BLUMGART’S Surgery of the Liver, Biliary Tract, and Pancreas Volume 1

Frontispiece BLUMGART’S Surgery of the Liver, Biliary Tract, and Pancreas Copyright Page Dedication Editors Contributors Preface Acknowledgments Video contents Techniques of Hepatic Resection Introduction Hepatobiliary and pancreatic surgery Ancient History Until the Eighteenth Century Eighteenth Century to Modern Times Imaging in Hepatobiliary and Pancreatic Surgery Surgery of the Biliary Tract and Pancreas Biliary Tract Pancreas Liver Surgery Major Hepatic Resection Liver Tumors Liver Transplantation References 1 Embryologic development of the liver, biliary tract, and pancreas Overview of Liver and Biliary Tract Development Endodermal Patterning Hepatic Competence Hepatic Induction Morphogenesis of the Hepatic Bud Liver Bud Growth Overview of Hepatoblast Differentiation Biliary Epithelial Cell Differentiation and Formation of the Ductal Plate Remodeling of the Ductal Plate Developmental Relationship Between the Ducts, Vessels and Mesenchyme of the Portal Tract Hepatocyte Differentiation Pancreas Overview of Pancreatic Development Basic Pancreatic Embryology Endodermal Patterning of the Pancreas Dorsal and Ventral Pancreatic Bud Development Pancreatic Mesenchyme TGF-β Signaling NOTCH Signaling HEDGEHOG Signaling WNT Endothelial Cells Glucagon Extracellular Matrix Transcription Factors PTF1a. NEUROG3. RFX6. PAX6. PAX4/ARX NKX2.2. NKX6.1 and NKX6.2. MAFA and MAFB. HNF Cascade. SRY Sex-Determining Region Y-Box: SOX9 References 2 Surgical and radiologic anatomy of the liver, biliary tract, and pancreas Anatomy Overview Liver Retrohepatic Inferior Vena Cava Hepatic Veins Functional Surgical Anatomy Surgical Implications and Exposure Biliary Tract Intrahepatic Bile Duct Anatomy Extrahepatic Biliary Anatomy and Vascular Anatomy of the Liver and Pancreas Main Bile Duct and Sphincter of Oddi Gallbladder and Cystic Duct Biliary Ductal Anomalies Anomalies of the Gallbladder and Cystic Duct Bile Duct Blood Supply Anatomy of Biliary Exposure Biliary-Vascular Sheaths and Exposure of the Hepatic Bile Duct Confluence Umbilical Fissure and Segment III Ligamentum Teres Approach Surgical Approaches to the Right Hepatic Biliary Ductal System Exposure of the Bile Ducts by Liver Resection Extrahepatic Vasculature Celiac Axis and Blood Supply of Liver, Biliary Tract, and Pancreas Variations in the Hepatic Artery Portal Vein Pancreas Pancreatic Duct Annular Pancreas Lymphatic Drainage Liver and Pancreas Nerve Supply to the Liver and Pancreas References 3 Assessment of hepatic function Preoperative Considerations Volumetric Assessment of Liver Remnant Techniques of Volumetric Assessment Volumetric Thresholds Response to Portal Vein Embolization Functional Assessment of Liver Remnant Clinical Scoring Systems Measurement of Hepatic Uptake, Metabolism, and Elimination Indocyanine Green Clearance Nuclear Imaging Techniques Other Measures of Metabolic Function Magnetic Resonance Imaging Hepatic Agents Transient Elastography Texture Analysis Conclusion References 4 Pancreatic Physiology and Functional Assessment Endocrine Pancreas Structure Synthesis and Storage Of Insulin Stimulus-Secretion Coupling for Insulin Secretion Glucagon and Other Islet Hormones Pancreatitis Consequences on Endocrine Pancreas Function Exocrine Pancreas Exocrine Pancreas Structure Acinus The Ductal Network Centroacinar Cells Ductal Epithelial Compartment Neurohormonal Regulation of Exocrine Pancreatic Function Digestive and Interdigestive Periods of Pancreatic Secretion Water, Bicarbonate, and Ion Secretion From the Ductal Network Regulation of Exocrine Secretion Feedback Inhibitory Regulation Digestive Enzymes Stimulus-Secretion Coupling in Acinar Cell Stimulus-Secretion