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Chapter 17
140
217
167
353
Figure17.9 • Distribution of pancreatic injuries in the world literature. Note the preponderance of injuries in the
junctional area of the neck of the gland. Reproduced from Frey CF, Wardell JW. Section 9. Injuries to the pancreas. In:
Trede M, Carter DC (eds) Surgery of the pancreas. Edinburgh: Churchill Livingstone, 1993. With permission from Elsevier.
47
Initial management of pancreatic injury
In a major retrospective clinical casenote review
of pancreatic trauma from six hospitals, Bradley
et al. demonstrated a significant association between pancreas-related morbidity and injury to
the main pancreatic duct.79 Delayed intervention
(due to delay in recognition of main pancreatic
duct injury) was associated with high morbidity.
CT was unreliable for the assessment of main pancreatic ductal integrity and an accurate assessment
required ERCP.
237
182
241
Operative management of pancreatic injury
The mainstay of treatment remains operative as
pancreatic injuries are usually diagnosed at laparotomy. The important principles at operation are
to gain good access to allow thorough inspection
of the gland. Access to the lesser sac is best done by
creating a window in the gastrocolic omentum outside the gastroepiploic arcade to allow examination
of the body of the pancreas. A Kocher manoeuvre
is necessary to permit palpation of the head of the
pancreas between the thumb and fingers. A thorough inspection of the base of the transverse mesocolon is also undertaken. Injury to the pancreas
Assessment of the integrity of the main
pancreatic duct is critical to the treatment of
pancreatic injury. In patients with a suspected
pancreatic injury (who are haemodynamically
stable), ERCP is indicated to assess major duct
integrity. Demonstration of an intact main pancreatic
duct at ERCP in a patient with suspected isolated
pancreatic injury may allow for a trial of nonoperative management.
is suspected if retroperitoneal haemorrhage can be
seen through the base of the mesocolon or the lesser
omentum. Absence of any sign of haemorrhage over
the pancreas and duodenum makes injury unlikely.
Experience of patients with pancreatic injury from
Durban led to the recommendation for operative
treatment of patients with penetrating or gunshot
injury and signs of peritoneal irritation.80 In this
large series of 152 patients with pancreatic trauma
320
Hepatobiliary and pancreatic trauma
presenting during a 5-year period, 63 patients had
been shot, 66 stabbed and 23 had blunt trauma.
The mainstay of treatment was exploratory laparotomy followed by drainage of the pancreatic injury
site. Large-bore soft silastic drains were used to minimise the risk of drain erosion into a major vessel.
The mortality rates in these groups were 8% after
gunshot injury, 2% after stab wounds and 10% after
blunt trauma. The majority of these deaths were attributed to damage of other organs. The proportions
of patients that developed pancreatic fistulas in the
three groups were 14%, 9% and 13%, respectively.
The authors concluded that ‘conservative’ surgical
drainage (avoiding pancreatic resection) was justified after pancreatic injury. This large series lends
weight to the treatment plan proposed by Lucas
for grade I injuries, which consists of passive closed
drainage using a wide-bore drain.
Simplified management guidelines based on the
treatment protocols developed during the treatment of
124 pancreatic injuries at the University of Tennessee81
also advocate simple drainage alone for proximal pancreatic injuries. There were 37 (30%) patients with
proximal injuries. The ‘pancreas-related’ morbidity was 11% – principally the sequelae of pancreatic
fistulas. Of 87 distal pancreatic injuries, the integrity
of the main pancreatic duct was not established in 54
(62%). Patients thought to have a high probability
of duct transection were treated by distal pancreatectomy. A concern with simple drainage for injuries in
the head of the pancreas is persistent pancreatic fistula, and thus a surgical alternative is to drain the head
of the pancreas into a Roux-en-Y limb of jejunum.
