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Hepato-pancreato-biliary surgery

Team of doctors
Assoz.-Prof. Priv.-Doz. Dr. Manuel Maglione, MBA MCI
Univ.-Prof. Dr. Stefan Schneeberger, Executive MBA HSG
Priv.-Doz. Dr. Christian Margreiter (currently on leave)
Assoz.-Prof. Priv.-Doz. Dr. Rupert Oberhuber, PhD, FEBS
Dr.in Eva Braunwarth
Priv.-Doz. Dr. Thomas Resch, PhD
Priv.-Doz. Dr. Benno Cardini, FEBS

Special consultation hour:
Friday 09.00 - 13:30
phone +43 (0)50 504 22511

Our special consultation hours advise patients with diseases of the liver, gallbladder, bile ducts and pancreas. You can come to us with benign as well as malignant diseases. Many patients come to our outpatient clinic with already known complaints - for example a gallstone disease - and ask for treatment options. Furthermore, we look after patients in whom either special symptoms ("yellowing" of the skin = icterus, increased itching = pruritus, right-sided upper abdominal pain), conspicuous laboratory values or imaging findings (by ultrasound examination) have been found in a screening examination (= preventive examination) and carry out further clarification. All malignant tumors of the liver, gallbladder and pancreas, as well as metastases of malignant tumors into the liver are discussed in an interdisciplinary tumor conference.

The typical procedure of an examination at our outpatient clinic includes a detailed medical interview (anamnesis) with a corresponding clinical examination and a blood test. Depending on your needs, imaging examinations are then arranged either immediately or by appointment. A detailed examination of the liver or pancreas includes not only a clinical examination and the determination of various blood values, but also at least one imaging examination. Very often the initial examination is a computed tomography (CT), often supplemented by a magnetic resonance imaging (MRI). In some cases, a special ultrasound examination with a contrast medium, an endoscopic x-ray of the bile ducts (ERCP) or an endoscopic ultrasound examination (endosonography) may also be required as a supplement. In most cases, some of these examinations have already been performed and the corresponding findings and values are available at the initial consultation. However, in the case of changes in the liver and pancreas, examinations with special contrast medium protocols are often necessary for a diagnosis. It may therefore be necessary to repeat a CT examination at our clinic, for example.

Especially in the case of extensive liver resections, an exact measurement of the residual liver volume in relation to the total volume using CT is essential for planning the therapeutic procedure.

Gall Bladder

The bile is produced in the liver and flows intrahepatic through small tubules into the interlobular bile ducts, which unite to form increasingly larger bile ducts. Finally, all these ducts open into the right and left bile ducts (ductus hepaticus), which unite to form the common bile duct and - once the bile-bladder duct has been opened - the main bile duct (ductus choledochus), which opens into the duodenum. The gallbladder is a hollow organ which has grown on the lower edge of the liver and is connected to the bile ducts via the gallbladder duct. The gallbladder is about 8-12 cm long and 4-5 cm wide and serves as a storage for the bile produced in the liver. The bile stored in this way is concentrated in the gallbladder and, if necessary (when fatty foods are ingested), is released into the duodenum via the bile duct. An examination of the gallbladder is usually carried out by means of a clinical examination, a blood test with determination of liver values, and an ultrasound examination. Only in rare cases is computer tomography or imaging of the bile ducts (by means of magnetic resonance imaging (MRCP) or endoscopy (ERCP) necessary. In addition to very rare malignant changes of the gallbladder (gallbladder carcinoma - see section 2 (liver) - bile duct tumors), the most frequent changes treated by surgery are gallstones on the one hand and benign changes of the gallbladder mucosa (gallbladder polyps) on the other hand.