Coupling in the Ductal Cell Functional Assessment Assessment of Endocrine Function Assessment of Exocrine Function Indirect Pancreatic Test Direct Pancreatic Function Test References 5 Liver blood flow Physiology Liver Blood Supply Hepatic Artery Portal Vein Hepatic Veins Hepatic Microcirculation Control of Liver Blood Flow Liver-Intrinsic Blood Flow Regulation The Hepatic Arterial Buffer Response. The Hepatic Inflow Is Not Controlled by Liver-Intrinsic Metabolic Needs. Regulation of Intrahepatic Resistance at the Sinusoidal Level. Liver-Extrinsic Factors Affecting Liver Inflow Endogenous Factors Blood Gas Tensions. Sympathetic Nervous System. Other Endogenous Vasoactive Agents. Exogenous Factors Anesthetic Agents. Measurement of Liver Blood Flow and Perfusion Flow in Single Vessels and Assessment of Portal Hypertension Invasive Techniques Electromagnetic Flowmeter. Transjugular Hepatic Venous Pressure Measurement. Noninvasive Techniques Doppler Ultrasound. Total Blood Flow Clearance Techniques Other Techniques of Physiologic Interest Indicator Dilution. Indicator Fractionation. Hepatic Tissue Perfusion Inert Gas Clearance Laser Doppler Flowmetry In Vivo Fluorescent Microscopy Near-Infrared Spectroscopy Investigational Techniques Clinical Relevance Hemorrhagic Shock, Hypoperfusion, and Ischemia-Reperfusion Injury Liver Atrophy Impact of Acute and Chronic Bile Duct Obstruction on Liver Blood Flow Liver Resection and Regeneration Liver Blood Flow and Hemodynamic Studies in Liver Transplantation Small-for-Size Syndrome Portal Hypertension Hemodynamics Treatments Prevention of Variceal Bleeding. Treatment of Acute Bleeding See Chapter 83. Blood Flow in Hepatic Tumors Effect of Laparoscopy on Liver Blood Flow Acknowledgements References 6 Liver regeneration: mechanisms and clinical relevance Clinical Relevance of Liver Regeneration Basic Characteristics of Liver Regeneration Models of Liver Regeneration General Features of Liver Regeneration Liver Stem Cells Induction of Proliferation: Priming and Cell-Cycle Progression Distinct Intracellular Pathways in Liver Regeneration Remodeling of the Liver Maintaining Liver Function During Regeneration Termination of Proliferation Liver Atrophy Mechanisms of Liver Atrophy Portal Vein?Induced Hepatic Atrophy Biliary-Induced Hepatic Atrophy Clinical Causes of Atrophy Compensatory Regeneration Triggered by Atrophy Factors Influencing Liver Regeneration Patient-Related Factors Age Biliary Obstruction Diabetes Mellitus Nutritional Status Gender Intrinsic Liver Disease: Steatohepatitis Pharmacologic Therapy Liver Transplantation Ischemic Injury Minimal Liver Mass Effect of Immunosuppression Donor Age Inflammation: Viral Hepatitis and Bacterial Infections Other Factors Experimental Strategies to Promote Liver Regeneration Clinical Implications When to Stimulate Liver Regeneration Preoperatively The Use of Portal Vein Embolization to Promote Regeneration Associating Liver Partition With Portal Vein Ligation for Staged Hepatectomy ALPPS Ischemic Preconditioning IPC to Stimulate Regeneration Regenerative Potential of the Liver After Chemotherapy New Horizons and Future Perspectives Therapeutic Use of Stem Cells Decellularized Hepatic Matrix and Hepatic Tissue Engineering The Role of miRNA in Liver Regeneration Summary References 7 Liver fibrogenesis Molecular and Cellular Mechanisms of Fibrosis Common Triggers of Hepatic Fibrogenesis Hepatic Stellate Cell Activation: Hepatic Myofibroblasts Functions of Hepatic Myofibroblasts Fibrogenesis Proliferation Immunoregulation Vasoregulation Structural Features of Hepatic Fibrogenesis Regulation of Collagen Deposition and Degradation Diagnosis and Clinical Monitoring of Hepatic Fibrosis Biochemical Tests Serum Assays of