Moncure and Goins described their experience
over a 6-year period with a consecutive series of 44
patients with pancreatic injury,82 of which penetrating abdominal trauma accounted for the majority of
cases. Class I pancreatic injuries occurred in 55% of
patients and the majority were managed by simple
drainage. Grade II injuries occurred in 18% and grade
III injuries in 21%. Coexistent duodenal injuries were
treated by primary closure in 21% and more complex
duodenal exclusion techniques were used in 20%. The
most frequent complications were intra-abdominal
abscesses (31%) and pancreatic fistulas (16%).
Krige et al. reported on a series of 110 patients
with pancreatic injuries after blunt trauma.83 One
hundred and one patients underwent a total of 123
operations, including drainage of the pancreatic
injury (n=73), distal pancreatectomy (n=39) and
Whipple resection (n=5). The overall complication
rate was 74.5% and the mortality rate was 16.4%.
Only two of the 18 deaths were attributable to the
pancreatic injury. Mortality increased exponentially
as the number of associated injuries increased.
Severe Lucas grade III injuries involving the head
of the pancreas, duodenum and distal bile duct
represent a major challenge, but fortunately are
relatively rare, occurring in approximately 5% of
all duodenal injuries.84 The principles of treatment
are to ensure that haemorrhage from concomitant
injuries is dealt with first, as this is likely to be
the major source of mortality. Similarly a prolonged operative procedure should be avoided in
a potentially unstable patient and the involvement
of an experienced pancreatic surgeon is desirable. Duodenal injuries can be closed primarily or
drained into a Roux loop. Bile duct injuries may be
repaired primarily over a T-tube or drained into a
Roux limb of jejunum. The large variety of operative procedures described for these complex injuries suggests that treatment has to be tailored to
the individual injury complex and that no single
procedure is likely to be uniformly applicable or
successful. Very rarely, pancreatico-duodenectomy
may be required for complex, severe pancreatic injuries with concomitant duodenal and distal bile
duct injuries. Clearly, this sort of resection should
not be undertaken lightly in an individual suffering from shock and its sequelae, but rather like
liver transplantation for trauma it is useful to have
an index of awareness of the available therapeutic
options.
Complications of pancreatic injury
The most common post-traumatic complications
include necrotising pancreatitis, pseudocyst formation, pancreatic abscesses and pancreatic fistula.
Cerwenka et al. reported the incidence of these
complications to be 15%, 9%, 6% and 4%, respectively.85 The principles regarding management
are similar to those for treating these complications when they arise as a result of pancreatitis or
pancreatic surgery. Inflammation of the pancreas
after trauma behaves in much the same way as
acute biliary or acute alcohol-induced pancreatitis,
with the possible exception that there is a higher
incidence of development of local complications
such as pseudocyst – possibly relating to the nature of duct disruption in trauma. The Cape Town
group reported that, of a series of 64 patients
with pancreatic trauma, pseudocysts developed in
15 patients (23%), of whom eight had a duct injury demonstrated by endoscopic retrograde pancreatography.86 Patients with pseudocysts related
to distal duct injury were treated successfully by
percutaneous aspiration. Three patients with duct
injuries in the neck/body region underwent distal
pancreatectomy. Pseudocysts related to ductal injury in the head of the pancreas were drained internally by Roux-en-Y cyst-jejunostomy. The authors
concluded that traumatic pancreatic pseudocysts
associated with a peripheral duct injury may resolve
321
Chapter 17
spontaneously, whereas those associated with inju-
ries to the proximal duct would more likely require
surgical intervention. Alternative treatment strate-
gies include endoscopic transpapillary or transmu-
ral drainage of the pseudocyst.
The incidence of pancreatic fistula after surgery for
trauma is dependent on the type of procedure, with
some evidence that the fistula rate is higher after
drainage procedures than after resection. Successful
insertion of pancreatic duct stents has been reported
for management of major pancreatic duct disruption; however, the incidence of long-term ductal
stricture is high and therefore the role of pancreatic
duct stenting needs to be further defined.
Management of post-traumatic pseudocysts and
fistulas will depend on the time from injury, presence
of ongoing ductal leak, site of leak and presence
of debris within a pseudocyst cavity. The optimal
treatment strategy should involve a multidisciplinary
approach in a specialist unit employing similar
principles to those of managing these complications
following an attack of acute pancreatitis.
