In Hepatopancreatobiliary (Liver, Pancreas and Gall Bladder Surgery) Clinic of Liv Hospital, all diseases of liver, gall bladder and pancreas are treated by specialist physicians with multidisciplinary approach. Diseases of gall bladder and bile ducts, liver and pancreas tumors as well as hepatic metastases are managed with ERCP, laparoscopic method, open surgery and robotic surgery by ensuring patient’s comfort.

In Hepatopancreatobiliary (Liver, Pancreas and Gall Bladder Surgery) Clinic of Liv Hospital, where experienced specialists are employed, the patients can engage daily life activities within the shortest time possible thanks to robotic surgery, which represent the future of the surgery, and the risks of infection and bleeding are minimized comparing to the conventional surgeries.

1)     LIVER CANCANCERCER

What are the symptoms?

•   Abdominal distension,

•   Yellow discoloration of skin.

•   Itching

•   Sudden weight loss

•   Loss of appetite persisting for weeks

•   Postprandial fullness and flatulence even if patient eats a little

•   Nocturnal sweating

•   Sudden-onset worsening of overall health

•   Dark discoloration of urine and light or clay-colored stool

•   Pain originating from right upper abdominal quadrant and refers to the back

•   Fever

How is it diagnosed?

The first step of diagnosis is a physical examination by physician. This examination focuses on intra-abdominal organomegalies, such as hepatomegaly and splenomegaly, fluid collection in abdominal cavity – also referred to as ascites, and yellowing of skin and eyes. Blood tests may reveal out hepatic dysfunctions. Imaging modalities such as ultrasound, computed tomography and MRI may be necessary. Moreover, tissue specimens may be collected from the liver for testing. A tissue specimen is collected from the liver during the biopsy and this specimen is examined under microscope. If cancer is diagnosed, the condition is staged to understand the extent of the spread and to decide the treatment method. Staging is not only based on computed tomography and magnetic resonance imaging, but it is also determined with laparoscopic exploration under general anesthesia.

How is it treated?

There are various treatment methods for liver cancers. Treatment plan should consider the stage of the cancer and whether the rest of the liver is intact. Primary treatment options for the liver cancer are as follows:

•    Surgical intervention (partial hepatectomy or liver transplant)

•    Regional therapies like ablation or embolization

•    Chemotherapy and targeted treatment

•    Radiotherapy

A combination of these treatments may be required for some patients.

The first-line treatment is surgery, although not all patients are operable. This is related with the tumor load of the liver. If tumor load is very high in liver or if there is more than one lesion and the remaining hepatic tissue is not sufficient for the patient, surgical treatment is contraindicated. Volume of liver is measured on a CT scan.  First, the portal vein is embolized at the side of the liver to be resected and thus, the hepatic lobe that will not be resected in enlarged in 4 to 6 weeks. Next, surgery is carried out and postoperative hepatic failure is prevented. Chemotherapy and specific drugs are therapeutic options for the group of inoperable patients. Radio-embolization is reserved for metastatic lesions. In radioembolization method, microspheres (20 to 50 microns in size) labeled with radioactive substance are directly instilled into the feeding artery of liver and thus, treatment is applied.

What to expect after treatment?

After the treatment is completed, patients should necessarily be followed up at certain intervals. Liver and intra-abdominal organs are imaged using ultrasound, computed tomography or magnetic resonance imaging to check the post-operative course in the follow-up. Cancers usually relapse within two to three years.  For recurrences, a new treatment method is decided considering the stage of the relapsed cancer.

************************************

2)    PANCREATIC CANCER

What are the symptoms?

Pancreatic cancers become symptomatic at very late stages. However, some alarming signs emerge before the cancer is diagnosed.

Jaundice: Sudden-onset jaundice is a sign of bile duct obstruction. When this symptom develops, bile ducts should necessarily be evaluated with imaging methods (Ultrasound, computed tomography or MRI).

Weight loss: Unintended weight loss in a short period is a finding that should be investigated.
Diabetes mellitus: Diagnosis of diabetes mellitus may be an early sign, if family history is unremarkable for diabetes.

Steatorrhea (Fatty Stool): Many patients may experience changes in bowel habits secondary to the insufficiency of pancreatic enzymes. Patients generally neglect this finding, but workup is necessary if diarrhea persists for a long time.