Extracellular Matrix Molecules Cytokines and Chemokines Associated with Hepatic Fibrosis Proteomics and Glycomics Stiffness Assessments Therapeutic Strategies Reversibility of Fibrosis: “Point of No Return? Prevention of Hepatocyte Apoptosis in Liver Injury Caspase Inhibitors Inhibition of Hepatic Stellate Cells Activation or Inactivation of Myofibroblasts Induction of Myofibroblast Apoptosis Blocking Myofibroblast?Extracellular Matrix Interactions Antagonizing Compounds That Mediate Inflammation Selectively Antagonizing Pathways of Hepatic Stellate Cell Activation Enhancing Extracellular Matrix Degradation References 8 Bile secretion and pathophysiology of biliary tract obstruction Overview Bile Secretion Bile Formation Bile Composition Bile Salt Secretion Biliary Lipid Secretion Bilirubin Secretion Bile Flow Enterohepatic Circulation Biliary Obstruction Causes of Jaundice Pathophysiology Hepatobiliary Cardiovascular Renal Coagulation Immune System Wound Healing Other Factors Management Cardiopulmonary Renal Nutrition Coagulation Pruritus Cholangitis Preoperative Drainage Summary References 9A Advances in the molecular characterization of liver tumors Overview Molecular Alterations in Cholangiocarcinoma Chromosomal Aberrations Detection of Somatic Mutations Following the Era of Deep Sequencing Translocations Consequence of Epigenetic Alterations Aberrant DNA Cytosine-Guanine Dinucleotide CpG Methylation Alterations in the Noncoding RNA Landscape Future Directions for Molecular Analysis of CCA Implementation of Next-Generation Sequencing to the Clinic References 9B Molecular pathology of pancreatic cancer and premalignant tumors Pancreatic Cancer Overview Progression Model of Pancreatic Ductal Adenocarcinoma Intraductal Papillary Mucinous Neoplasm Genetics of Pancreatic Ductal Adenocarcinoma Genomic DNA Alterations in Pancreatic Cancer Copy-Number Aberrations Specific Gene Mutations Oncogenes Tumor Suppressor Genes Other Caretaker Genes Telomere Length Abnormalities Alternative Genetic Silencing: Epigenetic Abnormalities Core Signaling Pathways Disrupted in Pancreatic Cancer Familial Pancreatic Cancer Transcriptomic RNA Abnormalities in Pancreatic Cancer Posttranscriptional Regulation MicroRNAs Molecular Genetics of Other Pancreatic Neoplasms Acinar Cell Carcinoma Pancreatic Neuroendocrine Tumors Final Thoughts and Perspectives References 9C Molecular pathogenesis of biliary tract cancer Biliary Tract Cancers Classification Epidemiology Chronic Biliary Inflammation and Cholestasis Clinical Risk Factors Biology of Clinical Risk Factors Bile Content and Deconjugation of Xenobiotics DNA Mutagens Inherited Syndrome Molecular Pathogenesis Biology of Biliary Epithelial Injury and Repair Genetic Polymorphism at Cytochrome P450 MRP2/ABCC2 MUTYH and NEIL1 Activation-Induced Cytidine Deaminase Human CYP1A2 and Arylamine N-Acteyltransferases NAT1 and NAT2 Trefoil Factor Family Biliary Epithelial Proliferation Mitogenic Factors Malignant Transformation Gene Expression Analysis Copy-Number Alterations Pre?Next-Generation Sequencing Post?Next-Generation Sequencing Epigenetic Alterations MicroRNA Alterations Tumor Growth and Metastasis Dysregulated Signaling Pathways Embryonic Signaling Epidermal Growth Factor Receptor Hepatocyte Growth Factor HGF/MET Vascular Endothelial Growth Factor and Angiogenic Signaling IL-6/JAK/STAT Cytokine Signaling Polo-Like Kinases Epithelial-to-Mesenchymal Transition Tumor-Stromal Interactions Summary References 9D Molecular biology of liver carcinogenesis and hepatitis Overview of Molecular Etiology Epidemiology Risk Factors Genetic and Epigenetic Alterations Signal Transduction Pathways Liver Cancer Stem Cells Hepatitis B Virus Hepatitis C Virus Future Directions References 