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17 Surgical Decision-Making inHepatobiliary andPancreatic Surgery
197
must be exible and adapt to these technical
modications, while still considering every
aspect discussed in the preoperative setting.
An experienced anesthesiology team is of
uttermost importance. Communication during
surgery is fundamental for surgical success.
Major or complex HBP surgeries can cause great
hemodynamic instability, and dialog between
surgeons and anesthesiologists is pivotal to
reduce morbidity and mortality risk in order to
maximize the chances of cure. One example of
this setting is the patient’s uid balance as it can
severely change the course of the procedure.
Intraoperative complications impose denite
decisions under pressure, which can dramatically
impact the surgeon. HBP surgery presents a
broad spectrum of potential complications due to
the complexity of the resections, presence of anatomical variations, and technical challenges
which are frequently caused by advanced tumors.
These complications range from major lifethreatening bleeding, which must be dealt with
immediately, to less urgent although no less
severe, irreversible ductal injuries which may
hinder future surgical reconstruction.
The importance of a well-trained and wellprepared team cannot be stressed enough.
Fellows should be taught to perform surgical
techniques in the same manner, increasing reproducibility throughout the entire team. The epitome of intraoperative decision-making process is
perhaps liver transplant surgery, where all the
previously mentioned aspects are part of the regular practice. Even the most technically competent surgeon can be lost without a cooperating
team, reinforcing the need for high-volume centers in the HBP pathology treatment.
Postoperative
The immediate postoperative period is frequently
the most critical for patients, their relatives, and
even the surgeon. Advanced HBP surgery requires
a dedicated intensive care unit and team, equipped
with state-of-the-art monitoring and organ support. These complex procedures can severely
impact hemodynamic and metabolic stability,
which must be rapidly and efciently reversed in
order to decrease patient morbidity and mortality
and improve overall outcomes. In recent years,
procedure-specic postoperative protocols have
been shown to improve patient outcomes [15]
and are in place in most high- volume centers, to
aid the surgical team and decrease variability in
postoperative decision-making.
During the postoperative period, the surgical
team must closely monitor patients’ status in
order to rapidly act if there are changes in the
normal postoperative course. In case of clinical
deterioration, surgeons must decide on which
pathway to take, aided by adequate complementary diagnostic exams. Often the most difcult
decisions for the HBP surgeon are not when a
life-threatening complication occurs, and
decision- making is particularly hard in patients
who are still stable but gradually worsen. One
must bear in mind the avoidance of futility without compromising patient treatment.
In the event of a surgical complication, a
multidisciplinary step-up approach is usually
used, i.e., endovascular embolization in the case
of major bleeding, percutaneous or endoscopic
drainage for intra-abdominal collections after
liver and pancreatic surgery, stent placement
for bile leaks, etc. In modern HBP surgery, reintervention is often the last resort in the management of surgical complications. In pancreatic
surgery, in particular, difcult decisions must be
made regarding patient’s gradual deterioration,
with refractory intra-abdominal collections and
peritonitis in the setting of clinically relevant pancreatic stula. In this case re-intervention can be
the last resort although not guaranteed to immediately improve patients’ status. Immediate postoperative surgeons must overcome their wishful
thinking and critically evaluate patient’s status to
reduce failure-to-rescue in these procedures.
Surgical treatment, however, is not nished
when the patient is discharged home after a successful surgery. Outpatient follow-up is increasingly more important given the shortening
admission times in minimally invasive surgery.
Close monitoring and patient education are
warranted to rapidly detect complications and act
accordingly.
198
In oncological patients, subsequent management is decided in MDT meeting setting as it
might be necessary to undergo systemic therapy.
This decision is not always straightforward and
can be hindered by patient status following HBP
surgery. On the other hand, the long-term survival in non-oncological patients also holds its
own challenges. For example, bile duct reconstructive procedures can cause bile congestion,
with anastomotic stenosis and secondary biliary
cirrhosis. In these patients a long time follow-up
should be implemented.
Practical Examples
ofMultidisciplinary DecisionMaking inHBP Surgery
Case 1
A 42-year-old female, with no relevant medical
history, was referred to our center due to obstructive jaundice with a total bilirubin of 9mg/dL and
a Ca 19.9 of 25u/mL.A CT scan was performed
(as shown in Fig.17.1) and suggested a Klatskin
tumor type IIIb.