87
Key points
Conclusion
The contemporary management of patients with
suspected liver, biliary or pancreatic injury involves detailed clinical assessment and resuscitation followed, in haemodynamically stable
patients, by imaging investigations. If surgical intervention is required, the mainstay of treatment
is to control haemorrhage. In European healthcare systems, the optimum care of the patient
may consist of packing followed by transfer to
a regional hepato-pancreatico-biliary unit. A paper by Hoyt et al. examining preventable causes
of death in 72 151 admissions with abdominal
trauma to North American level I trauma centres
identified abdominal injury as the cause of death
in 287, with liver injury being responsible for
92.88 Delays in packing were highlighted as a preventable cause of death, as was a need for better
understanding of the end-points to be achieved by
packing. The conclusion of this large survey was
that the management of liver injury remains a major technical challenge.
• Management of patients with suspected liver, biliary or pancreatic injury involves detailed clinical
assessment and resuscitation.
• Haemodynamic instability resistant to fluid resuscitation associated with clinical signs of peritonism
is an indication for immediate laparotomy.
• Patients who are haemodynamically stable or who respond to initial fluid resuscitation should
undergo further imaging investigations.
• Laparotomy is generally required for patients with an abdominal gunshot wound.
Liver trauma
• Non-operative management of liver trauma is now a well-established treatment option.
• Significant liver haemorrhage can initially be controlled at operation by manual compression of the liver
parenchyma, a Pringle manoeuvre or by compression of the aorta above the coeliac trunk. Perihepatic
packing is a highly effective technique to control bleeding from the liver or juxtahepatic veins.
• Resectional debridement of non-viable hepatic parenchyma may be undertaken, but anatomical
resection is rarely indicated.
• Other techniques to control haemorrhage include suture ligation of vessels, mesh wrapping of a
liver lobe and selective hepatic arterial ligation.
• Postoperative complications include bile leakage or sepsis, and may require radiological,
endoscopic or surgical intervention.
Extrahepatic biliary tract trauma
• This uncommon injury is more likely to be due to penetrating rather than blunt abdominal trauma.
• It is rarely diagnosed before operation and is usually recognised incidentally at laparotomy.
• Concomitant vascular injury of the portal vein or hepatic artery is rare.
• ERCP may demonstrate bile leakage and allow therapeutic insertion of a biliary stent.
• Definitive operative intervention for gallbladder trauma is cholecystectomy.
• Roux-en-Y hepatico-jejunostomy is the operation of choice for most injuries to the bile duct.
322
Hepatobiliary and pancreatic trauma
Pancreatic trauma
• This is most commonly diagnosed by CT; however, ERCP may be undertaken to assess
pancreatic duct integrity and may allow therapeutic stenting if leakage of contrast is identified.
• Exploratory laparotomy and drainage of the pancreatic region remains the mainstay of surgical
treatment.
• Selected injuries may be managed by distal pancreatectomy, pancreatico-duodenectomy or
pancreatico-jejunostomy Roux-en-Y.
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325
Index
NB: Page numbers followed by f indicate figures,
t indicate tables and b indicate boxes.