10 Liver immunology Fundamentals of Immunology Anatomic Considerations Tolerance and Immunosuppression Liver Immune Cells Antigen-Presenting Cells Dendritic Cells Kupffer Cells Liver Sinusoidal Endothelial Cells Effector Cells T Cells γδ T Cells Natural Killer T Cells Natural Killer Cells B Cells Immunoinhibitory Pathways and Suppressor Cells Cytokines Tumor Necrosis Factor-α Interleukin-6 Type I Interferons Type II Interferons Immune System in Benign Liver Diseases Transplantation Hepatitis Autoimmune Hepatitis Primary Biliary Cirrhosis Primary Sclerosing Cholangitis Ischemia/Reperfusion Injury Obstructive Jaundice Partial Hepatectomy Drug-Induced Liver Disease Bacterial and Parasitic Liver Disease Immune System in Malignant Liver Diseases Immune Response to Primary Liver Cancer Immune Response to Metastatic Liver Cancer Immunotherapy for Liver Cancer Summary References 11 Cytokines in liver, biliary, and pancreatic disease Overview Cytokines, Stimuli, and Signaling Immune Recognition and Toll-Like Receptors Endotoxin and the Immune Response Tumor Necrosis Superfamily Interleukin-1 Interleukin-6 FAS Ligand Transforming Growth Factor-β Cytokines in the Liver and Pancreas Regulation of Cytokine Expression in the Liver Cytokines and the Hepatic Acute-Phase Response Cytokines and the Pancreas Cytokines and Apoptosis Nitric Oxide Liver Regeneration Pathogenesis of Endotoxin and Cytokines in Liver, Biliary, and Pancreatic Disease Pathogenesis of Proinflammatory Cytokines Cytokines in Ischemia-Reperfusion Injury Cytokines in Hepatic Tumor Ablation Future Directions References 12 Infections in hepatic, biliary, and pancreatic surgery Normal Host Defenses Defining Infectious Complications Surgical-Site Infection Remote-Site Infections General Risk Factors for the Development of Surgical-Site Infection Patient-Related Risk Procedure-Related Risk Discussion of Surgery-Specific Risk Factors for Postoperative Infectious Complications Hepatic Resection Preoperative Risk Mitigation Operative Risk Mitigation Perioperative Antibiotics Drains Postoperative Risk Mitigation Nasogastric Decompression Early Enteral Nutrition and Synbiotics Blood Glucose Control Preoperative Biliary Drainage in the Hilar Cholangiocarcinoma Patient See Chapters 27 and 51 Pancreatic Resection Preoperative Risk Mitigation Body Mass Index and Nutritional Status Preoperative Biliary Drainage Operative Risk Mitigation Preoperative Antibiotics Other Operative Risk Factors Postoperative Risk Mitigation References 13 Clinical investigation of hepatopancreatobiliary disease Clinical History Examination of the Abdomen Portal Hypertension Alcoholic Liver Disease Primary Biliary Cirrhosis Primary Sclerosing Cholangitis Budd-Chiari Syndrome Hemochromatosis Polycystic Disease and Large Liver Cysts Autoimmune Hepatitis Liver Disease in Pregnancy Acute Liver Failure Liver Masses Gallbladder and Biliary Tract Disease Gallbladder Acute Cholecystitis Biliary Colic Cholelithiasis Gallstones in the Bariatric Population Biliary Obstruction Asymptomatic Bile Duct Dilatation Bile Duct Stones Cholangitis Acalculous “Functional? Biliary Pain Sphincter of Oddi Dysfunction Pancreas Acute Pancreatitis Diagnosis and Severity Scoring Chronic Pancreatitis Pancreatic Cancer Investigation of Patients with Pancreatic Disease Assessment of Fitness for Major Hepatopancreatobiliary Surgery References 14 Emerging techniques in diagnostic imaging Dual-Energy Computed Tomography Functional Imaging with Magnetic Resonance Imaging Diagnostic Criteria Radiomics Summary References 15 Ultrasound of the liver, biliary tract, and pancreas Ultrasound Basics Principles of Ultrasound Interpretation Gray Scale Ultrasound Terminology and Artifacts Doppler Ultrasound Liver Ultrasound