A percutaneous cholangiogram was performed, and an external biliary stent was placed
to optimize biliary drainage (Fig.17.2). Biopsies
of the bile duct were compatible with
cholangiocarcinoma.
The case was discussed in our MDT meeting,
and a robotic left hepatectomy extended to seg-
B. Chumbinho et al.
Fig. 17.2 Placement of an external biliary drainage using
percutaneous cholangiography
Fig. 17.3 Identication of median hepatic artery
Fig. 17.1 CT scan showing Klatskin tumor type IIIb
ments I and V was planned. Here, we present the
most important steps of the surgical procedure:
1. Lymphadenectomy of stations 7, 8a, 8p, 12,
and 13a was performed.
2. Identication of right hepatic artery coming
from the superior mesenteric artery
(Fig.17.3).
3. Identication and ligation of the left branch of
the portal vein (Fig.17.4).
4. Parenchyma is divided after indocyanine
green injection, ensuring good
vascularization.
17 Surgical Decision-Making inHepatobiliary andPancreatic Surgery
Fig. 17.6 Synchronous CLRM in right hemi liver. The
Fig. 17.4 Identication of the left branch of the portal
vein
left hemiliver presents several cysts
199
Fig. 17.5 Ligation of the left hepatic vein and remaining
right liver parenchyma
5. Identication of proximal right biliary duct
that is sent to frozen section analysis.
6. Identication and ligation of left hepatic vein
(Fig.17.5) and removal of the specimen (left
extended hemihepatectomy and bile duct).
7. Hepaticojejunostomy for the right bile ducts
using 5/0 PDS.
Case 2
Male, 73 years old, presented with six synchronous right liver metastases (biggest lesion was
69mm) in the context of ascending colon cancer,
Fig. 17.7 Liver imaging post-right portal vein
embolization
previously submitted to right colectomy
(Fig.17.6). Due to high tumor burden on the right
liver, it was decided on our MDT meeting that the
patient should be submitted to a right hepatectomy although due to insufcient liver volume, a
right portal vein embolization had to be done
before liver resection. The volumetry imaging
after embolization revealed a future liver remnant
(FLR) of 47% (Figs.17.7 and 17.8), and a right
hemihepatectomy was performed.
Case 3
A male, 83 years old, with a personal history of
rheumatoid arthritis, presented with obstructive
jaundice. Imaging showed a bile duct stone and a
200
Fig. 17.8 Liver imaging post-right portal vein
embolization
Fig. 17.9 Cystic lesion in pancreatic head
cystic lesion of the pancreatic head (45 mm)
(Fig.17.9). After ERCP with clearance of the bile
duct and stent placement, it was decided that the
patient should be monitored in outpatient
appointments. During this follow-up period, a
ne- needle aspiration (FNA) biopsy was performed. The biopsy revealed a mucinous neoplasm. In the following 2 months, the patient
presented again with obstructive jaundice which
was attributed to the presence of the mucinous
lesion. He was again discussed in our MDT meeting, and it was decided to perform a Whipple
procedure.
B. Chumbinho et al.
Fig. 17.10 Central cystic mass with enhancing solid
components
Case 4
A female, 74 years old, with a personal history of
hypertension presented with iron deciency anemia. A CT scan was performed which showed a
central liver mass encompassing segments IV, V,
and VIII, with approximately 11x9cm, with cystic areas and solid components (Fig. 17.10),
highly suggestive of biliary cystic tumor.
In our MDT discussion, it was decided that
the patient should be submitted to a right trisectionectomy with previous right portal vein embolization due to insufcient liver volume. A left
biliary drainage was also performed as the patient
developed obstructive jaundice.
Intraoperatively, we became aware of probable
insufcient liver volume and invasion of the left
portal vein. We were forced to alter our initial strategy and performed an associating liver partition
and portal vein ligation for staged hepatectomy
(ALPPS) procedure, with reconstruction of the left
portal vein to the main trunk (Figs. 17.8 and 17.9).
The postoperative period was uneventful and
volumetry imaging at 1-week post-op revealed a
FLR of 32%. The patient was then submitted to
completion of the ALPPS procedure with a right
trisectionectomy 2 weeks following the rst surgery (Figs.17.11, 17.12, 17.13 and 17.14).