Gallstones are caused by the thickening of the bile in the gallbladder and are frequently found in examinations of the gallbladder. However, we now know that the presence of stones alone is not a reason for intervention. Intervention is only necessary when patients experience symptoms caused by gallstones. However, in this case - in contrast to kidney stones, for example - the dissolution of the stones by medication or even ultrasound fragmentation are no longer recommended due to the low chances of success. The therapy of choice in this case is the surgical removal of the gallbladder. In this procedure, the gallbladder duct and the artery that supplies the gallbladder are exposed. Both structures are then closed towards the liver and the gallbladder is detached from the liver. While in cases of severe inflammation of the gallbladder, the operation is performed through an incision running below the right costal arch (open surgery), in 90-95% of cases a minimally invasive operation is performed through several (usually four) sleeves in the abdominal wall (laparoscopic surgery). The surgical techniques do not differ with regard to the gallbladder, but the advantage of a minimally invasive technique lies in the smaller scar, the lower postoperative pain and the shorter hospital stay.

Gall Bladder Polyps are benign thickenings of the gallbladder wall. Since these changes usually do not cause any symptoms, the diagnosis is almost always a random finding during sonography. These altogether rare changes seem to change only very slowly in the vast majority of patients, which is why no therapy is usually necessary. Smaller polyps should be sonographically checked at annual intervals. Very large polyps, however, have the potential to become malignant over time, similar to the colon. For this reason, removal of the gallbladder (cholecystectomy) is recommended for polyps with a diameter of one centimeter or more.

Liver

The liver is the second largest organ in the human body after the skin and, at about 1,500 g, the heaviest. It is located in the right upper abdomen on the lower surface of the diaphragm and is almost completely covered by the right costal arch. Clinically important is the division into a total of 8 liver segments (left liver lobe segment I-IV, right liver lobe segment V-VIII) according to the vascular supply (left liver lobe segment I-IV, right liver lobe segment V-VIII) The liver is the only organ in the abdominal cavity with a pronounced ability to regenerate, so that - provided there is no other damage to the remaining liver tissue - up to 75% of the liver can be surgically removed.

Benign liver tumors

There are a number of benign tumor-like changes (tumors) in the liver. This means that no metastases can develop from these tumors. Benign liver tumors typically cause the patient discomfort late due to their size. Nevertheless, it may be necessary to remove such changes if they continue to grow, crowd or constrict surrounding structures of the liver (e.g. bile ducts or vessels), or - in rare cases - can develop into a malignant tumor.  

Liver hemangiomas (cavernous hemangiomas) are the most frequent benign liver tumors originating from vessels. Women are affected about 3 times more often than men. In most cases a clear diagnosis is possible by means of a contrast medium CT examination. In up to 40% of those affected, such changes are found on both sides of the right and left lobe of the liver. While most of these "blood sponges" are less than 5 cm in size, in isolated cases they can become considerably larger and thus cause symptoms (feeling of pressure in the right upper abdomen). Hemangiomas may occasionally show a distinct growth in size, and a hormonal influence is discussed, since size growth has been described during pregnancy and under estrogen and gestagen influence. In most cases, however, these lesions remain relatively constant in size, so that resection is only necessary in case of pain or - very rarely - spontaneous or traumatic bleeding.

The focal nodular hyperplasia (FNH) is the most common benign liver cell tumor and accounts for about 1-2% of all liver tumors. Women are 8-9 times more frequently affected than men, with an increase in size being described by the use of oral contraceptives ("pill") or during pregnancy. The diagnosis is usually made by the typical presentation (central scar with large vessel) in the various imaging modalities. FNH is - except for its size - mostly asymptomatic and not progressive, and complications such as bleeding or necrosis are very rare. Furthermore, there is - in contrast to adenomas - no danger of degeneration. Resections are therefore only necessary in exceptional cases of very large or growing lesions.

Hepatocellular adenomas are benign liver tumors, which occur almost exclusively (about 90%) in younger women. There is a clear relation to the use of oral contraceptives ("pill"). In contrast to other benign liver tumors, adenomas often lead to complications in the course of the disease: About a quarter of the patients become conspicuous due to right-sided pain in the upper abdomen, and in 30-40% of cases massive bleeding occurs. Furthermore, there is a potential for transformation into a malignant liver tumor (about 1% of cases). In addition to the imaging diagnostics and the frequently existing pain, liver cell adenomas are often elevated in blood tests. Surgical removal is necessary both because of the risk of bleeding (mortality up to 7%) and because of the possibility of degeneration. Small lesions are removed laparoscopically with good success.

