Key Facts

Hepatobiliary surgery is a specialist field dealing with complex liver, bile duct, and gallbladder pathology. In the UK, hepatobiliary surgical services are centralised to specialist centres. Liver resection is the only curative option for many primary and secondary hepatic malignancies.

Epidemiology

Primary liver cancer affects approximately 6,200 people per year in the UK. Colorectal liver metastases develop in approximately 50% of colorectal cancer patients. Gallstone disease affects 10-15% of the UK adult population, with ~70,000 cholecystectomies performed annually.

Aetiology

• HCC: Cirrhosis (alcohol, hepatitis B/C, NAFLD), aflatoxin exposure
• Cholangiocarcinoma: Primary sclerosing cholangitis, liver fluke, choledochal cysts
• Colorectal liver metastases: Haematogenous spread via portal circulation
• Gallstone complications: Cholecystitis, choledocholithiasis, cholangitis, gallstone pancreatitis, Mirizzi syndrome

Pathophysiology

The liver's dual blood supply (portal vein 75%, hepatic artery 25%) and remarkable regenerative capacity underpin the feasibility of major liver resection. A future liver remnant (FLR) of at least 25-30% (normal liver) or 40% (cirrhotic/chemotherapy-treated) is required. Portal vein embolisation can induce contralateral hypertrophy pre-operatively.

Hepatocellular Carcinoma

• Often incidental finding on cirrhosis surveillance USS
• Decompensation of previously stable cirrhosis
• Right upper quadrant pain, weight loss, hepatomegaly
• AFP elevated (>400 ng/mL highly suggestive)

Colorectal Liver Metastases

• Often detected on staging CT or surveillance imaging
• Rising CEA during follow-up
• May present with hepatomegaly, jaundice (rare unless extensive)

Biliary Obstruction

• Painless jaundice (malignant) vs painful jaundice (stone disease)
• Courvoisier's sign: palpable, non-tender gallbladder with jaundice suggests malignancy
• Cholangitis (Charcot's triad): fever, jaundice, RUQ pain; Reynolds' pentad adds confusion and shock

Red Flags

• Painless jaundice with weight loss — suspect pancreatic/biliary malignancy
• Charcot's triad/Reynolds' pentad — emergency ERCP required
• Rapidly deteriorating liver function in known cirrhosis — consider HCC
• Post-cholecystectomy bile leak — urgent hepatobiliary referral

Bedside

• Observations: NEWS2, jaundice assessment
• Abdominal examination: Hepatomegaly, ascites, stigmata of chronic liver disease

Bloods

• LFTs: Obstructive vs hepatocellular pattern; bilirubin, ALP, GGT, ALT, AST
• Coagulation: INR — synthetic liver function
• Albumin: Nutritional and synthetic liver function
• AFP: >400 ng/mL diagnostic for HCC in cirrhosis; >200 ng/mL highly suggestive
• CA19-9: Elevated in cholangiocarcinoma and pancreatic cancer
• CEA: Colorectal liver metastases monitoring
• Hepatitis serology: HBV, HCV screening

Imaging

• USS abdomen: First-line; detects gallstones, liver lesions, biliary dilatation
• CT triple-phase (arterial, portal venous, delayed): Standard for liver lesion characterisation and staging
• MRI liver with hepatocyte-specific contrast (Primovist): Superior for lesion characterisation and surgical planning
• MRCP: Non-invasive biliary tree assessment
• PET-CT: Detect extrahepatic disease before liver resection
• ERCP: Therapeutic — stenting, stone extraction, brushings

Special Tests

• Liver volumetry (CT): Calculate FLR before major hepatectomy
• ICG clearance test: Assess hepatic functional reserve (mainly in Asian practice)
• Child-Pugh score / MELD score: Assess severity of cirrhosis and transplant eligibility
• Liver biopsy: Percutaneous or transjugular — for uncertain lesions (avoid in suspected HCC if transplant candidate)

Non-pharmacological

• MDT discussion: All hepatobiliary malignancies discussed at specialist HPB MDT
• Prehabilitation: Exercise, nutrition optimisation before major surgery
• Alcohol abstinence: Mandatory for liver transplant consideration

Pharmacological

• Chemotherapy for colorectal liver metastases: FOLFOX/FOLFIRI ± bevacizumab/cetuximab (neoadjuvant or conversion)
• Sorafenib/lenvatinib: First-line systemic therapy for advanced HCC
• Atezolizumab + bevacizumab: First-line for unresectable HCC (IMbrave150 trial)
• Gemcitabine + cisplatin: First-line for advanced cholangiocarcinoma (ABC-02 trial)
• Ursodeoxycholic acid: For primary sclerosing cholangitis (limited evidence)

Surgical/Interventional

• Liver resection: Curative for CRC metastases, HCC (non-cirrhotic), cholangiocarcinoma
• Liver transplantation: HCC within Milan criteria, selected cholangiocarcinoma
• Laparoscopic cholecystectomy: Gold standard for gallstone disease
• ERCP with sphincterotomy: CBD stone extraction, biliary stenting
• Portal vein embolisation: Induce FLR hypertrophy before major hepatectomy
• Ablation (RFA/MWA): For small HCC or metastases not amenable to resection
• TACE/TARE: Locoregional therapy for intermediate HCC

Referral Criteria

• All liver lesions of uncertain nature — specialist HPB centre
• Colorectal liver metastases — HPB MDT for resectability assessment
• Biliary obstruction requiring intervention — HPB surgery/gastroenterology
• Suspected bile duct injury — urgent specialist HPB referral

• Colorectal liver metastases post-resection: 5-year survival 40-50%; without treatment, median survival <1 year
• HCC after resection: 5-year survival 50-70% (non-cirrhotic); recurrence rate 50-70% at 5 years
• HCC with transplant (within Milan): 5-year survival 70-80%
• Cholangiocarcinoma post-resection: 5-year survival 20-40%; R0 margin is the strongest prognostic factor
• Operative mortality for major hepatectomy: 1-5% in specialist centres

Couinaud Liver Segments

Child-Pugh Score

Class A: 5-6 points; Class B: 7-9; Class C: 10-15. Only Child-Pugh A patients are typically candidates for resection.

Landmark Trials