Hepatopancreatic-biliary surgery

Our centre performs the most complex operations on the hepatobiliary area. Patients with colorectal cancer, hepatocellular carcinoma, cholangiocarcinoma and pancreatic tumours are treated under the OMS.

Hepatocellular cancer

Hepatocellular cancer (HCC) (hepatocellular carcinoma, liver cell carcinoma) is the most common (about 85 % of cases) malignant tumour of the liver, originating from hepatocytes (liver cells).
Less common are cholangiocellular cancer (cholangiocarcinoma), a malignancy originating from the epithelium of the intrahepatic bile ducts, and mixed hepatocholangiocarcinoma, fibrolamellar carcinoma, which is formally classified as liver-cell variant cancer.
Causes of development
Hepatocellular carcinoma most commonly develops against a background of cirrhosis (approx. 80 % of cases) or chronic inflammation of any aetiology: viral hepatitis B and C, alcoholic and non-alcoholic steatohepatitis, primary sclerosing and autoimmune hepatitis, exogenous toxic liver damage (caused by aflotoxins, vinyl chloride, use of steroid hormones), hereditary diseases (alpha-1-antitrypsin deficiency, tyrosinemia and haemochromatosis) and immune system disorders that cause liver damage and lead to chronic hepatitis and cirrhosis. Less than 10% of cases of HCC develop in healthy liver tissue.
TNM staging (8th revision, 2017)
T - primary tumour.
TX - it is not possible to assess a primary tumour;
T0 - no evidence of a primary tumour;
T1 - solitary tumour:
-T1a - solitary tumour ≤2 cm in the greatest dimension with or without vascular invasion.
-T1b - A solitary tumour >2 cm in the greatest dimension without vascular invasion.
T2 - A solitary tumour >2 cm with vascular invasion, or multiple tumours ≤5 cm in greatest dimension.
T3 - Multiple tumours, including at least one tumour >5 cm in the greatest dimension.
T4 - Single tumour or multiple tumours of any size with protrusion into a major branch of the portal vein or into the hepatic vein, or with protrusion into adjacent organs, including the diaphragm (except the gallbladder), or with protrusion into the visceral peritoneum.
N - involvement of regional lymph nodes.
Regional lymph nodes are lymph nodes of the liver gate (located in the hepatic duodenal ligament).
NX - insufficient data to assess regional lymph node status.
N0 - no evidence of metastatic involvement of regional lymph nodes.
N1 - there is a lesion of regional lymph nodes with metastases.
M - distant metastases.
MH - insufficient data to identify distant metastases.
M0 - no distant metastases.
M1 - there are distant metastases.
pTNM - pathohistological classification.
Staging Barcelona Clinic Liver Cancer (BCLC classification)
Barcelona Clinic Liver Cancer (BCLC) classification is the most commonly used classification for liver cancer, which takes into account the extent of the tumour process, the functional status of the liver, the objective condition of the patient and the expected effectiveness of treatment.
Very early stage (BCLC 0) - solitary liver tumour
Early stage (BCLC A) - solitary liver tumour of any size or no more than 3 nodes up to 3 cm in size, not spreading on main vessels of liver, adjacent anatomic structures, in patient without tumour-specific complaints, in satisfactory objective condition (ECOG 0) with preserved liver function.
Intermediate stage (BCLC B) - cases of isolated asymptomatic multiple hepatic tumor lesions without macrovascular invasion in patients in satisfactory condition (ECOG 0) with preserved liver function.
Advanced stage (BCLC C) - asymptomatic tumour that worsens the objective status of the patient (ECOG 0-2), of any size, with or without invasion into the main hepatic vessels and/or with extrahepatic spread with preserved hepatic function.
Terminal stage (BCLC D) - cases with significant objective deterioration (tumour/cirrhosis), decompensated cirrhosis (Child - Pugh grade C).
Стадирование рака по Барселонской системе
Most commonly, HCC develops on the background of chronic liver disease - cirrhosis, viral hepatitis, steatohepatitis - which, like the tumour process, may present with specific symptoms, require specific therapy, competitively affect quality of life and impair survival. As part of a multidisciplinary assessment of the patient's condition, it is necessary to evaluate the functional reserves of the liver, the severity of background liver disease, and the extent of the tumour process.
The primary tumour/s are visualised by abdominal ultrasound and assessment of the oncological marker alpha-fetoprotein (AFP).
If the nodule is less than 10 mm and the AFP level is normal, the tests must be repeated after 3 months. If the AFP level is elevated or there is a nodule of more than 10 m, the next step is to perform a CT or MRI scan of the abdomen with IV contrast. If suspicion of cancer is confirmed, liver function reserves, background liver disease and the extent of the tumour must be assessed as part of a multidisciplinary assessment of the patient's condition.
Стадирование рака по Барселонской системе
The task of the multidisciplinary team is to decide on further treatment:
Surgical treatment:
- Bridge therapy (waiting therapy, which aims to slow down tumour progression and reduce the likelihood of dropping out of the transplant waiting list) or down-staging therapy (which aims to reduce the intrahepatic spread of the tumour in the absence of extrahepatic changes). It includes ablation, transarterial embolisation, liver resection, and drug therapy.
- Surgical intervention is possible in BCLC stage 0/A, BCLC B with limited organ damage, and in selected BCLC C.
In some cases, it is advisable to perform ablation after preliminary transarterial (chemo-) embolisation of the liver tumour. Local destruction is contraindicated in multiple liver lesions, decompensated cirrhosis (Child-Pugh class C), extrahepatic manifestations of the disease, presence of portal shunt, non-displaced adjacency of the tumor node to adjacent organs as well as extra-(intra-) hepatic tubular structures.
Transarterial chemoembolisation (TACE) of tumour vessels in 1st-line palliative treatment in patients with HCC with unresectable/inoperable process without signs of invasion/thrombosis of the main hepatic vessels and without extrahepatic manifestations of the disease in combination with other methods of local and systemic treatment, as well as in the waiting period for a liver transplant to improve control of tumour growth.
Стадирование рака по Барселонской системе
Metastatic liver injury in colorectal cancer
Despite improvements in early diagnosis, 20% of patients with colorectal cancer have detached metastases already at the stage of diagnosis, and another 25-30% are detected during follow-up. The latest therapies - the emergence of new treatment regimens, improvements in surgical instruments and surgical techniques allow colorectal cancer metastases in the liver to be removed, with minimal interruption between cycles of chemotherapy.
Performing a CT scan of the 3 zones with IV contrast, performing an MRI of the OBP with IV contrast allows us to evaluate the size, degree of metastasis infiltration, area of perifocal inflammation, ratio of tumour foci to the veins and arteries of the liver, thus allowing a multidisciplinary team consisting of a radiation diagnostician, an oncological surgeon, a chemotherapist oncologist, a radiation oncologist rehabilitation therapist to build a 3D visualisation of the liver tumours, assess the resectability of metastases, select the date of surgery between cycles of drug therapy, prescribe pre-rehabilitation and rehabilitation, thereby reducing the risk of postoperative complications, obtain R0 resection status, and continue drug therapy without delays in treatment.
Pre-rehabilitation should be carried out before the start of treatment
In order to increase cardiorespiratory endurance in preparation for anticancer treatment, home exercise classes (aerobic and moderate-intensity anaerobic exercise) of at least 15 min a day, 6-7 times a week are recommended in patients with HCC to reduce the incidence of postoperative complications Nutritional support is recommended in patients with at least one of these factors: unintentional weight loss of 10% or more of baseline over the past 6 months, Body mass index <18.5 kg/m2 , inadequate food intake (calories <1500 kcal/d) to improve treatment outcomes and survival.
Rehabilitation for surgical treatment
First phase of rehabilitation