A apeworm infestation der Leber (Ecchinococcus) of the liver (Ecchinococcus) represents a typical parasitic disease of humans and is one of the oldest known diseases in humans and animals (already mentioned in the Talmud / Hippocrates). In all tapeworms, humans are only an "accidental" intermediate host, which is infected by accidentally ingesting the worm eggs. While originally 16 Echinococcus species were known, four species are clinically relevant for humans:

- Echinococcus granulosus (cysticus) – Dog Tapeworm (world-wide)
- Echinococcus multilocularis (alveolaris) – fox tapeworm (northern hemisphere)
- Echinococcus oligarthus (Central and South America)
- Echinocuccus vogelii (Central and South America)

After the often asymptomatic uptake of the worm eggs (occasionally diarrhea-like symptoms), there is often a symptom-free interval, often lasting years, in which the cysts in the liver grow slowly. While the cysts usually become displacingly larger, only Echinococcus multilocularis (alveolaris) shows aggressive growth infiltrating the tissue (similar to a malignant tumor). Sypmtomas occur on the one hand due to the growth of the cysts (compression / capsule tension pain), on the other hand due to infection of the cysts. An often dramatic event is an allergic reaction to the worm components due to a rupture of a cyst. In such a rupture, there is also the risk of the worm components spreading in the free abdominal cavity. Without treatment, all these tapeworm diseases are progressive, with a 10-year survival rate of only 6-25%, especially in Echinococcus multilocularis (alveolaris). The diagnosis is made by imaging (sonography / CT examination) and blood tests (which can be negative despite worm infestation). 

Therapeutically, a drug therapy (e.g. albendazole) will be suggested in all cases. However, in larger herds, surgical therapy is always necessary for a cure. Only small lesions (<5cm) or completely calcified (= most likely killed) foci can be observed. Large lesions or all Echinococcus multilocularis (alveolaris) foci require removal in healthy liver tissue (pericystectomy), whereby it is extremely important not to injure the cyst in order to avoid seeding in the abdomen. Medium sized foci and lesions caused by Echinococcus cysticus can be less invasive by chemical killing of the worm followed by removal of the cyst.

Malignant liver tumors

Tumors that originate from the liver tissue itself are called primary liver tumors. The most common primary liver tumor is hepatocellular carcinoma (HCC). Due to the high incidence of HCC in livers damaged by viral hepatitis, it is one of the most common tumors of a solid organ worldwide. These tumors rarely occur in otherwise healthy livers, but are much more common in damaged (cirrhotic) organs. In addition to the viral hepatitis in Central Europe already mentioned, cirrhosis of the fatty liver (often caused by alcohol) and liver damage caused by metabolic diseases (e.g. Wilson's disease, hemochromatosis) or toxins are frequent causes of liver cirrhosis.

The hhepatocellular carcinoma HCC often grows rather slowly over a long period of time before the diagnosis is made. Patients often complain of general symptoms such as weakness, fatigue, weight loss and unclear fever. Jaundice and itching appear late. In most cases, the diagnosis is made by a combination of imaging findings and laboratory values. In blood tests, the alpha-feto-protein (AFP), which can be elevated in HCC, is considered a tumor marker. The typical presentation of these tumors in two separate procedures (e.g. CT with contrast medium and MRI) is often sufficient for imaging; confirmation by direct puncture is not necessary. As with all malignant tumors, HCCs can spread throughout the body. In most cases, the lymph glands near the liver, the lungs, the bones and the abdominal cavity are the first to be affected.