Normal Liver Anatomy Hepatic Masses Liver Mass Detection and Characterization Role of Contrast-Enhanced Ultrasound in Evaluation of Focal Liver Lesions Benign Liver Lesions Cystic Masses Hepatic Hemangioma Focal Nodular Hyperplasia Hepatic Adenoma Malignant Liver Neoplasms Hepatocellular Carcinoma Liver Metastases Sonography of Diffuse Liver Disease Fatty Liver Disease Viral Hepatitis Cirrhosis Role of Sonoelastography Vascular Evaluation Portal Vein Thrombosis and Cavernous Transformation Budd-Chiari Syndrome and Venoocclusive Disease Liver Transplant Evaluation Transjugular Intrahepatic Portosystemic Shunt Evaluation Ultrasound of the Gallbladder and Biliary Tree Anatomy and Technique Gallbladder Gallstones and Biliary Sludge Cholecystitis Hyperplastic Cholecystoses and Gallbladder Polyps Gallbladder Carcinoma Biliary Ducts Choledochal Cysts Biliary Obstruction Cholangiocarcinoma Ultrasound of the Pancreas Anatomy and Technique Pancreatitis Pancreatic Neoplasms Solid Neoplasms of the Pancreas Cystic Neoplasms of the Pancreas Conclusion References 16 Endoscopic ultrasound of the biliary tract and pancreas Imaging and Diagnosis Endoscopic Ultrasound Technique Endoscopic Ultrasound-Guided Fine-Needle Aspiration and Biopsy Endoscopic Ultrasound Fine Needle Aspiration Technique Diagnosis of Pancreatic Cancer Endoscopic Ultrasound Fine-Needle Aspiration of Solid Pancreatic Lesions Endoscopic Ultrasound Fine Needle Aspiration of Pancreatic Cystic Lesions Complications of Endoscopic Ultrasound Fine-Needle Aspiration Staging of Pancreatic Cancer Endoscopic Ultrasound Tumor-Node-Metastasis Staging Endoscopic Ultrasound Determination of Vascular Involvement Preoperative Reassessment after Neoadjuvant Chemoradiotherapy Diagnosis and Staging of Cholangiocarcinoma Endoscopic Ultrasound-Guided Therapy Celiac Plexus Neurolysis Drainage of Pseudocysts and Peripancreatic Collections Tumor Localization Novel Therapeutics Summary References 17 Role of nuclear medicine in diagnosis and management of hepatopancreatobiliary disease Radiopharmaceuticals Diagnostic Imaging in Nuclear Medicine “Can I Order Two Nuclear Medicine Scans on the Same Day?? Advantages of Positron Emission Versus Single-Photon Imaging Fusion Imaging “Are All PET and SPECT Scanners Created Equal?? Pharmacology and Biology in Radiopharmaceutical Imaging Radiation Dose in Nuclear Medicine Diagnostic Nuclear Imaging in Hepatopancreatobiliary Oncology Nuclear Oncology Fluorodeoxyglucose Positron Emission Tomography Colorectal Cancer Metastasis to Liver Unresectable Liver Cancer Management of Patients With Hepatocellular Carcinoma Initial Presentation See Chapter 91 Tumor-Response Evaluation Recurrence Cholangiocarcinoma See Chapters 50 and 51 Focal Liver Lesions Diagnosis and Follow-Up of Pancreatic Diseases Pancreatic Cancer See Chapters 59 and 62 Detection Staging See Chapter 62 Pancreatic Tumor Response and Recurrence Assessment of Pancreatic Function See Chapter 4 Gastroenteropancreatic Neuroendocrine Tumors See Chapter 65 Peptide Receptor Radionuclide Imaging and Therapy Hepatobiliary Scintigraphy Normal Hepatobiliary IDA Radiotracer Scan Augmented Hepatobiliary Scintigraphy Right Upper Quadrant Pain Acute Cholecystitis See Chapter 33 Chronic Cholecystitis See Chapter 33 Extrahepatic Bile Duct Obstruction Postcholecystectomy Syndrome and Sphincter of Oddi Dysfunction See Chapter 38 Biliary Tract Complications After Surgery Liver Transplantation Pediatric Imaging Neonatal Jaundice Biliary Atresia Role of General Nuclear Medicine in Assessment of Adults With Malignant Involvement of the Liver and Hepatobiliary Tree Sulfur Colloid Imaging Hepatic Arterial Perfusion Studies References 18 Computed tomography of the liver, biliary tract, and