A
ABC-02 trial 229, 231–232
Aberrant arteries, defined 21
Abscess
amoebic 70–71, 71f
liver see Liver abscess
pancreatic 256
Accessory arteries, defined 21
ACOSOG trial, gastrointestinal (GI) stromal tumours
(GISTs) 136–137
Acute cholecystitis 176, 180
Acute liver failure 2–3
criteria 1
scoring system 1, 2b
Acute pancreatitis 244–259
aetiology 246–247
genetic factors 246
iatrogenic causes 246
inflammatory causes 247
metabolic factors 246
mild acute pancreatitis, defined 245b
obstructive factors 246
physiological causes 247
toxic factors 246
trauma 246
complications 256–257, 256f
defined 245b
diagnosis 245, 246f
imaging 248–249
computed tomography (CT) 86f, 89
endoscopic retrograde cholangiopancreatography
(ERCP) 251
endoscopic ultrasound (EUS) 249
magnetic resonance cholangiopancreatography
(MRCP) 248–249
magnetic resonance imaging (MRI) 248–249,
249f
ultrasound (US) 248
management 249–251
initial 249
medical 250–251
supportive 249–250
management issues 251–257
necrosis 253–256
peripancreatic fluid collections 252–253
recurrence, prevention 251–252
natural history 244–245, 245b
pathophysiology 244
severity, assessment 247
biochemical measures 247–248
clinical assessment, repeated 248
intra-abdominal hypertension (IAH) 247
Acute pseudocyst, defined 245b
Adenocarcinoma
gastrointestinal (GI) 139–140
pancreatic see Pancreatic adenocarcinoma
Adrenocortical tumours 141
Advanced Trauma Life Support (ATLS) guidelines 305
Aflatoxin 83
AJCC (American Joint Committee on Cancer) 101,
118–119, 139
Consensus Conference on HCC (2002) 43–44
T-stage system 223–224, 224b
see also TNM staging system (AJCC)
Alanine transaminase (ALT) 177
Alcohol 82, 262b, 276
Alcohol-induced acute pancreatitis 244, 246
Alkaline phosphatase (ALP) 177
α-Fetoprotein (AFP) 86, 92, 94, 100, 102
Alveolar hydatid disease 71
American Association for the Study of Liver Diseases
(AASLD) 42, 89–90, 91, 98
American Association for the Surgery of Trauma (AAST)
165, 165t, 305t
American College of Surgeons, Committee on Trauma 305
American Hepato-Pancreato-Biliary Association
(AHPBA) 114–115
Consensus Conference on HCC (2002) 43–44
American Society of Clinical Oncology (ASCO) 125
Aminopyrine breath test 6
Amoebic abscess 70–71, 71f
Ampulla
carcinoma 48t
tumours 246
Anaemia
autoimmune haemolytic 167
sickle cell 167
Androgens 84
Angiosarcoma 104–105
Anti-angiogenic targeted therapies 99
Antibiotics 69–70, 152b, 250
APACHE II predictive system 247
Aromatic amino acids (AAAs) 4, 13
Ascaris lumbricoides 212
Ascites, management 157–158
Asian Pacific Association for the Study of Liver Disease
(APASL) 42
Aspartate transaminase (AST) 177
Aspergillus flavus 83
AURC 9002 trial 122
Autoimmune chronic pancreatitis (CP) 262–263
Autoimmune haemolytic anaemia 167
Autoimmune hepatitis 83
B
Barcelona Clinic Liver Cancer (BCLC) staging system
43–44, 91
Basingstoke Predictive Index (BPI) 119t
BEAT trial 122
327
Index
Beger procedure 268, 268f
Benign biliary tract diseases 196–217, 197b
biliary strictures 209–213
congenital abnormalities 196–199
functional 214
iatrogenic see Iatrogenic biliary injury
Benign liver lesions 59–79
abscess see Liver abscess
adenoma see Liver cell adenoma
amoebic abscess 70–71, 71f
bile duct adenoma (hamartoma) 68
classification 60, 60b
cystadenoma 75–77, 76f
cysts see Hydatid cyst; Liver cysts, simple;
Polycystic liver disease (PCLD)
