, or umbilical area. Varices can rupture and bleed, resulting in potentially life-threatening complications.

Key Hepatobiliary Procedures

Radiofrequency ablation and chemoembolization of liver tumors and cancers

Dedicated to providing the highest quality medical and surgical liver care services, Apollo Hospitals offers a broad range of effective treatments for cancer that have shown promising results. Radiofrequency ablation and Chemoembolization are highly successful treatment options available for select patients, whose suitability is recommended after meticulous evaluation by skilled doctors.

Radiofrequency ablation, sometimes referred to as RFA, is a minimally invasive treatment for cancer. It is an image-guided technique that heats and destroys cancer cells. Imaging techniques such as ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) are used to help guide a needle electrode into a cancerous tumor. High-frequency electrical currents are then passed through the electrode, creating heat that destroys the abnormal cells. Some common indications for RFA are: 1) hepatocellular carcinoma, which is a primary liver cancer; 2) colon cancer that metastasizes or spreads from the colon to the liver. RFA is an effective liver cancer treatment for patients who might have difficulty with surgery or those whose tumors are less than one and a half inches in diameter. The success rate for cure of liver cancers where the liver tumors are small, is greater than 85 percent.

Your doctor will instruct you on how to prepare. Inform your doctor if there’s a possibility you are pregnant and discuss any recent illnesses, medical conditions, allergies and medications you’re taking. Your doctor may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners several days prior to your procedure and instruct you not to eat or drink anything for several hours beforehand.

Chemoembolization is a combination of local delivery of chemotherapy and a procedure called embolization to treat cancer, most often of the liver. Anti-cancer drugs are injected directly into the blood vessel feeding a cancerous tumor. In addition, synthetic material called an embolic agent is placed inside the blood vessels that supply blood to the tumor, in effect trapping the chemotherapy in the tumor.

Chemoembolization delivers chemotherapy drugs directly to a tumor, while minimizing exposure to healthy tissues. This delivery method minimizes side effects, like nausea and vomiting, and maximizes the cancer-killing properties of the drugs.

During chemoembolization, chemotherapy is injected through a catheter directly into a tumor using image guidance. The chemotherapy drugs are mixed with particles, called microspheres, which block the flow of blood to the tumor. Without a blood supply, the tumor no longer has the oxygen and nutrients it needs to grow.

Chemoembolization allows high doses of chemotherapy drugs to be targeted directly to the cancerous tissue for a longer period of time, without exposing the entire body to the effect of the drugs.

This method of chemotherapy is primarily used for the treatment of liver cancer, and may also be used for the treatment of cancers that have spread to the liver.

Unlike other organs, the liver has two blood supplies – the portal vein that feeds most normal liver cells and the hepatic artery that feeds cancer cells in the liver. This unique feature of the liver allows your doctor to kill the cancer cells while sparing the healthy tissue.

Liver Resection

The most common operation performed on the liver is a resection (removal of a portion of the liver). The most typical indication for liver resection is a malignant tumor. Tumors can be primary (developed in the liver) or metastatic (developed in another organ, then migrated to the liver). The single tumor or more than one tumor confined to either left or right side of the liver can be successfully resected with 5-year survival as high as 60%. Benign tumors of the liver (cyst, adenoma, hemangioma) can be successfully managed by liver resection as well.

Pancreatic Surgery - pancreatic resections are offered to patients with pancreatic cancers as well as chronic pancreatitis

Gall Bladder Surgery

The treatment of gallstone disease, both open and laparoscopic gall bladder removal and surgical management of biliary disorders are the common procedures.

Palliative and curative resections for biliary cancer and palliative drainage procedures are performed. Combined liver and bile duct resection for advanced bile duct cancers are being performed regularly. Patients who have inoperable diseases are offered various palliative measures like stenting or bypass procedures.

Biliary reconstruction surgery for bile duct strictures

Repair to healthy bile duct: In the repair, a segment of intestine is brought up to the bile duct and the bile duct is then sutured to the intestine. For long term healing and for good results a normal uninjured bile duct away from the site of the injury should be used. This may be difficult to accomplish in high bile duct injuries.The type of repair performed to the bile duct depends on the level of the injury. For patients who have low injuries to their bile duct finding an area of normal bile duct above the site of the injury and suturing that area to the intestine is easily accomplished for the repair. In patients whose injury is high up in the bile duct close to the liver, the repair is much more complex since finding a segment of normal bile duct above the injury may be extremely difficult.

Portal Hypertension Surgery for Liver Cirrhosis

The goal of portal hypertension treatment is to reduce high blood pressure in the portal vein, the blood vessel that connects the intestines and the liver, and prevent abdominal bleeding. Portal hypertension usually results from various types of cirrhosis (scarring in the liver).

Portal hypertension can cause tiny, thin-walled veins at the base of the esophagus and in the stomach to break and bleed. At this point they are referred to as varices. Physicians usually choose to control varices with medications or endoscopy. Endoscopy involves the insertion of a fiber-optic viewing tube into the gastrointestinal tract. Once the source of variceal bleeding is located, physicians use one of the following endoscopic techniques to control the varices:

  • Sclerotherapy, the injection of hardening agents;
  • Latex banding; and
  • Balloon tamponade.

Endoscopic techniques stop bleeding in 90 percent of patients. When medical and endoscopic treatments have failed to control bleeding, portal hypertension surgery may be indicated. The surgery creates an alternate pathway for venous blood flow, called a shunt, to relieve portal hypertension and bleeding varices. The surgical procedure that is most commonly used is called distal splenorenal shunt (DSRS).Alternatively, a minimally invasive treatment called transjugular intrahepatic portosystemic shunt (TIPS) may be appropriate for some patients.

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