pancreas Imaging Overview and History Recent Technical Advances Role of Computed Tomography in Liver and Biliary Imaging Technique and Protocols Noncontrast Computed Tomography of the Liver Contrast-Enhanced Computed Tomography of the Liver Arterial Phase Imaging. Portal Venous Phase Imaging. Delayed Imaging Phases. Anatomy Gross Morphology Segmental Anatomy Vascular Anatomy Biliary Anatomy Lesion Evaluation Benign Tumors and Tumor-Like Conditions of the Liver Cyst See Chapters 75 and 90B Hemangioma See Chapter 90A Focal Nodular Hyperplasia See Chapter 90A Adenoma See Chapter 90A Biliary Hamartoma See Chapters 48 and 90A Bile Duct Adenoma See Chapters 48 and 90A Inflammatory Conditions Pyogenic Abscess See Chapter 72 Fungal Abscesses See Chapter 72 Echinococcus See Chapter 74 Amebic Abscess See Chapter 73 Diffuse Hepatocellular Diseases Fat Deposition See Chapter 71 Cirrhosis See Chapters 76 and 103D Budd-Chiari Syndrome See Chapter 88 Hepatic Infarction Malignant Lesions of the Liver Hepatocellular Carcinoma See Chapter 91 Fibrolamellar Carcinoma See Chapter 91 Angiosarcoma See Chapter 89 Hepatic Lymphoma Hepatic Metastases See Chapters 92 to 94 Biliary System Gallstones Cholecystitis See Chapter 33 Mirizzi Syndrome See Chapter 33 Choledocholithiasis See Chapters 36 and 37 Gallbladder Carcinoma See Chapter 49 Cholangiocarcinoma See Chapters 50 and 51 Perihilar Cholangiocarcinoma See Chapter 5. Distal Cholangiocarcinoma See Chapter 59. Intrahepatic Peripheral Cholangiocarcinoma See Chapter 50. Biliary Cystic Tumors Cystadenoma and Cystadenocarcinoma See Chapter 90B Computed Tomography in Pancreatic Imaging: History and Role Technique and Protocols Anatomy of the Pancreas Tumors of the Pancreas Pancreatic Ductal Adenocarcinoma See Chapters 59 and 66 Pancreatic Endocrine Neoplasm See Chapter 65 Cystic Pancreatic Neoplasms See Chapter 60 Intraductal Papillary Mucinous Neoplasm See Chapter 60. Serous Cystadenoma See Chapter 60. Mucinous Cystic Neoplasms See Chapter 60. Solid Pseudopapillary Neoplasm See Chapters 59 and 60. Other Cystic Pancreatic Lesions. Metastatic Disease to the Pancreas See Chapter 64 Acinar Cell Carcinoma of the Pancreas See Chapter 59 Inflammatory Diseases of the Pancreas Pancreatitis See Chapters 54 to 58 Lymphoplasmacytic Autoimmune Pancreatitis See Chapter 59 Groove Pancreatitis Other Nonneoplastic Pancreatic Masses: Ectopic Splenic Tissue References 19 Magnetic resonance imaging of the liver, biliary tract, and pancreas Principles of Magnetic Resonance Imaging Magnetic Resonance Imaging Safety Magnetic Resonance Imaging Cholangiopancreatography Magnetic Resonance Imaging Contrast Agents Normal Hepatic Appearance on Magnetic Resonance Imaging Diffuse Hepatic Disease Fatty Liver Iron Deposition Disease Focal Hepatic Lesions Cysts Hemangioma Focal Nodular Hyperplasia Hepatic Adenoma Hepatic Abscess/Infection Hepatic Metastases Hepatocellular Carcinoma Fibrolamellar Carcinoma Less Common Hepatic Tumors Lymphoma Angiomyolipoma Mesenchymal Tumors Epithelioid Hemangioendothelioma Biliary Cystadenoma and Biliary Cystadenocarcinomas Biliary Tumors Gallbladder Carcinoma Bile Duct Cancer Benign Diseases of the Biliary Tract Cholelithiasis and Choledocholithiasis Choledochal Cysts Postoperative Biliary Complications Pancreas Solid Tumors of the Pancreas Pancreatic Cancer Cystic Lesions of the Pancreas Intraductal Papillary Mucinous Neoplasms Autoimmune Pancreatitis References 20 Direct cholangiography Direct Cholangiography Overview Percutaneous Transhepatic Cholangiography History Preprocedural Preparation Procedure Right-Sided Puncture Left-Sided Puncture Success Rate and Accuracy Pitfalls in Interpretation Lack of Opacification Ductal Dilatation Complications Endoscopic