haemangiomas see Haemangiomas
hepatic pseudotumours 68
hyperplasia see Focal nodular hyperplasia (FNH)
nodular regenerative hyperplasia 68
tumours, miscellaneous 68–69
Benign pancreatic duct stricture 246
Berne procedure 269
Bevacizumab 134
Bile duct
adenoma (hamartoma) 68
common see Common bile duct (CBD)
distal see Cholangiocarcinoma, distal bile duct
intrahepatic see Cholangiocarcinoma, intrahepatic bile
ducts (IHC)
proximal see Proximal bile duct tumours
see also Hilar cholangiocarcinoma;
Bile ducts, anatomy
blood supply 32–34, 33f
extrahepatic 31–32
anomalies 32
resection 22–24, 22f, 23f
Biliary tract
atresia 196
colic 176
disease 246
malignancy see Biliary tract, malignancy
trauma see Extrahepatic biliary tract trauma
see also Benign biliary tract diseases
Biliary tract, malignancy 218–243
cholangiocarcinoma see Cholangiocarcinoma
following injury 209, 210f
gallbladder see Gallbladder cancer
strictures imitating 197
Biliary tree, strictures 197b
Bioartificial liver systems 13–14
BioLogic-DT system 13
Bismuth classification, biliary strictures 201, 201t
Bismuth-Corlette classification, hilar
cholangiocarcinoma 52, 53f
modified 223–224, 224b
Black stones 174, 175f
Blood flow
liver resection effects 8, 8f
measuring 7–8
Blunt finger dissection 254, 254f
Bone marrow 14–15
Branched chain amino acids (BCAAs) 4, 13
Breast cancer 137
British Committee for Standards in Haematology 165b
General Haematology Task Force 167b
Brown stones 174–175, 175f
Budd–Chiari syndrome (hepatic venous thrombosis)
146–147, 158–159
acute 158–159
chronic 159
C
Calcifying chronic pancreatitis (CP) 262
Cambridge Classification, chronic pancreatitis (CP) 260
Cancer
breast 137
endometrial 141
gallbladder see Gallbladder cancer
hereditary pancreatic 276
lung 141
ovarian 137–138, 138f
urothelial 141
see also Carcinoma; Malignancy; Tumours
Capsule, liver 29–30
Carbohydrate metabolism 3
Carboplatin 138
Carcinoembryonic antigen (CEA) 102
Carcinoid syndrome 296t
Carcinoid tumour 296t
Carcinoma
fibrolamellar (FLC) 100
hepatocellular see Hepatocellular carcinoma (HCC)
renal cell (RCC) 138–139
see also Adenocarcinoma; Cholangiocarcinoma entries
Cardiopulmonary exercise testing (CPET) 113–114
Caudate arcade 32
Caudate lobe 24
Cavitron ultrasonic surgical aspiration system
(CUSA™) 64
CELIM study 122
Cetuximab 120, 121
Chemotherapy 11, 98, 120–124, 229
hyperthermic intraperitoneal (HIPEC) 138
Chenodeoxycholic acid (CDCA) 179
Child–Pugh score 44, 90, 93, 157
A cirrhosis 99
B cirrhosis 99
C cirrhosis 99
chronic liver disease 3, 3t
portal hypertension 147–148, 148t
Cholangiocarcinoma 218–232
aetiology 219
epidemiology 218
hilar see Hilar cholangiocarcinoma
histopathology 219–221, 220f
natural history 218
TNM staging system (AJCC) 49t
Cholangiocarcinoma, distal bile duct 229–230
clinical presentation/diagnosis 229–230
staging/assessment 230
treatment options 230
Cholangiocarcinoma, intrahepatic bile ducts (IHC)
230–232
clinical presentation 230
diagnosis 230–231
radiological investigations 231, 231f
staging/assessment 231
treatment options 231–232
Cholangiography
direct 222
intraoperative (IOC) 181–182
328
Index
Cholecystectomy 283
laparoscopic 180–181
mini-laparotomy 180
needlescopic 181
open 179–180
Cholecystitis, acute 180
Cholecystokinin (CKK) 190–191
Cholecystolithiasis 175–176
clinical features 176
pathophysiology 175–176
