What is the management of hepatobiliary disease in surgical patients?

Management of Hepatobiliary Disease in Surgery

Surgical management of hepatobiliary disease requires a comprehensive multidisciplinary approach with careful preoperative assessment, appropriate surgical technique selection, and meticulous postoperative care to optimize outcomes related to morbidity, mortality, and quality of life.

Preoperative Assessment and Optimization

Liver Function Evaluation

• Preoperative liver function assessment is crucial before complex hepatic resections, especially in patients with:

  • Suspected or known underlying liver disease
  • History of chemotherapy-associated liver injury
  • Drug-induced liver injury 1

• Assessment should include:

  • Clinical evaluation for signs of liver dysfunction
  • Blood-based scores reflecting liver function (albumin/bilirubin ratio, platelet count)
  • Volumetry of future liver remnant (FLR) as foundation for assessment 1
  • Functional testing with:
    • Indocyanine green clearance
    • LiMAx® test
    • Functional MRI
    • Hepatobiliary scintigraphy (combines FLR volume and function) 2

Biliary Drainage

• Preoperative biliary drainage should be performed selectively rather than routinely, with specific indications including cholangitis, planned major hepatectomy with bilirubin >50 μmol/L, need for neoadjuvant therapy, or when extensive surgery (>50% of liver parenchyma) is planned 3

• Indications for preoperative biliary drainage in perihilar cholangiocarcinoma:

  • Major hepatectomy (>60% of total liver volume) with total bilirubin >200 μmol/L
  • Cholangitis
  • Prior to portal vein embolization (PVE)
  • Malnutrition 3

• Technique considerations:

  • Endoscopic approaches are preferred when possible 3
  • Removable plastic stents should be used for preoperative drainage 3
  • Drainage should include all opacified segments, avoiding atrophic segments 3

Surgical Management by Disease Type

Cholangiocarcinoma

• Primary treatment is complete resection with negative margins (R0) 4

• Surgical approach depends on tumor location:

  • Intrahepatic: Resection of involved segments or lobe of liver
  • Perihilar (Klatskin): En bloc resection of extrahepatic bile ducts and gallbladder, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy
  • Distal: Pancreatoduodenectomy (Whipple procedure) 4

• Technical considerations:

  • Right portal vein embolization often needed to induce hypertrophy of future liver remnant
  • Caudate lobe (segment I) must be removed in any curative-intent procedure
  • Lymphadenectomy should be standard with ≥7 lymph nodes for adequate staging 4

Bile Duct Injury (BDI)

• Management depends on timing of detection and severity:

  • Minor BDIs (Strasberg A-D): Initial observation if drain is placed; if no drain, percutaneous drainage is indicated 3
  • Major BDIs (Strasberg E1-E2) diagnosed within 72 hours: Urgent referral to hepatopancreatobiliary center for surgical repair with Roux-en-Y hepaticojejunostomy 3
  • Major BDIs diagnosed between 72h and 3 weeks: Percutaneous drainage, targeted antibiotics, nutritional support, and consideration of ERCP with sphincterotomy; definitive repair with Roux-en-Y hepaticojejunostomy after minimum 3 weeks 3

• Preoperative accurate assessment of BDI is essential, including:

  • Location of injury or stenosis
  • Degree and length of bile duct loss or stenosis
  • Status of proximal bile duct (expansion)
  • Connection between left and right hepatic ducts
  • Involvement of right posterior hepatic duct
  • Associated vascular injury 3

Perioperative Management

Fluid Management

• Low central venous pressure (below 5 cm H₂O) with close monitoring during hepatic transection
• Balanced crystalloid preferred over 0.9% saline or colloids for maintenance
• Goal-directed fluid therapy to optimize cardiac output and end-organ perfusion, especially after liver resection 3

Infection Control

• In patients with biliary fistula, biloma, or bile peritonitis, antibiotics should be started immediately (within 1 hour)
• For surgical prophylaxis in hepatobiliary procedures, ceftriaxone is effective for preventing infections at the operative site 5

Postoperative Care and Complications

Monitoring for Complications

• Prompt investigation of patients who do not rapidly recover after laparoscopic cholecystectomy
• Alarm symptoms include fever, abdominal pain, distention, jaundice, nausea, and vomiting 3
• Assessment of liver function tests, including serum levels of direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin 3

Management of Postoperative Liver Failure

• Posthepatectomy liver failure (PHLF) is a significant contributor to morbidity and mortality
• Risk factors include underlying liver disease, extensive resection, and inadequate future liver remnant
• Management includes supportive care, nutritional support, and treatment of complications 1

Multidisciplinary Team Approach

• All patients with hepatobiliary malignancies should be discussed in a multidisciplinary team (MDT) meeting

• MDT should include at minimum:

  • Hepatobiliary/transplant surgeon
  • Hepatologist
  • Oncologist
  • Radiologist
  • Pathologist 3

• Potential biases in MDT decision-making to avoid:

  • Excessive empiricism (too much weight on personal experiences)
  • Excessive rationalism (too much weight on quantifiable parameters)
  • Uneven perception of gain and loss (risk aversion)
  • Lack of clustered principle (considering treatments in isolation) 3

Follow-up and Surveillance

• For malignancies, consider imaging studies every 6 months for 2 years after resection
• Re-evaluation according to initial workup if disease progression occurs 4
• Regular audit and feedback should be implemented to monitor and improve postoperative outcomes 3