17 Surgical Decision-Making inHepatobiliary andPancreatic Surgery
Fig. 17.11 Liver hepatotomy during the rst procedure
Fig. 17.14 Completion of right trisectionectomy
(ALPPS stage 2)
References
1. Pioneers in laparoscopic hepato-biliary-pancreatic
surgery. Miyasaka, Yoshihiro. 2018, J Hepato-BiliaryPancreatic Sci, pp.109–114.
2. Delpero, Jacques Belghiti e Jean Robert. Blumgart’s
Surgery of the Liver, Biliary Tract and Pancreas. s.l. :
Elsevier, 2023. 0323697844.
3. Flin, Rhona. How do surgeons make intraoperative
decisions? 2007, Jun.
Fig. 17.12 ALPPS stage 1 with reconstruction of the left
portal vein
Fig. 17.13 Liver volumetry at 1 week post-op
4. Advances in histological and molecular classication
of hepatocellular carcinoma. Choi, Joon Hyuk. s.l. :
Biomedicines. 2023;11(9):2582.
5. How molecular discoveries have changed liver tumor
pathology: a brief review. Taheri, Negar. s.l. : Arch
Pathol Lab Med. 2023.
6. Cholangiocarcinoma: recent advances in molecular
pathobiology and therapeutic approaches. Khosla,
Divya. s.l. : Cancers. 2024;16(4):801.
7. Advances in Immunotherapy for Hepatocellular
Carcinoma (HCC). Bicer, Fuat. s.l. : Cur Oncol.
2023;30 (11):9789-9812.
8. Advances in the management of cholangiocarcinoma. Zori, Andreas G. s.l. : World J Hepatol.
2021;13(9):1003–1018.
9. Updated management of colorectal cancer liver
metastases: scientic advances driving modern therapeutic innovations. Patel, Ranish. 6, s.l. : Cell Mol
Gastroenterol Hepatol. 2023;16:881–894.
10. Setup of multidisciplinary team discussions for
patients with cholangiocarcinoma: current practice
201
202
B. Chumbinho et al.
and recommendations from the European Network
for the Study of Cholangiocarcinoma (ENS-CCA).
Casadio, M. 1, s.l. : ESMO Open, 2022;7.
11. The impact of a hepatobiliary multidisciplinary team
assessment in patients with colorectal cancer liver
metastases: a population-based study. Engstrand,
Jennie. 9, s.l. : Oncologist. 2017;22:1067–1074.
12. Effect of specialist decision-making on treatment
strategies for colorectal liver metastases. Jones, R P.
9, s.l. : Br J Surg. 2012; 99:1263–1269.
13. A 10-year study of outcome following hepatic resection for colorectal liver metastases– the effect of evaluation in a multidisciplinary team setting. Lordan, J.T.
3, s.l. : Eur J Surg Oncol. 2009;35:302–306.
14. Current level of shared decision-making in hepatobiliary surgical oncology (SAPACHA). Haaft, Britte
H.E.A. ten. s.l. : HBP, 2024;26.
15. Enhanced recovery following liver surgery: a systematic review and meta-analysis. Hughes MJ, McNally
S, Wigmore SJ. s.l. : HPB (Oxford), 2014;16:699–706.
Decision-Making inHepatobiliary
andPancreatic Surgery: Acute
Care Surgeon’s Perspective
ThavThambi-Pillai, J.M.Guido, StephanieY.Hung,
andHassanTuraihi
18
Introduction
Being a competent acute care surgeon is a challenging job as one needs to be a master of many
areas. There is nothing more daunting than being
condent in managing hepatobiliary pathology
especially trauma related to this part of the body.
For ease of discussion, we have detailed the
chapter under the following four topics:
1. Management of acute pancreatitis
2. Approach to difcult gallbladder
3. Surgical techniques for managing pancreatic
trauma
4. Management of liver trauma
Acute Pancreatitis
Acute pancreatitis (AP) is one of the most common gastrointestinal conditions encountered in
the United States, resulting in ER visits of 13.5
per 10,000 persons with an annual estimated
admission incidence of 13–40 per 100,000 persons [1]. Admission rates for acute pancreatitis
have steadily risen over the last 2 decades [2].
While mortality overall from acute pancreatitis is
low at 1%, complicated pancreatitis can result in
mortality more than 20% of the time [1].