Cholecystostomy 181
subtotal 181
Choledochal cysts 196–199, 197f, 219
classification 197, 198f
malignancy, risk 197, 197f
management 197
operative techniques 198–199, 199f
Choledocholithiasis 176
clinical features 176
pathophysiology 176
Choledochotomy
laparoscopic 187, 187b
open 187
Chronic liver disease
Child–Pugh score 3, 3t
dysplastic nodules (DNs) 84–85
hepatocellular carcinoma (HCC) 84–85,
99–100
Chronic liver failure 3, 3t
Chronic pancreatitis (CP) 260–274
aetiology 261, 261b
assessment/investigations 264
imaging studies 264, 264b
laboratory evaluation 264
autoimmune 262–263
calcifying 262
clinical course 261–262
complications 270–272, 271f, 272f
definition 260
hereditary (HCP) 263
incidence 261
pathogenesis 263, 263b
pathophysiology/pain mechanisms 262–263
surgery 265–266
procedure selection 270
salvage procedures 270, 270t
techniques 267–270, 270t
treatment 264–270
conservative 264, 265b
endoscopic/interventional 264–265, 265f, 267b
surgery 265–266
Cirrhosis 81, 83, 146–147
therapy 157
Clinical risk scores (CRSs) 41, 42, 112–113
CLIP staging system 91
CLOCC trial (EORTC 40004) 125
Clonorchis sinensis 219
Cochrane reviews 117, 250, 251
Coeliac artery 36–37
Colorectal cancer (CRC) 132, 133
Colorectal liver metastases (CRLMs) 39–42,
109–131
ablative therapies 125
microwave (MWA) 125
radiofrequency (RFA) 125
cardiopulmonary exercise testing (CPET) 113–114
Colorectal liver metastases (CRLMs) (Continued)
chemotherapy 120–124
agents 120
-associated hepatotoxicity 123–124, 123f
conversion/induction 120–122, 120f, 121f, 121t
intent 120
liver-targeted 124
pathological response 123
perioperative 122–123, 122f
classification 118–120
computed tomography (CT) 40, 40f, 109–110, 110f,
111f, 112f, 113f, 114f, 115f
laparoscopy/laparoscopic ultrasound (LUS) 41,
112–113
magnetic resonance imaging (MRI) 40, 110–112
morbidity/mortality/survival 118
multidisciplinary team (MDT) approach 125–126
patient selection 109–114
positron emission tomography (PET) 40–41, 40f, 110f,
112, 112f, 113f, 114f, 115f
selective internal radiation treatment (SIRT) 125
staging/assessment 41–42, 112–113, 118–120,
119t
surgical strategies 116–117
extrahepatic colorectal disease 116–117
extreme surgery 116
portal vein embolisation (PVE) 116
repeat hepatectomy 116
resection, criteria 114–116, 115f
two-stage hepatectomy 116
surgical techniques 117–118
fibrin sealants 117
laparoscopic surgery 117–118
transection 117
transabdominal ultrasound 39
Common bile duct (CBD)
stenosis 271
see also Gallstones
Common hepatic duct (CHD) 31–32
Communicating arcade 32
Computed tomography (CT)
acute pancreatitis 86f, 89
cholangiocarcinoma 222
colorectal liver metastases (CRLMs) 40, 40f, 109–110,
110f, 111f, 112f, 113f, 114f, 115f
CT Severity Index (CTSI) 248
gallstones 177
hepatocellular carcinoma (HCC) 42–43, 87
pancreatic/periampullary carcinoma 45, 45f
proximal bile duct tumours 50–51
Congenital biliary cystic disease see Choledochal cysts
CONKO-001 trial 285b
Contraceptives 84
Contrast-enhanced ultrasound (CEUS) 90
Cori cycle 3
Corticosteroid therapy 166b
Courvoisier sign 278
C-reactive protein (CRP) 247
Critical view, gallbladder 181–182
CRYSTAL trial 121
CUPI staging system 91
Cyanoacrylate 152–154
Cystadenoma 75–77, 76f
Cystic artery, anatomy 31
Cystic duct, anatomy 30–31, 30f
Cystic plate 28–29
329
Index
Cystic tumours 298f, 299–301
Cysts 168