- Early mobilization and activation of patients with HCC (verticalization, breathing exercises, physical therapy) under the supervision of a trainer, starting on day 1-2 after surgery to reduce the incidence of complications and shorten the period of hospitalization
- Early enteral feeding (on the 2nd postoperative day) with focus on the general principles of nutritional support after abdominal surgery to reduce the incidence of complications and length of hospital stay. The purpose of nutritional support is to improve cardiorespiratory endurance of a patient, which results in decrease of non-surgical complications and length of hospital stay.

Second stage of rehabilitation

- Aerobic with gradual increase in its intensity up to 150 min/wk, and resistance exercises (8-10 repetitions on the main muscle groups) 2 times a week under the supervision of an exercise instructor to improve the patient's quality of life and speed up social rehabilitation. The aim of physical activity is to restore cardiorespiratory endurance, which prevents the development of muscle weakness and the appearance and progression of sarcopenia, improves the patient's quality of life and speeds up social rehabilitation.

The third stage of rehabilitation

- home - regular exercise, starting with low-intensity aerobic exercise and gradually increasing to moderate-intensity aerobic exercise in combination with resistance exercises on the major muscle groups (15-20 min, 8-10 repetitions) twice a week to improve cardiorespiratory endurance and quality of life [72]. The strength of recommendation is C (level of evidence: 5). Comments: The aim of exercise training is to maintain muscle mass, improve cardiorespiratory endurance, enhance quality of life and increase overall survival. A minimum of 30 minutes a day of moderate-intensity exercise on several (most) days a week is desirable, considering the presence and severity of complications of anti-tumour treatment.

In our centre, we perform both diagnostic operations: trepan biopsies, diagnostic laparoscopies with incisional biopsies; and operations to treat the underlying disease:
1) Extended right-sided hemihepatectomy
2) Extended left-sided hemihepatectomy
3) Right-sided hemihepatectomy
4) Left-sided hemihepatectomy
5) Left-sided caval lobectomy
6) Right lateral lobectomy
7) Resection of IV, V segments
8) Laparoscopic atypical resections within 2 segments
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