Injury from cholecystectomy: Injury to the common bile duct during laparosopic cholecystectomy occurs in 1 in 1000 patients. The type of injuries are classified as shown below. Patient's with a bile duct injury have the best outcome when repaired by a surgeon experienced with hepato-pancreato-biliary surgery.



The repair usually involves complete removal of the injured bile duct and reconstruction using a segment of intestine to reconnect the bile to. This procedure is called a hepatico-jejunostomy with roux-en-y limb.



Factors that effect a success repair are surgeon experience, injury to the artery supplying blood to the bile duct, and local infection.

Cysts:

Stricture:

Cholangiocarcinoma:

All patients being considered for treatment for hepatitis B need to be tested for the presence of liver cancer and cirrhosis.

Blood tests necessary to determine how best to treat patients include: surface antigen, e-antigen, e-antibody, viral load and genotype.

Drugs for HBV treatment fall mainly into two categories: immune modulators (interferons) and those that inhibit HBV replication. Responses to therapy are described as “initial response”, measured at 6 months or 12 months into treatment, “maintained response” when the response is still present at the patients last visit, and a “sustained response” when the response is still present 6 months after the completion of therapy. A resolved infection or "response" is a sustained loss of HBsAg.

Immune Modulators
pegylated interferon (Pegasys, Roche)
pegylated interferon (Peg-Intron A, Merck)

Inhibitors of HBV replication
tenofovir, (Viread, Gilead Sciences)
entecavir (Baraclude,Bristol-Myers Squibb)
adefovir dipivoxil (Hepsera, Gilead Sciences)
telbivudine (Tyzeka, Novartis)
lamivudine (Epivir-HBV, GlaxoSmithKline)

Of these, tenofovir is the most potent with no reported viral resistance reported after 3 years on treatment. Entecavir also has low reported resistance after long term use. Advantages over interferons include a more rapid response, oral administration, and a good tolerability with fewer adverse effects. The disadvantages of these drugs include uncertainty about the durability of HBeAg seroconversion and development of antiviral resistance. The 3-year relapse rate has varied between 38% and 77%.

Although drug treatment has yielded disappointing results, the National Institutes of Health recommends that all patients with chronic HCV be considered for drug treatment. Factors that affect outcome are underlying liver damage, patient motivation, and HCV genotype and patient polymorphism testing. Treatment of HCV genotypes 1 or 4 have a success rate of about 40% to 55%, but patients with HCV genotypes 2 or 3 have a 70% to 80% treatment success rate, commonly referred to as a sustained viral response (SVR), meaning virus is no longer detectable in the blood.

For HCV genotype 1 patients, patient polymorphism testing allows doctors to determine which patients are mostly likely to have a SVR. Polymorphism results can be CC, TC, or TT. HCV genotype 1, CC polymorphism patients have a 7-8 out of 10 chance of a SVR. HCV genotype 1, TT polymorphism patients have a 2-3 out of 10 chance of a SVR. TC polymorphism patients have a 4-5 out of 10 chance of a SVR.

Numerous Direct Antiviral Agents (DAA) are in development. First generation protease inhibitors should be available during spring 2011. The first two agents to be approved by the Federal Drug Administration (FDA) will be Telaprevir (Vertex Pharma) and Boceprevir (Merck Pharma). These agents are to be given in combination with pegylated interferon and ribavirin. The overall SVR with these combinations are expected to be 70-80%.

Options to treat liver cancers:

Due to the low survival of liver cancer, patients should consider participation in a clinical trial to find better treatments.

FDA approved agents
Nexavar (Sorafenib) is a drug that stops the growth of small blood vessels that feed cancers and allow them to grow. Sorafenib is FDA approved for the treatment of patients with unresectable hepatocellular carcinoma (HCC).

Patients with a healthy liver.
1) Surgery: If your liver is healthy
a. Laparoscopic: less painful, shorter hospitalization
b. Open: if laparoscopic surgery not possible

Patients with an unhealthy liver (cirrhosis).

1) Liver transplant: in patients with small cancers liver transplant is a treatment option. Eligible patients either have a single tumor , less than 5 cm in diameter or no more than 3 tumors, each being no greater than 3 cm in diameter. There can be no tumor outside the liver or invasion of tumor into visible vessels in the the liver.