How is it diagnosed?

Since symptoms of pancreas cancer are very similar to symptoms of many other diseases, they are not taken as seriously as they should be. Diagnosis is generally made with various tests and detailed examination and imaging of the pancreas and the peripancreatic region. Blood test, tissue analysis, magnetic resonance imaging, computed tomography, positron emission tomography, ultrasound and endoscopic ultrasound (EUS), ERCP, laparoscopy and biopsy methods are used for the diagnosis.

How is it treated?

For pancreatic cancer, treatment modalities include surgery, chemotherapy and radiotherapy and they require multidisciplinary approach. If the tumor is operable, surgery is the most efficacious modality. Whipple surgery is performed for tumors that involve the head of the pancreas (pancreatic head, duodenum, gallbladder and bile duct as well as peripheral lymph nodes are excised), while distal pancreatectomy is the surgical method preferred for tumors that are located in corpus and tail of the pancreas (middle segment and the tail of the pancreas, spleen and peripheral lymph nodes are excised). If venous involvement (portal vein, splenic vein) is identified in locally advanced tumors, the involved vein is also resected. The patient can be started on chemotherapy to prevent postoperative recurrence of the cancer. For locally advanced pancreatic cancers, treatment options are chemotherapy and radiotherapy combined with chemotherapy. Sometimes, these treatments are used to shrink the tumor into an operable size. One of the standard treatments for advanced stage pancreatic cancers is chemotherapy.

What to expect after treatment?

Patients face less postoperative problems, if the disease is diagnosed and treated in the early stage. Chemotherapy or radiotherapy is planned depending on the stage of the disease. In this period, the body tries to adapt to the surgery. Occasionally, complaints of abdominal pain, constipation and dyspepsia can be experienced. The doctor may prescribe additional medicines to manage those complaints. Nutritional disorder is one of the important problems. If nutrition is insufficient, food supplements or nutrition solutions may be required. If the patient cannot tolerate oral nutrition, the patient can be given intravenous fluid support. Nutrition requires extra attention for patients who need additional treatment (chemotherapy).

********************

3)     GALLBLADDER DISEASES AND CANCER

A)     GALLSTONES

What are the symptoms?

This health problem is usually asymptomatic. Gallstone or sludge is found in almost one of every 5 individuals. Indeed, only one of five patients is aware of gallstones or gallstones cause complaints such as pain, dyspepsia and distension in only one of 5 patients. The pain is typically felt in the right upper corner of the abdomen or around the mid-line just above the belly button. As the pain worsens, it may refer to the back or other abdominal quadrants. The pain lasting longer than 4 to 5 hours usually points to the irritation of the gallbladder. When foods rich in fat are consumed, post-prandial flatulence will be experienced, as the fat makes the digestion difficult.

How is it diagnosed?

The easiest modality to diagnose gallstones is an ultrasound scan.

How is it treated?

Up-to-date technological and medical advancements maximized comfort and minimized duration of operation in gallbladder surgeries. The gallbladder is surgically removed along with gallstones and thus, recurrence of gallstones is prevented. Laparoscopic or robotic methods allow very small incisions for gallbladder surgeries. Success rate is above 99 percent when the surgery is performed by experienced doctors. If gallbladder is not surgically removed in a patient with gallstones, severe problems, such as obstructive jaundice, can be faced when the gallstone migrates and obstructs the bile duct. If the gallbladder is left untreated for a long time, the condition may transform into cancer. 75% of gallbladder cancer is diagnosed in women and gallstone is identified in 80% of those patients. If the stone measures >3 cm in diameter, the risk of gallbladder cancer increases.

B)    GALLBLADDER CANCER

What are the symptoms?

The gallbladder cancer may not cause a symptom or symptoms may point to different diseases.

•    Jaundice

•    Abdominal pain

•    Digestive problems

•    Nausea, vomiting

•    Food intolerance.

•    Weight loss

•    Dark discoloration of urine, white stool

How is it diagnosed?

It is highly important to diagnose the gallbladder cancer at the early stage. Imaging modalities, such as ultrasound, tomography and MRI, are used depending on the symptoms. As the case many types of cancers, final diagnosis of the gallbladder cancer is made by biopsy following advanced imaging studies. These methods are used to diagnose a gallbladder cancer;

How is it treated?