Treatment with the aim of a cure (curative surgery) is only possible as long as the tumor is confined to the liver and can be completely removed. Very small foci can be removed minimally invasively (laparoscopically), while larger foci require not only a liver resection but also the removal of the lymph glands near the liver. Furthermore, in the case of not completely resectable tumors in the sense of a multimodal therapy, the administration of various systemic therapies (e.g. chemotherapy) has an important role in the treatment of HCC. A special case is the early detection of HCC in a cirrhotic liver. Due to the general scarring (cirrhosis) of the liver, the calculated residual function of the remaining liver after a resection would often not be sufficient on the one hand, and on the other hand, the risk of the occurrence of new foci in the altered liver tissue would be massively increased. Therefore, the best therapy for these patients at present is a liver transplant, i.e. an exchange of the entire organ. Early detection and a quick decision on transplantation is crucial, as this therapy is only useful as long as no tumor cells have spread in the body. Since the average waiting time for transplantation in Innsbruck is significantly less than one year, we do not recommend - even if technically feasible - liver resection of small foci before a planned transplantation, but rather local tumor control by means of RFA or TACE. After tumor removal, all patients must be included in a regular follow-up program - as with any malignant tumor - in order to be able to detect and treat recurrence (relapse) in time.

Just as malignant tumors can develop from liver cells, there are also tumors that develop from the cells of the bile ducts or gall bladder. Depending on the place of origin, a distinction is therefore made between gallbladder carcinomas, intrahepatic cholangiocarcinomas (develop in the bile ducts in the liver) or extrahepatic cholangiocarcinomas (develop in the bile ducts outside the liver). A special form is represented by the so-called Klatskin tumors, which are extrahepatic cholangiocarcinomas of the bile ducts of the right and left bile ducts.

Type I: The tumor is localized only in the common bile duct and does not reach the fork of the right and left branch.

Type II: The tumor also reaches the fork, but does not extend into the intrahepatic bile ducts.

Type III: The tumor infiltrates the entire bile duct on one side (type IIIa on the right, type IIIb on the left) and reaches the segmental inflows there.

Type IV: The tumor extension reaches the segmental bile ducts in both liver lobes.

Cholangiocarcinomas are rare diseases with 1-2 new cases per 100000 inhabitants per year. These tumors are often discovered late, as patients are usually free of symptoms until the bile flow is increasingly blocked. There are no indicative laboratory values for the diagnosis of a cholangiocarcinoma. Instead, the diagnosis is made on the basis of the accumulation of bile ducts and - if possible - by obtaining a biopsy (often via ERCP). Since there is very often already a significant accumulation of bile, it may also be necessary to drain the bile before a planned operation - either by puncturing the enlarged bile ducts in the liver, or by draining it into the intestine (usually by inserting a stent). The only potentially curative therapy is a complete surgical removal of all tumor-affected liver and bile ducts in a center that is very experienced with this particular type of tumor. In selected cases, an accompanying chemotherapy and - in special cases - a liver transplantation can be part of the therapy concept.