Retrograde Cholangiopancreatography History Indications Technique Pancreatography Cholangioscopy and Pancreatoscopy Complications Pancreatitis Infection Bleeding Perforation Direct Cholangiography and Pancreatography by Percutaneous Transhepatic Cholangiography OR Endoscopic Retrograde Cholangiopancreatography Interpretations Bile Leaks Filling Defects Air Bubbles, Blood Clots, Calculi, Primary and Secondary Bile Duct Cancers, and Parasitic Diseases Conclusion References 21 Diagnostic angiography in hepatobiliary and pancreatic disease Overview Angiography Technique Hepatobiliary and Pancreatic Arterial Anatomy Arterial Anatomy Venous Anatomy Angiography Indications Treatment of Bleeding/Hemorrhage Splenic Bleeding Hepatic Bleeding Pancreas Bleeding Diagnosis of Arterial Occlusive Disease Diagnosis and Treatment of Arterial Stenosis Treatment of Visceral Arterial Aneurysms Diagnosis of Vasculitis Vasculitis Diagnosis of Other Visceral Vascular Disease Segmental Arterial Mediolysis Hereditary Hemorrhagic Telangiectasia Peliosis Hepatitis Localization of Functional Pancreatic Neuroendocrine Tumors See Chapter 65 Insulinomas Gastrinomas Glucagonoma Venographic Technique References 22 Percutaneous biopsy Overview Biopsy Technique Fine Needle Aspiration Core Biopsy Imaging Guidance Ultrasound Computed Tomography Computed Tomographic Fluoroscopy Cone-Beam Computed Tomography Magnetic Resonance Imaging Positron-Emission Tomography Other Guidance Biopsy of Specific Sites Liver Biopsy Focal Liver Lesions Liver Parenchyma Biopsy Transvenous Biopsy Biopsy of Other Organs Adrenal Biopsy Pancreas Biopsy Retroperitoneal and Pelvic Biopsy Lung and Mediastinum Biopsy Bone Biopsy Complications of Percutaneous Biopsy Conclusion References 23 Intraoperative diagnostic techniques Overview Intraoperative Ultrasonography Hepatic Disease Evaluation of the Liver Technical Considerations Biliary Disease Evaluation of the Biliary Tree Technical Considerations Pancreatic Disease Evaluation of the Pancreas Technical Considerations Intraoperative Cholangiography Choledocholithiasis Biliary Injuries Controversies Technical Considerations Staging Laparoscopy Surgical Technique Technical Considerations Laparoscopic Ultrasound Complications Staging Laparoscopy for Potentially Resectable Disease Hepatobiliary Malignancy Pancreatic and Periampullary Malignancy Controversies References 24 Intraoperative and immediate postoperative management Overview Preoperative Evaluation Risk and Outcome Improvement Cardiac Evaluation Pulmonary Evaluation Hepatic Evaluation See Chapter 3 Alcohol Use Disorder Jaundice Bloodless Surgery: Blood Conservation Intraoperative Management Hepatic Blood Flow Volatile Anesthetics Anesthetic Hepatotoxicity Hemodynamics Intravenous Anesthetics and Muscle Relaxants Epidural Anesthesia EDA Special Anesthetic Considerations Anesthesia for Hepatectomy Low Central Venous Pressure Technique: General Anesthesia Phase 1: Prehepatic Postresection: Phase 2 Goal-Directed Individual Fluid Therapy Low Central Venous Pressure: Epidural Anesthesia Air Embolus Bloodless Surgery: Blood Conservation, Transfusion Minimally Invasive Liver Resection Ablation Postoperative Care Cardiopulmonary Cardiac Dysfunction Pulmonary Dysfunction Venous Thromboembolism Liver Dysfunction See Chapters 79 to 81 Jaundice Coagulation Ascites Renal Dysfunction Glucose Metabolism Analgesia Epidural Analgesia Intraabdominal Infection Delirium: Encephalopathy References 25 Perioperative critical care in hepatopancreatobiliary patients Introduction Preoperative Assessment and Care Hepatic Reserve with Child-Turcotte-Pugh and Model for End-Stage Liver Disease Scores Comorbid Conditions Ascites, Portal Hypertension, and Variceal Bleeding Nutrition