Treatment of the gallbladder cancer requires surgical removal of the tumor. It may be necessary to remove a part of the liver. If the gallbladder cancer is diagnosed at advanced stage, surgery is no more an option. However, early diagnosis of the cancer ensures successful cure of the gallbladder cancer. For patients with inoperable advanced stage disease, possible options include certain endoscopic procedures that aim elimination of jaundice and alleviation of pain, analgesia and radiological intervention. Heated chemotherapy and recently developed smart drugs may also interfere with the progression of tumor.

c) BILE DUCT STONES (CHOLEDOCHOLITHIASIS)

A stone is identified in the choledochus in one of every 10 patients with gallstones and the percent rises to 25%, if the patient is older than 60.

What are the symptoms?

Bile duct stones can be clinically asymptomatic or can be manifested by complications such as biliary colic (post-prandial abdominal pain and nausea), obstructive jaundice, inflamed bile duct (cholangitis), liver infection (cholangiohepatitis), liver abscesses and pancreatic inflammation (pancreatitis).  The biliary colic is frequently accompanied by nausea and vomiting.

If the gallstone that obstructs the choledochus is left untreated, it can lead to cirrhosis of liver.

How is it diagnosed?

Diagnosis of choledocholithiasis is based on physical examination, laboratory, ultrasound and magnetic resonance imaging (MRCP), if necessary. Endoscopic ultrasound (EUS) is rarely necessary for the diagnosis. Physical examination can be completely unremarkable or minimal tenderness is noted in upper-middle and right (epigastrium and right hypochondrium) abdominal quadrants or mild yellowness is seen in sclera. The body turns yellow completely in advanced stage jaundice.

How is it treated?

ERCP: Endoscopic retrograde cholangio-pancreatography is the gold standard in the treatment of choledocholithiasis. Endoscope is inserted by mouth and the procedure lasts 10 to 15 minutes and the success rate is 98%, if the procedure is performed by experienced doctors. Most patients can start eating meals 2 hours after ERCP is completed and they are discharged on the same day. PTC (percutaneous transhepatic cholangiography) or a surgery may rarely be necessary for the treatment of choledocholithiasis.

4)    PERIPANCREATIC COLLECTIONS SECONDARY TO PANCREATIC INFLAMMATIONS

Endoscopic Drainage of Pseudocyst and Walled-Off Necrosis (WON)

Pancreatic pseudocyst and walled-off necrosis (WON) are local peripancreatic fluid collections that develop following injury of pancreas, including the common pancreatic canal and/or sub-ducts. The pancreatic canal can be damaged secondary to acute pancreatitis (gallstone, alcohol, trauma, abdominal surgery, ERCP, etc.) or chronic pancreatitis (alcohol, autoimmune etc.).

The early peripancreatic collections gets chronic form by 5-15% if it superimposes on acute pancreatitis or by 40% if it superimposes on chronic pancreatitis; the chronic collection is referred to as pancreatic pseudocyst.

A pseudocyst is a peripancreatic fluid collection that is enclosed by a fibrous pseudocapsule and does not contain solid material. Walled-off necrosis (WON) is necrotic pancreas parenchyma and peripancreatic tissue that become a collection with internal pancreatic fluid and solid-necrotic tissue which is confined by an inflammatory capsule following necrotizing acute pancreatitis.

What are the symptoms?

It can be manifested by abdominal pain, persistent nausea and vomiting, fatigue, weight loss and abdominal distension following pancreatic inflammation.

How is it diagnosed?

Blood tests, ultrasound and CT (computed tomography) are used to make the diagnosis.

How is it treated?

The pancreatic pseudocyst and walled-off necrosis are mostly cured with non-surgical endoscopic cystogastrostomy. An endoscope is inserted through the mouth and a plastic or metallic stent is placed in the cyst via the stomach or duodenum and the fluid is drained into the stomach. In walled-off necrosis, it may be necessary to pull the dead (necrotic) tissue of the cyst to the stomach with the endoscope. Laparoscopic or open surgery is required rarely if the endoscopic treatment fails.

Prof. Dr. Kemal Dolay

General Surgery

Liv Hospital