Advanced Centre For HPB Surgery at Fortis Hospital Bangalore

Hepatopancreatobiliary disorders are conditions that affect the liver, pancreas and bile duct.
Significant organ specific expertise and specialist training in these disorders helps us deliver quality
care for patients. Availability of the complete gamut of multidisciplinary inputs and patient centric
safe surgery by our team for cancers as well as benign conditions ensures good outcomes.

Hepato-Pancreato-Biliary Tumors

Liver cancer

Tumors in the liver can be of two types- primary liver tumors arise within the liver and secondaries
which spread from a primary source elsewhere in the body. Hepatocellular cancer (HCC) is the
commonest primary tumor of the liver. People who have diabetes, hepatitits B, hepatitis C and
obesity are at a higher risk of developing HCC. Symptoms are usually non-specific and diagnosis is
usually made on scans done for screening. Various treatment options are available for HCC ranging
from liver transplantation, liver resection, locoregional therapies like transarterial
chemoembolization (TACE), trans arterial radioembolization (TARE), radiofrequency/microwave
ablation and medicines like Sorafenib/Lenvatinib. Choosing the correct treatment option involves
consideration of the patient’s general condition, co-morbidities, fitness, condition of the liver and
extent of the tumor, all of which are carefully discussed in a multidisciplinary meeting.
Cholangiocarcinoma is the next common primary liver tumor. It is best diagnosed on a CT scan of the abdomen. Resection of the involved portion of the liver is often the best treatment.
Secondaries in the liver signify distant spread and almost always merit consideration for
chemotherapy. Secondaries from pancreatic cancer or gallbladder cancer do not carry a good
prognosis; however, secondaries from the colon or rectum are eminently treatable. Colorectal
metastases are usually managed with a combination of chemotherapy and liver resection and
patients can have long survival with modern treatment.

Neuroendocrine tumors are a special class of tumors which are slow growing most of the time,
treatable with various modalities including surgery and associated with good patient survival.

Bile duct cancer

Cholangiocarcinoma can occur in any part of the biliary tree. Patients usually present with jaundice,
yellow urine, pale stools and itching. Diagnosis requires a CT scan and a MRI scan (especially for bile
duct tumor located at the hilum of the liver). If the disease is localized, surgical resection offers the
best chance of survival. Lower bile duct cancers are treated with pancreaticoduodenctomy. Hilar
cholangiocarcinoma by virtue of its location can involve crucial structures like the hepatic artery and portal vein. Liver resection for hilar cholangiocarcinoma requires significant expertise, meticulous planning and preparation for good outcomes and is considered among the most major procedures in HPB surgery.

Gallbladder Cancer

Gallbladder cancer is extremely common in India. If confined to the gallbladder or involving the
adjacent liver, this tumor is amenable to surgical resection. If associated with jaundice or multiple
lymphnodes, only a select few of these are amenable to curative treatment. Surgical resection
involves removing the gallbladder en bloc with an adjacent portion of the liver and lymph node
dissection according to oncological principles.

Pancreatic Cancer

Pancreatic cancer can involve the head/ neck/body or tail of the gland. Pancreatic head cancers can present with jaundice while neck/body or tail cancers have non-specific symptoms like fatigue or weight loss and usually present in a slightly advanced stage with involvement of adjacent vessels. A CT scan is the cornerstone for diagnosis. Tumors that are uprfront resectable are offered surgery although there is a lot of new literature emerging on the role of neoadjuvant chemotherapy even in this setting. Tumors that are borderline resectable are offered neoadjuvant chemotherapy followed by surgery. Tumors that are locally advanced are considered unresectable and only a small percentage of such patients will eventually be candidates for surgery. Tumors that are advanced or metastatic are offered palliative, best supportive treatment. Pancreatic head tumors are treated by pancreaticoduodectomy while body and tail tumors are treated with distal pancreatectomy with or without a splenectomy.

Cystic pancreatic tumors are a heterogenous group of lesions with distinctive age of presentation,
imaging features and histopathological findings. They have much better prognosis than pancreatic
adenocarcinomas and are treatable with pancreatic resection.

Pediatric Hepatobiliary Disorders

Extrahepatic biliary atresia

Biliary atresia is a condition in infants in which the bile ducts outside and inside the liver are scarred
and blocked. Bile can’t flow into the intestine, so bile builds up in the liver and damages it. The
damage leads to scarring, loss of liver tissue and function, and cirrhosis. Symptoms of the disease
typically appear anytime in the first two months of life. Symptoms include: jaundice, dark urine,
acholic stools (white or clay-colored stools), weight loss and irritability. Biliary atresia is treated with
a surgery called the Kasai procedure and eventually, in many cases, a liver transplant. Due to
advances in treatment, more than 80 to 90 percent of infants with biliary atresia survive to
adulthood.