Liver metastases are metastases from other tumors in the liver. An important task of the liver is to be a filter for blood from other organs (gastrointestinal tract). Therefore, tumor cells from these regions that are carried along with the blood stream can easily get caught in this filter and grow there. This also means, however, that a liver metastasis always means a very advanced tumor stage with tumor cells already carried along in the body. Overall, liver metastases (= secondary liver tumors) are significantly more common than primary liver tumors. By far the most frequent liver metastases come from colorectal carcinomas. Therefore, the therapy of liver metastases is always only a local control of the tumor in the liver, so that several procedures are available for the removal of the tumor, but in principle, one tries to remove as little liver tissue as possible. Due to the often very small lesions that occur equally in both liver lobes, accurate imaging (CT/MRI/ultrasound/PET) is required prior to the planned surgery. Furthermore, in many cases a puncture (biopsy) of the tumor from outside is necessary. Especially in the case of colorectal metastases, however, there are modern multimodal therapy concepts (combination of systemic pre- and post-treatment together with surgery/local ablation), which in recent years have also enabled successful therapy with long-term survival for tumors metastasized to the liver (5-year survival of up to 40%). The modern treatment of liver metastases is an interdisciplinary concept, involving a large number of other disciplines in addition to surgery. All patients are discussed several times in a joint tumor conference. A particular challenge is the treatment of bilateral liver metastases where complete removal does not seem possible. However, with a coordinated sequence of chemotherapy and in some cases successive resections, maximum interdisciplinary therapy is possible at a center such as the University Hospital Innsbruck. Possibilities for improving operability in such multiple metastases are, in addition to the already mentioned chemotherapy regimens, the targeted enlargement of non-tumor liver parts (through targeted closure of individual portal vein branches with increased regeneration of the surrounding liver parts = portal vein embolization), as well as a precisely coordinated combination of surgery and radiofrequency ablation (RFA). With the help of these multimodal approaches, a potentially curative therapy is possible in many cases for patients who until a few years ago were considered inoperable. The University Clinic Innsbruck offers to perform a second opinion on treatment options for patients with extensive liver involvement.

Pancreas

The pancreas is located behind the abdominal cavity immediately in front of the spine at the level of the 1st and 2nd lumbar vertebrae. It runs from the middle of the body behind the stomach to the spleen in the left upper abdomen. Due to its club-like shape, it can be divided into three sections - a head section, a body section and a tail section. The pancreas has two functions in the body:
The largest part of the organ produces digestive enzymes (pancreas), which are released into the intestines when food is consumed and help to decompose the food (= exocrine part).
In addition, there are specialized cell groups (islet cells), which regulate blood sugar via two hormones - insulin (lowers blood sugar levels) and glucagon (raises blood sugar levels). Therefore, functional limitations of the pancreas lead to a lack of digestive enzymes on the one hand, and to a disturbance of the blood sugar balance on the other hand (diabetes mellitus). Diseases of the pancreas - especially changes that require surgery - are often difficult to treat due to the location in the body and the nature of the organ and require special experience. In this context, the cooperation with other disciplines is of particular importance for an optimal treatment.

Inflammation of the pancreas (pancreatitis) can occur acutely and - after removal of the cause - heal, or take a chronic course with formation of scarring and cavity formation (pseudocysts) in the organ. Any acute inflammation of the pancreas is a serious disease requiring hospitalization. In most cases, however, such an acute inflammation can be cured by a non-surgical therapy. In some cases (inflammation caused by a gallstone that has slipped out of the gallbladder = biliary pancreatitis), however, it may be necessary to perform an endoscopy with stone removal (ERCP) and subsequent removal of the gallbladder. Likewise, any severe current inflammation can lead to the development of infection foci, which require further therapy - usually by puncture from the outside. However, recurrent inflammation (chronic pancreatitis) leads to progressive scarring (often mainly in the head area) of the pancreas, which leads to slow failure of the organ.

Symtoms of a chronic pancreatic disease are among others: pain in the upper abdomen and back, weight loss, change in stool habits (diarrhea), diabetes mellitus (diabetes)
An examination of the pancreas is carried out by means of imaging (usually computer tomography (CT), often also magnetic resonance imaging or ultrasound), a direct examination of the pancreatic duct (ERCP), and a blood test. While the loss of function of the organ can be compensated for by the addition of tablets on the one hand, and by the administration of insulin in the case of diabetes on the other, many patients with chronic pancreatic disease suffer primarily from persistent pain caused by scarring in the head area. In selected cases, surgery (pancreatic head resection) can be offered.

Benign tumors  

Changes in the pancreas that lead to cell proliferation are called tumors. A distinction is made between tumors that multiply unhindered in the organ and spread to other organs (malignant tumors), and those that grow slowly but do not destroy the organ and do not spread to other organs (benign tumors). Benign tumors of the pancreas are generally rare. The most common of these tumors are either from the hormone-producing cells (islet cells), or from the ductal system (mostly hollow roviding = cystic tumors).