2) Local destruction of cancer within your liver: If your liver is not healthy enough to tolerate surgery, options to treat the cancer include

a. Hepatic artery embolization: injection of tiny particles to block blood supply to cancer, causing it to die. Often combined with injecting chemotherapy into blood supply feeding cancer.

b. Radio Frequency Ablation: uses a multi-prong needle to cook cancer within your liver. Can be performed using laparoscopic surgery or through the skin (percutaneous).

c. Alcohol injection: for cancers less than 2 cm in diameter injection of 5-10 ml of alcohol can be used to destroy the cancer.

d. 3D conformal radiation: If the cancer invades the veins feeding your liver (portal vein), highly focused radiation is used to stop the growth of the tumor in the vein.

e. Yitrium-90 particle: These are insoluble glass microspheres where Yttrium-90 is an integral constituent of the glass. Yttrium-90 emits pure beta radiation that can kill a cancer.

Colon & Rectal cancer metastasis:

Neuroendocrine:

Adenomas:

Hemangiomas:

Cysts:

Fatty liver is an American epidemic that is directly related to the obesity epidemic. About 5% of patients with a fatty liver develop inflammation in the liver. This is called steatohepatitis. Most fatty liver and steatohepatitis improve with weight loss and increased exercise.

Vitamin E (800 international units a day) can help reduce abnormal liver laboratories associated with steatohepatitis. However, weight loss and exercise are most helpful in restoring normal liver function

Complications from untreated steatohepatitis include cirrhosis, liver cancer, and liver failure. By the year 2022, complications from steatohepatitis will be the leading cause for need of liver transplant.

Hydatid cyst (ecchinococcus)

Liver abscess (pyogenic)

Liver abscess (amebic)

Drug over dose:

Acute hepatitis:

The pancreas is organ located deep in the back of the body (retroperitoneal space) in the upper part of the abdomen. It is almost completely covered in front by the stomach and duodenum. The pancreas may be divided into five major regions—the head, neck, body, tail and uncinate process. Acute pancreatitis refers to an acute inflammatory process of the pancreas, usually accompanied by abdominal pain, nausea, vomiting and elevations of serum pancreatic enzymes. Eighty percent of the cases of acute pancreatitis in the United States are related to alcohol use or biliary stones. Pancreatitis may be classified as mild, moderate, or severe based on physical findings, laboratory values, and radiological imaging. Mild disease is not associated with complications or organ dysfunction and recovery is uneventful. In contrast, severe pancreatitis is characterized by pancreatic dysfunction, local and systemic complications, and a complicated recovery.



Gallstones are the most common cause of pancreatitis in the United States. It is believe that obstruction of the major papilla by a stone causes reflux of bile into the pancreatic duct





Alcohol is the second leading cause of acute pancreatitis. In many patients, however, chronic pancreatitis is already present. The cause of alcohol related pancreatitis is believed to result from abnormal major papilla function, direct toxic and metabolic effects, and small duct blockage by protein plug formation.




Drugs: are a well-recognized cause of pancreatitis. These drugs may be divided into those that have a definite association and probable association with the development of acute pancreatitis.
Clearly linked drugs include:
Azathioprine, 6-mercaptopurine, Trimethprim-sulfamethoxazole, Pentamidine, 2',3'-Dideoxyinosine, Asparaginase, Methyl-dopa
Likely linked drugs:
Sulfasalazine, Captopril, Alfa-interferon, Estrogens, Aminosalicylic acid,Corticosteroids, Corticotropin, Acetaminophen, Sulindac, Tetraclcline, Metronidazole, Thiazide diuretics, Furosemide, Isotretinoin, Valproic acid

Pancreas Divisum: The most common congenital anomaly of the pancreas, occurs in approximately 10% of the population, and results from incomplete or absent fusion of the dorsal and ventral pancreatic ducts during embryological development.

Microlithiasis: Many patients with acute pancreatitis of unknown cause will have microlithiasis. This may be diagnosed either as gallbladder sludge on ultrasound (ultrasound of gallbladder sludge) or as crystals on microscopic examination of bile

Metabolic Causes: Hyperlipidemia and hypercalcemia can cause acute pancreatitis. In patients with hyperlipidemia, triglyceride levels are usually greater than 2,000mg/dl. It is believed that lipase present in the pancreatic capillaries metabolizes the levels of triglyceride generating toxic free fatty acids. Hypercalcemia has been shown to induce experimental pancreatitis, probably by increasing pancreatic duct permeability. Its mechanism for the development of clinical pancreatitis is not clear.