Choledochal cyst

A choledochal cyst is a congenital anomaly of the duct (tube) that transports bile from the liver to
the gall bladder and small intestine.  The tubes get bigger than normal (dilates) or pouches form on
the tubes. This keeps bile from flowing well. The symptoms include pain in the upper-right belly, soft
mass that can be felt in the upper-right belly, pale or clay-colored stools, fever- if there is infection
(cholangitis) and pancreatitis. In the long run tumors can develop in it. A choledochal cyst is most
often suspected if an abdominal ultrasound scan shows a dilated bile duct in a baby or child with
jaundice or if the child has abdominal pain. Once suspected some other tests are required to get
more information such as MRI. Choledochal cysts are treated with surgery. Whole of the
extrahepatic biliary tree is removed and reconstructed using intestine.

Hepatoblastoma

Hepatoblastoma is a rare cancer of liver that occurs in childhood. It usually affects children less than 3 to 4 years of age. Symptoms include lump in abdomen, pain, weight loss, fever. Diagnosis is by imaging, most often CT scan, to stage the disease, blood AFP level to diagnose and monitor, biopsy to confirm the diagnosis. Most of the cases require chemotherapy followed by surgery. In select cases where surgery is not feasible, liver transplant is required.

Embryonal sarcoma

Childhood embryonal sarcoma of the liver is a rare. This type of liver cancer usually occurs in
children between 5 and 10 years. It often spreads all through the liver and/or to the lungs.
Multidisciplinary approach is required. Liver resection, and if not feasible, liver transplant is required
along with chemotherapy.

Surgery for portal hypertension

Extrahepatic portal venous obstruction (EHPVO) and Non cirrhotic portal fibrosis (NCPF) are
conditions in which the liver function is preserved but patients develop complications of portal
hypertension. The most common complication is upper GI bleed which requires urgent endoscopy.
Other complications are hypersplenism, growth retardation and portal biliopathy. If endoscopy fails
other complications develop children require a shunt surgery in which the spleen is removed and the splenic vein is joined to the renal vein. This reduces the pressure in the veins that are present in the food pipe and prevents bleeding.

Pancreatic Disorders

Acute pancreatitis

Acute pancreatitis means inflammation of the pancreas that develops quickly. The main symptom is
abdominal pain. It usually settles in a few days but sometimes it becomes severe and very serious.
The most common causes of acute pancreatitis are gallstones and drinking a lot of alcohol. Severe
pancreatitis requires admission and organ support in ICU which can be prolonged. If the infection
develops in the dead part of pancreas a “STEP UP” approach is followed in which the magnitude of
intervention is increased stepwise. Interventions include percutaneous drainage, minimally invasive
necrosectomy and eventually open surgery. Patients with gall stones or gallbladder sludge have to
get their gall bladder removed to prevent further attacks. Patients with severe pancreatitis can have
a long hospital stay and have to be managed by an experienced team.

Chronic pancreatitis

It is inflammation of pancreas which develops slowly over the years. The causes are varied and
include alcohol, smoking, autoimmune, hereditary and idiopathic etc. The main symptom is pain and
later in the course diabetes and steatorrhea (diarrhea due to impaired digestion of fat) occurs. The
diagnosis is made by imaging such as MRI or CT scan. Medical management include analgesics and
pancreatic enzymes. Intervention is required if the pain is refractory or complications of chronic
pancreatitis such as bile duct obstruction, duodenal obstruction, or pancreatic cancer develop.
Interventions include endoscopic stone removal and stenting. Surgery is required in some cases where endoscopy fails or a complication requires pancreatic resection. The surgical options are
Frey’s operation, lateral pancreatojejunostomy, and pancreaticoduodenectomy. 

Biliary Disorders

Gallstones

Asymptomatic gallstones detected incidentally on ultrasound during a health checkup do not need
surgery. There are no medications to dissolve stones. Pain in the right upper quadrant of the
abdomen, lasting for a few hours, severe enough many times to seek medical attention and usually
precipitated by a fatty meal (otherwise called biliary colic) is a hallmark of gallstones. Laparoscopic
cholecystectomy for symptomatic gallstones is among the commonest operations performed in the
world. This operation should not however be considered ‘minor’ and safety measures during surgery
are indispensable for good outcomes.

Biliary strictures

Narrowing of any part of the biliary tree can occur due to a wide variety of conditions including
tumors, inflammatory, infectious and autoimmune disorders. Clinical presentation, imaging, blood
tests (liver function tests, tumor markers) and cholangioscopy in select cases helps in diagnosis.
Treatment depends on the reason for these strictures and may include medicines, endoscopic
therapy or surgery. A special category of biliary strictures can occur after laparoscopic
cholecystectomy and many of these require repair and reconstruction with a hepaticojejunostomy.