Anemia Coagulopathy Cardiovascular and Respiratory Parameters Hepatopulmonary Syndrome and Portopulmonary Hypertension Electrolytes Infection Surgical Procedures Assessment for Pancreatobiliary Surgery Intraoperative Management Selection of Anesthetic, Narcotic, and Sedative Agents Management of Mechanical Ventilation Fluid/Blood Loss and Hemodynamic Parameters Correction of Electrolyte Abnormalities Improved Surgical Techniques Postoperative Management Postoperative Hepatic Failure Fluid Management and Abdominal Compartment Syndrome Acute Renal Failure and Hepatorenal Syndrome Anemia and Hemorrhage Sedative and Pain Management and Hepatic Encephalopathy Liver Regeneration, Hyperglycemia, and Nutrition Postoperative Care after Pancreaticoduodenectomy Venous Thromboembolism Prophylaxis References 26 Preoperative and postoperative nutrition in hepatobiliary surgery Goals of Nutritional Support in Hepatopancreatobiliary Surgery Alterations in Liver Metabolism That Affect Nutritional Status Antioxidant Nutrient Depletion in the Pathogenesis of Liver Injury Vitamin E Vitamin C Omega-3 Fatty Acids Obstructive Jaundice Cirrhosis and Liver Failure Liver Resection Transplantation Hepatocellular Carcinoma Nutritional Problems in Patients With Pancreatic Diseases Etiology of Malnutrition With Pancreatic Disease Pancreatic Cancer See Chapter 62 Pancreatic Exocrine Insufficiency Biliary Obstruction Pain Cancer-Related Effects on Metabolism Malnutrition and Pancreatic Resection Nutritional Implications of Pancreatic Resection Chylous Ascites Delayed Gastric Emptying Pancreatic Fistula Identification of Patients at Risk for Postoperative Complications Anthropometric Measurements Bioelectrical Impedance Sarcopenia Serum Biochemical Markers Albumin Prealbumin Nutritional Scoring Systems Nutritional Risk Index Nutritional Risk Score Subjective Global Assessment Malnutrition Universal Screening Tool Glasgow Prognostic Score Nutritional Support of Patients Undergoing Hepatopancreatobiliary Surgery Routes of Feeding Parenteral Nutrition Enteral and Parenteral Nutrition Nutritional Support as Part of Enhanced Recovery after Surgery Programs Immune-Modulating Nutrition Vitamins Probiotics and Synbiotics Appetite Stimulants Disease- and Condition-Specific Management Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis Cirrhosis and Hepatic Failure Liver Resection Liver Transplantation Pancreatic Cancer Summary References 27 Postoperative complications requiring intervention Overview Pancreatectomy Defining and Grading Complications After Pancreatectomy Postoperative Pancreatic Fistula: A Unifying System for Reporting Management of Postpancreatectomy Complications Postoperative Pancreatic Fistula Delayed Gastric Emptying Postpancreatectomy Hemorrhage Postpancreatectomy Hemorrhage: Definitions, Terminology, and Grading Postpancreatectomy Hemorrhage Validation Studies Imaging and Image-Guided Therapy of Complications After Pancreatectomy Imaging After Pancreatectomy Interventional Radiology Techniques After Pancreatectomy Image-Guided Abdominal Drainage Drain Management Interventional Management of Pancreaticocutaneous Fistulae Percutaneous Biliary Drainage Angiography, Embolization, and Covered Stent Placement See Chapters 21 and 30 Hepatectomy Complications Associated With Hepatic Resections Posthepatectomy Liver Failure Bile Leak Posthepatectomy Hemorrhage Techniques for Reducing Intraoperative Blood Loss Imaging and Image-Guided Therapy of Complications After Hepatectomy Imaging After Hepatectomy Interventional Radiology Procedures Posthepatectomy Intrahepatic Abscess Drainage Interventional Management of Bilomas and Bile Leaks Interventional Management of Biliary Strictures Bleeding Complications References