Morbidity and associated cost can be signicant,
with estimates of as high as 2.69 billion dollars
per year being spent on management of AP.
AP occurs after the pancreas sustains an acute
injury to the acinar cells, causing pancreatic
inammation. This injury triggers activation of
digestive enzymes, the kinin system, and complement cascade resulting in pancreatic parenchyma
autodigestion. Pancreatic duct obstruction, commonly seen with gallstone pancreatitis, is the
most common cause of acinar damage with alcohol remaining the second leading cause of AP [2,
3]. The severity of AP is thought to be correlated
with degree of apoptosis from cellular necrosis.
The early phase of AP occurs during the rst
week of disease resulting in a systemic inammatory response (SIRS). The late phase persists
beyond 1 week, lasting for 4 weeks to months,
and is frequently marked by persistent organ dysfunction and complications [3].
Diagnosis
T. Thambi-Pillai (*) · J. M. Guido · S. Y. Hung
H. Turaihi
Department of Surgery, University of South Dakota
Sanford School of Medicine, Sioux Falls, SD, USA
e-mail: Thavam.Thambi-Pillai@SanfordHealth.org;
Jenny.Guido@SanfordHealth.org;
Hassan.Turaihi@SanfordHealth.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
R. Lati (ed.), Surgical Decision-Making, https://doi.org/10.1007/978-3-031-67391-7_18
Acute pancreatitis is commonly characterized by
both the revised Atlanta criteria (RAC). The RAC
require 2 or more of the following to diagnose
acute pancreatitis: epigastric abdominal pain;
serum lipase and/or amylase greater than three
times the upper limit of normal; evidence of acute
203
204
T. Thambi-Pillai et al.
pancreatitis on imaging (ultrasound, contrastenhanced computed tomography, or magnetic
resonance imaging) [1, 3].
The RAC grades AP severity by presentation
and duration of organ failure in presence of local
symptoms. Mild AP is present in patients without
organ failure or local complications. Moderately
severe AP occurs in patients with transient organ
failure (less than 48-hour duration) and/or local
complications. Severe AP occurs in patients with
organ failure persisting beyond 48 hours with or
without local complications [2]. About 80% of
patients will develop mild to moderately severe
disease with anticipated discharge within 1 week
of hospitalization, 20% will develop severe disease with protracted clinical course that can
extend over weeks to months [2].
The RAC then uses morphologic types to
characterize acute pancreatitis either into interstitial edematous AP or necrotizing pancreatitis
(NP). Interstitial edematous pancreatitis (IEP) is
characterized by edema and inammation of the
pancreatic parenchyma and peripancreatic tissues. IEP occurs 85% of the time with acute pancreatitis with a mortality rate of 3% [1]. NP
occurs when this process progresses to peripancreatic or pancreatic tissue death. Necrotizing AP
constitutes approximately 15% of AP cases that
accounts for a mortality of 17%. Mortality then
rises to 30% if pancreatic necrosis becomes
infected [1]. Both forms of pancreatitis can be
associated with the development local complications of uid collections [2].
Peripancreatic collections are further classied by timing of onset to predict associated morbidity. IEP-associated uid collections are
present for less than 4 weeks and are characterized by a homogenous collection found adjacent
to normal fascial planes without associated
necrosis. These tend to be un-encapsulated collections. After 4 weeks, uid collections are then
named pseudocysts and appear as an encapsulated, usually homogenous, uid collections
without solid components. Encapsulated uid
collections in NP may be sterile or exhibit gas
formation on imaging to suggest underlying
infectious process. These uid collections are
then termed walled off necrosis (WON) [3].
Several different classication systems can
assist in determining appropriate initial level of
care and guide ongoing clinical management
based on predicted severity of disease. Given the
variability and clinical course of AP, prognostic
indicators for AP are set by several systems
including the Ranson criteria, Acute Physiology
and Chronic Health Evaluation II (APACHE II)
classication system, and more recently the bedside index for severity and acute pancreatitis
(BISAP) score. Initial assessment should include
assessment of the following risk factors that can
predict severe course: age greater than 60 years,
BMI greater than 30, chronic alcohol use, preexistent comorbidities, presence of SIRS, laboratory markers consistent with hypovolemia, and
presence of chest X-ray inltrates or effusions
[2].
