Hepatobiliopancreatic surgery is a complex surgery on extremely delicate organs and systems, rich in innervations and vascularization, connected together anatomically and functionally. There are diseases of benign surgical interest and neoplastic diseases. The benign pathologies include gallbladder stones , biliary tract stones , cystic and pseudocystic lesions and lesions considered preneoplastic. The neoplasms, whose treatment is extremely complex, are the most interesting aspect of hepatobiliopancreatic surgery, which for their wide variety and heterogeneity see the need to be treated by dedicated surgeons with high specialization incentives.
What are the main techniques and in which cases are they performed?
Primary malignancies can be recognized in the liver, that is, they arise as the first onset in the organ, or secondary (so-called ” metastases “), which reach the liver through the blood from tumors located in other organs (eg colon, stomach, pancreas, kidney , ovary, etc.). The interventions may require removal of important parts of the liver (major hepatectomies) or of smaller portions (minor hepatectomies). Resections of small parts of the liver (segmentectomies) or atypical resections in relation to the respect or not of well-defined anatomical plans can also be performed.
The biliary system, composed of the gallbladder and the intra and extrahepatic biliary tract, mainly sees primary tumors of the gallbladder and biliary tract (in these cases called ” cholangiocarcinomas“), Which may affect the part inside the liver or outside it. Treatment may involve removal of the biliary tract associated or not with hepatectomies or, in the case of distal tumors, treatment similar to pancreatic head tumors is required, i.e. removal of both the biliary tract and the duodenum and pancreas head (duodenocephalopancreasectomy). This multiple district removal is a consequence of the close anatomical connection of the structures and the need to carry out a surgery that is radical, that is, that does not leave any residual disease. In gallbladder cancer, cholecystectomy associated with the resection of portions of the liver adjacent to the bowel is expected.via biliary .
How are pancreatic neoplasms distinguished?
Pancreatic neoplasmsthey are distinguished by their location in tumors of the head of the pancreas (i.e. the so-called cephalic portion of the organ and attached to the duodenum) and neoplasms of the body-tail (i.e. of the distal part near the spleen). They present different problems and require different types of interventions. In the case of pancreatic head neoplasms, a duodenocephalopancreasectomy is performed, which is also associated with a cholecystectomy. In the distal tumors of the pancreas, the intervention of choice is the distal splenopancreasectomy (i.e. the removal of the body-tail pancreas and spleen). It should be noted that in the case of distal removal, the onset of postoperative diabetes is frequent, because these are the sites where Langherans cells are present, responsible for glycemic control. The diabetesiatrogenic can, in some cases, be avoided by performing an autologous transplantation of Langherans cells. At the moment, malignant tumors of the pancreas represent the 4th cause of death, with an incremental tendency of this percentage, and are burdened by a not exciting prognosis.
Are there any contraindications to this type of intervention?
Being a complex surgery to be performed in selected and well-studied cases, it is clear that it must be carried out with caution in patients with serious associated diseases, otherwise it may even become contraindicated.
Oncological diseases: why is the multidisciplinary approach important?
In the oncological field, advanced tumors, that is, which extend beyond the organ infiltrating nearby structures or even giving distant metastases, which therefore do not allow a radical therapeutic act, are absolutely to be proscribed. The advances in medical cancer therapies ( chemotherapy and radiotherapy) allow, after a multidisciplinary consultation, a joint multimodal treatment that often involves, where possible, the surgical act following the other therapies. In this way, better results are obtained in terms of surgical radicality and long-term survival.
How do you choose the most suitable technique for each patient?
Surgical techniques make use of traditional laparotomy surgery and minimally invasive surgery, both laparoscopic and robotic. The choice of surgical technique depends on the type of pathology, the location, the patient and can differ from subject to subject: we are in an era where treatment is increasingly oriented towards personalized surgery.
What are the advantages of minimally invasive surgery?
The advantages of minimally invasive techniques are manifold, among which the most interesting are:
- Less insult on the tissues with a patient benefit in terms of fast functional recovery;
- Shorter hospitalization time;
- Enhanced immune response;
- Less postoperative pain.
The aesthetic result, although extremely appreciated by the patient, is certainly the one of least interest from the medical point of view.
Is hepatobiliopancreatic surgery risky?
The surgery epatobiliopancreatica has made great strides with the introduction of increasingly sophisticated tools and innovative and should not be considered neither the only therapy or a therapy in its own right. Find the right effectiveness, only, if used at the right time and on the right patient. All this is feasible with a multidisciplinary and multi-professional approach. It should be emphasized that there is no surgical act, even a trivial one, that does not present a perioperative risk. It is related to the patient’s condition, associated diseases and the pathology for which treatment is sought. The risk reduction can be obtained with a correct preparation of the patient, a careful evaluation and carrying out the interventions in specialized centers.