Sphincter of Oddi Dysfunction: In a few patients with recurrent pancreatitis of unknown cause, pressure studies of the sphincter of Oddi show abnormal motility. Endoscopic or surgical sphincterotomy directed to the sphincter of Oddi, may be beneficial in these patients. Use of nitrates or calcium channel blockers may also provide short-term relief.

Other Causes: Viral, bacterial, and parasitic infection may cause pancreatitis, mumps and Coxsackie B virus infection being the most common. The human immunodeficiency virus (HIV) may cause elevation of serum pancreatic enzymes but rarely leads to severe pancreatitis. Bacterial infections that can cause acute pancreatitis include Salmonella, Shigella, Campylobacter, Escherichia, Legionella, Leptospira, and even brucella.

Patients chronic pancreatitis can suffer from scarring within the pancreatic duct in the pancreas or formation of pseudocysts. These are both basically caused by blockage of the pancreas duct. The basic procedure is to correct the blockage and let the pancreatic juices flow into the intestine.

Pseudocysts:
Communicating pseudocysts
Sphincteroplasty drainage: If the pseudocystcyst connects to the main pancreatic duct, use of endoscopic sphincterotomy via Endoscopic Retrograde CholangioPancreatography (ERCP) is usually the first option to try to fix a blocked pancreatic duct and let the pancreatic juices drain from the psedocyt.



Non-communicating pseudocysts
Transgastric Endoscopic Pseudocyst Drainage: Using endoscopy, if the pseudocyst is next to stomach, a plastic tube can be placed through he stomach wall into the cyst to



Pseudocyst Drainage: the cyst is drained into the stomach or a segment of small intestine



Longitudinal Pancreaticojejunostomy (Puestow Procedure): The pancreatic duct is opened from the tail to the head of the pancreas and attached to the small bowel.

Distal Pancreaticojejunostomy (Du Val Procedure): The pancreas is divided transversely at the neck, and the body and tail are drained via attachment to the small bowel.

Pancreas divisum is the most common congenital anomaly of the pancreas, and occurs in approximately 10% of the population. This anomaly results from incomplete or absent fusion of the dorsal and ventral ducts during embryological development. In pancreas divisum, the ventral Duct of Wirsung empties into the duodenum through the major papilla but draining only a small portion of the pancreas (ventral portion). Other regions of the pancreas, including the tail, body, neck and the remainder of the head, drain into the duodenum through the minor papilla via the dorsal duct of Santorini. Obstruction of the minor papilla can cause acute pancreatitis or chronic pancreatitis in patients with pancreas divisum when most of the pancreas drains through the minor dorsal duct (hence the term dominant dorsal duct syndrome).


Normal pancreas: main and accessory ducts joined


Pancreas Divisum: main and accessory ducts do not join


Endoscopic minor papilla sphincterotomy is an effective treatment for patients with recurrent pancreatitis and pancreas divisum. Good long-term results are found in about 70% of patients but may be significantly less if there are changes of chronic pancreatitis. Surgical sphincteroplasty of the minor pancreatic sphincter is indicated for unsuccessful or failed endoscopic minor papilla sphincterotomy in patients with pancreas divisum.

Pancreas cancer remains a deadly disease. Over 9 out of 10 people with pancreas cancer will not live longer than 5 years from the time they were first diagnosed. At surgery, only 4 out of 10 patient will be eligible for a curative surgical resection. Of patients surgically resected, 8 out of 10 will have have their pancreas cancer reoccur. Only 2 out of 10 patients surgically resected for cure will be alive 5 years after surgery.

Any patient with pancreas cancer should strongly consider enrolling in a clinical trial.

At the National Cancer Institute patient treatment information web site, clinical trials listed are possible treatment options for patients with pancreas cancer.

If you are eligible for surgical removal of a pancreas cancer, the 2 most common procedures are as follows

1) If the tumor is located in the head of the pancreas, a pancreaticoduodenectomy, also known as a Whipple procedure, is the surgery most commonly used. This involves removing the pancreas head, duodenum, gallbladder, portion of the bile duct,and part of the stomach. (figure 1)



The reconstruction is shown in figure 2



2) If the tumor is located in the body or tail of the pancreas, the procedure of choice is a distal pancreatectomy. The can usually be performed laparoscopically. (see below)