Initial Management ofAcute
Pancreatitis
For patients admitted with AP, treatment focuses
primarily on the acute symptoms. Consideration
for ICU admission should occur in patients with
severe pancreatitis and signs of inammatory
response or organ failure [3]. Pain control, uid
resuscitation, and optimal nutrition remain the
initial tenets of management. Goal-directed uid
resuscitation should address improvement in
urine output and vital signs to maximize improvement in end-organ perfusion. More recent literature supports uid resuscitation with lactated
Ringer’s solution compared to normal saline to
reduce risk of developing SIRS at 24 hours.
Caution should be undertaken to avoid uid overload, particularly in patients with pre-existing
heart failure or renal disease [1, 2].
Prophylactic antibiotic use has not demonstrated a mortality benet or reduction in the
development of pancreatic infection in NP in randomized controlled studies [1]. Broad-spectrum
antibiotics with pancreatic penetration that cover
both aerobic and anaerobic Gram-negative and
Gram-positive microorganisms should only be
prescribed if infected necrosis is conrmed or
strongly suspected [4].
18 Decision-Making inHepatobiliary andPancreatic Surgery: Acute Care Surgeon’s Perspective
205
Optimization of nutritional support is critical
for patients with AP, given hypermetabolism,
metabolic derangements, negative nitrogen
balance, and inammatory response found in this
condition. Historically, initiation of enteral nutrition was delayed in order to provide pancreatic
rest [1]. Current evaluation of existing literature
supports early use of enteral nutrition.
Patients receiving early enteral nutrition
exhibit decreases in multiple organ failure, systemic infection, and even mortality. Importantly,
it is not necessary to wait until the patient’s pain
is resolved prior to resuming enteral feeding in
AP.The most recent guidelines of the American
Gastroenterological Association recommend initiating enteral feeding within 24–72 hours of
admission. Patients who tolerate oral nutrition
should have a low fat or solid diet. If the patient
is unable to tolerate enteral nutrition within 72
hours of admission, nasal enteral feeding via
nasogastric or nasojejunal access should be initiated. If patients cannot tolerate enteral feeding
due to obstruction, paralytic ileus, or other
causes, parenteral nutrition should be started
within 72 hours. Patients with evidence of steatorrhea or malabsorption should be evaluated for
exocrine pancreatic insufciency and if present
semielemental formulas should be considered for
nutritional support [1, 2, 5–7].
Surgical Treatment ofAcute
Pancreatitis
Patients with severe AP often receive aggressive
uid resuscitation and may develop intraabdominal hypertension requiring decompression.
Intra-abdominal hypertension (IAH) can occur
early in severe AP secondary to pancreatic inammatory processes coupled with aggressive uid
resuscitation. The incidence of IAH can be as high
as 60-80%. IAH may be rapidly transformed into
abdominal compartment syndrome (ACS) secondary to increasing intra-abdominal inammation,
capillary leakage, and visceral edema causing progressive ascites. ACS is diagnosed when intraabdominal pressures are greater than 20 mmHg
and new onset organ dysfunction occurs. Medical
therapy is used rst line to manage IAH via nasogastric decompression, percutaneous drainage of
ascitic uid, and neuromuscular blockade if indicated. If patients fail to respond to these nonoperative measures and clinically deteriorate, they will
require surgical decompression. Management of
surgical decompression is performed most commonly via midline laparotomy, consideration of a
subcostal approach can be undertaken [3].
Gallstone pancreatitis
Biliary pancreatitis is a frequent consult for the
acute care surgeon. Early cholecystectomy after
gallstone pancreatitis is completed to prevent
complications of recurrent pancreatitis (8%) and
readmission (20%) associated with delayed cholecystectomy [1]. Biliary pancreatitis can recur
up to 33% of patients when cholecystectomy is
not performed [8].
The gallstone PANC randomized controlled
trial evaluated patients with mild gallstone pancreatitis undergoing cholecystectomy within
24hrs of admission(early) vs those undergoing
cholecystectomy after clinical resolution of
symptoms (control group). Signicant reduction
in length of stay (LOS) and health system costs
without increase in major complication or worsening in quality of life were reported. There was
a noted increase in minor complications and
more readmissions that occurred in the early cholecystectomy group compared to the control
group [9]. The Poncho (Same Admission versus
Interval Cholecystectomy for Mild Gallstone
Pancreatitis) multicenter randomized control trial
demonstrated that cholecystectomy during index
admission, versus delayed cholecystectomy,
reduced the rate of recurrent gallstone-related
complications in patients with mild gallstone
pancreatitis [8]. Further, current AGA guidelines
recommend cholecystectomy during index
admission, particularly in patients with mild AP
[1].