Hormone-producing tumors of the pancreas 

Hormone-producing tumors are usually very small and cause problems due to the overproduction of the corresponding hormone. The most common type of these tumors produces insulin (insulinoma), so that patients become conspicuous by a repeated drop in blood sugar levels. The therapy of choice in such cases is the removal of the hormone-producing tumor - either by removing part of the pancreas, or often only by targeted removal (peeling) of the tumor itself.

Cystic tumors of the pancreas  

Cystic tumors of the pancreas pose a special challenge to the treating physicians. On the one hand, they are very slowly growing changes that usually cause little or no discomfort to the patient. On the other hand, there are special groups of these tumors that are very likely to become malignant over time. In this context, mucinous-cystic neoplasias (MCN) and intraductal papillary mucinous neoplasias (IPMN) are particularly at risk of degeneration. Therefore, every cystic alteration of the pancreas should be intensively examined to determine the risk of malignant degeneration. However, such an examination is often difficult and requires special experience with this clinical picture. In addition to a blood test and a computer tomography, an endoscopic examination (gastroscopy) with endoscopic ultrasound and possibly puncture of the change is always necessary. At the University Hospital Innsbruck, patients with such diseases are treated by the University Clinic for Surgery and the University Clinic for Internal Medicine and a therapy proposal is jointly presented in an interdisciplinary tumor conference.

In this case either a further - but in any case consistent - follow-up check is required, or surgical removal (see below).

Malignant tumors of the pancreas originate to the largest part (>95%) from the exocrine gland (=ductal adenocarcinoma), only rarely from the hormone-producing cells (1-2%) or other cells. After colon and stomach carcinoma, pancreatic carcinoma is the third most common gastrointestinal tumor type in humans. Men are slightly more frequently affected than women (1.5:1). A major problem in the treatment of pancreatic carcinoma is that this type of tumor remains painless for a long time and usually causes symptoms only when surrounding structures (nerves, bile ducts) are affected or when metastases have settled. Unfortunately, pancreatic carcinoma tends to seed early, affecting the lymph nodes surrounding the pancreas and subsequently the liver and peritoneum. While today a modern therapy concept for the treatment of pancreatic carcinoma always includes a multimodal therapy with possible pre-treatment, surgery and post-treatment, healing is only possible through surgery as early as possible, in which it is possible to remove all tumor parts completely.

Therefore, a consistent clarification of every change in the pancreas until a carcinoma is reliably excluded is of decisive importance for the success of a therapy. In addition to the clinical examination, an examination here always includes a blood test, a computer tomography and sometimes an endoscopic sonography, sampling or examination of the bile and pancreatic ducts (ERCP). Surgical removal of the tumor is usually successful as long as the tumor has not spread further than the lymph nodes adjacent to the pancreas. Technically, surgery is possible as long as the tumor has not affected the arteries surrounding the pancreas. In special cases, surgery is also advisable if the liver is affected individually. At present, studies are being conducted in an attempt to enable individual patients who cannot undergo primary surgery due to a tumor that is too advanced to undergo surgery, to undergo surgery after all by means of intensive pre-treatment. The University Hospital Innsbruck regularly participates in international studies in this field. In contrast to tumors of the exocrine glandular part, an infestation of the liver with multiple metastases does not represent an absolute contraindication for surgical removal of the pancreatic tumor. Depending on the aggressiveness (proliferation index), surgical removal of the pancreatic tumor and surgically easily accessible liver metastases may be indicated in terms of tumor mass reduction in order to improve the therapeutic success of postoperative (= adjuvant) chemo-/ hormone therapy. In any case, at the University Hospital Innsbruck the decision whether surgery or systemic therapy can be recommended to the patient is made within the framework of an interdisciplinary oncological consultation. The University Hospital Innsbruck is happy to offer the performance of an appropriate specialist examination with the preparation of a second opinion regarding treatment options for pancreatic head cancer.