drainage 268
hydatid see Hydatid cyst
liver see Liver cysts, simple; Polycystic liver disease
(PCLD)
D
DEBIRI-TACE 124
Debridement 254–255
resectional 314, 314f
Diagnostic peritoneal lavage (DPL) 306
Diazoxide 296t
Diet 276
Drug-eluting beads for TACE (DEB-TACE) 124
Ductal carcinoma in situ (DCIS) 277
Ducts of Luschka 22–23
Duodenum-preserving pancreatic head resection
(DPPHR) 268–269
Duplex ultrasonography 222, 222f
Dutch Pancreatitis study group 255–256
E
Echinococcus spp 71, 212
Echinococcus granulosus 71, 212
Echinococcus multilocularis 71, 212
ECOG performance status 232
Elliptocytosis 167
Endocrine tumours 47t
Endometrial cancer 141
Endoscopic retrograde cholangiopancreatography
(ERCP)
acute pancreatitis 251
Ascaris lumbricoides infection 212
biliary disorders 203, 208, 214
choledocholithiasis 176
distal bile duct cancer 229
gallstones 178, 178f, 187–190, 188b, 188f
hepatolithiasis 211
intraoperative 189
vs laparoscopic common bile duct (CBD) exploration
189–190
vs magnetic resonance cholangiography 50–51
Mirizzi’s syndrome 210
postoperative 189, 204f, 205
preoperative 178, 178f, 189, 206–207
primary sclerosing cholangitis 212–213
proximal bile duct tumours 51
stent insertion 188–189, 188f
Endoscopic therapy 152
Endoscopic ultrasound (EUS)
acute pancreatitis 249
contrast-enhanced (CEUS) 88–89
gallstones 177
pancreatic/periampullary carcinoma 46
Enterobacter aerogenes 221
Enterococcus spp 221
Epicholedochal plexus 32, 33f
Epithelial tumours, classification 60b
Epithelioid haemangioendothelioma (EHE) 103–104
EPOC trial (EORTC 40983) 122, 122f, 123–124
Escherichia coli 221
ESPAC-3 trial 285b
European Association for the Study of Liver Disease
(EASLD) 42, 89–90, 91, 98
European Colorectal Metastases Treatment group 118–119
European Organization of Research and Treatment of
Cancer (EORTC)
QLQ-C30 instrument 229
trials 122, 122f, 123–124, 125, 285
Evans syndrome 167
Everolimus 134
Exocrine tumours 47t
Extended lymph node/vascular dissection 283–284
External beam radiation therapy (EBRT) 228
Extracellular growth factor receptor (EGFR) 120
Extracorporeal Liver Assist Device (ELAD) 13
Extrahepatic arteries, anatomy 32
Extrahepatic bile ducts 31–32
anomalies 32
Extrahepatic biliary tract trauma 316–318
classification 317
incidence 316
management 318
outcome 318
presentation/diagnosis 317–318
Extrahepatic biliary tree, strictures 197b
Extrahepatic colorectal disease 116–117
Extrahepatic left portal vein, absent 25, 25f
F
Familial adenomatous polyposis (FAP) 140
Fibrin sealants 117
Fibrolamellar carcinoma (FLC) 100
Fischer ratio 13
Flag technique, gallbladder 181–182
Flatulent dyspepsia 175–176
5-FU (fluorouracil) 122
see also FOLFOX
Focal nodular hyperplasia (FNH) 65–68
clinical features 67, 67f
management 67–68
pathology 65–66, 67f
Focused assessment with sonography for trauma (FAST)
165, 306
FOLFIRI (irinotecan-based regimens) 120–121, 122, 123,
124
FOLFOX (5-FU, leucovorin and oxaliplatin) 140
colorectal liver metastases (CRLMs) 120–121, 122,
122f, 123–124, 125
FOLFOXIRI 120–121, 122
Fong classification, colorectal liver metastases (CRLMs)
119
FOXFIRE trial 125
French classification system, colorectal liver metastases
(CRLMs) 118–119
Frey procedure 268–269, 269f
Functional biliary disorders 214
Future liver remnant (FLR) 114–115, 116
G
Gallbladder
agenesis 30
anatomy 30
double 30
stones 178–183
330