Current literature overall seems to support
early cholecystectomy with intraoperative cholangiogram during the same admission for mild
gallstone pancreatitis but question remains
206
T. Thambi-Pillai et al.
regarding timing for cholecystectomy in patients
with moderately severe acute biliary pancreatitis.
The few small retrospective studies in the
literature demonstrate conicting data. A more
recent study using data from the MANCTRA-1
(Compliance With Evidence-Based Clinical
Guidelines in the Management of Acute Biliary
Pancreatitis) data set examined whether early
cholecystectomy (within 14 days of hospital
admission) versus delayed cholecystectomy
(after 14 days of hospital admission) led to
changes in mortality or postoperative complications in patient with moderate or severe biliary
pancreatitis. Biliary pancreatitis was classied
using the RAC.Patients with moderately severe
biliary pancreatitis experienced increased postoperative morbidity and mortality after early cholecystectomy across all groups. ASA score, age,
severe complications of biliary pancreatitis
requiring surgical intervention, and absence of
bile duct clearance by ERCP were all risk factors
identied to be associated with morbidity and
mortality in these patients. While the risk of
gallstone- related events progressively increase if
cholecystectomy is not performed for biliary
pancreatitis, timing of surgical intervention must
be balanced with the understanding that patients
undergoing early cholecystectomy experience
increase in postoperative complications and even
mortality [8]. For patients with severe AP or
those with peripancreatic collections, consideration for delaying early cholecystectomy should
occur [4]. Consideration should also be given to
evaluation with contrast-enhanced CT or MRI for
peripancreatic uid collections prior to cholecystectomy in this population [4]. Further studies are
needed to determine optimal timing in this patient
subgroup of AP.
Some patients cannot tolerate cholecystectomy during same admission for AP. Patients
with clinical ndings suspicious for ongoing biliary obstruction including symptoms of ascending
cholangitis, choledocholithiasis, and total bilirubin greater than 4 mg/dL should be considered
for ERCP. ERCP should additionally be considered in patients who are poor surgical candidates,
in those that require biliary decompression to
prevent recurrent AP [3]. If cholecystectomy can-
not be completed during admission, patients ideally should still undergo delayed cholecystectomy
within 2–4 weeks after discharge if deemed medically t to minimize risk of recurrent gallstone
pancreatitis.
Gallstone pancreatitis is commonly selflimiting, but in the setting of NP with associated
peripancreatic uid collections, timing of cholecystectomy is challenging. Historically, cholecystectomy was postponed until resolution of
uid collections; for 6 weeks after development
of pancreatic uid collections; and/or general
improvement of local and systemic inammation. The Dutch pancreatitis group evaluated
optimal timing of cholecystectomy for necrotizing biliary pancreatitis and demonstrated that the
risk of recurrent AP and biliary events increased
when cholecystectomy is delayed more than 8
weeks after discharge. It is notable that timing of
cholecystectomy did not increase operative complications and this study, but early cholecystectomy was associated with an increase in
conversion to an open technique [10].
Management ofPeripancreatic Fluid
Collections
Peripancreatic uid collections in interstitial
edematous AP are classied by timing of development. Prior to 4–6 weeks after episode of AP,
these collections tend to remain asymptomatic
and resolve within 1–2 weeks. Generally, less
than 20% of the time these collections will persist for more than 4 weeks to form an encapsulated pseudocyst [1]. Between 5 and 15% of
patients with AP will develop a pseudocyst.
Asymptomatic collections, less than 50 mm in
diameter, can be monitored serially with ultrasound or contrast- enhanced CT imaging [4]. As
up to 70% of pseudocysts resolve without intervention, intervention should be considered for
patients developing symptoms associated with
their pseudocyst, infection of the pseudocyst, or
pseudocyst enlarging to greater than 6cm [3].
Patients may present with symptoms secondary
to mass effect including nausea and vomiting,
early satiety, and abdominal pain.