Chapter 69 The Liver

The liver is a highly complex organ found only in vertebrates that is responsible for over 500 individual functions. Liver development begins at 3–4 weeks’ gestation when a hepatic foregut diverticulum buds into the ventral wall of the primitive midgut. The liver is covered by visceral peritoneum, with a layer of connective tissue, the Glisson capsule, underneath. The porta hepatis is a pronounced transverse fissure on the visceral surface of the liver running between the cephalad end of the fissure for the ligamentum teres and the gallbladder fossa. The liver comprises approximately 100 000 hexagonal functional units known as lobules with a central vein surrounded by six hepatic portal veins and six hepatic arteries. These vessels are connected by capillary-like tubes called sinusoids, which extend to meet the central vein. Acute liver failure is the development of sudden, severe hepatic dysfunction from an acute insult associated with the onset of hepatic encephalopathy and coagulation abnormalities.

Advanced Learning Content
Chapter 69: The Liver
Multiple Choice Questions
Weblinks

Journal articles

https://jamanetwork.com/journals/jamasurgery/article-abstract/550916/ (paid)

Safe major surgery of the liver was impossible until anatomists realised that an understanding of the internal anatomy and the variations was essential. The studies of Healey and Schroy published in the early 1950s defined the intrahepatic biliary variations and illustrated the complexity of the anatomy surgeons would face.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5959441/ (free)

Internationally, pyogenic liver abscess remains a common condition associated with a significant morbidity and mortality. This paper presents the European experience over a 17-year period and highlights the diagnostic challenges, issues associated with the non-specific presentations, the spectrum of responsible organisms and the treatment options.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6018306/ (free)

Cystic lesions of the liver are an increasingly common, often incidental finding and pose diagnostic and management problems. There are additionally health economy issues associated with the burden on hepatobiliary multidisciplinary teams and the subsequent investigation of the lesions. This paper is a comprehensive review of the epidemiology, clinical presentation, classification (benign, premalignant, malignant and infective), investigation and management.

https://www.zora.uzh.ch/id/eprint/136159/1/ZORA136159.pdf/ (free)

Cholangiocarcinoma exists in a number of forms with the presentation, management, available treatment options and prognosis being quite different. This is an expert consensus document from the European Network for the Study of Cholangiocarcinoma. The heterogeneity of these tumours, which represent the second most common primary liver tumour, is discussed together with the issues related to their frequent late presentation and aggressive behaviour. The document stresses the need to encourage international collaboration in respect of research, translational and clinical studies based on the presently available data on these tumours. The classification, pathology, risk factors, development, genetics and therapeutic options are described.

https://journals.lww.com/annalsofsurgery/Abstract/2016/06000/A_Review_and_Update_of_Treatment_Options_and.17.aspx/ (paid)

The management of hepatocellular cancer must, by definition, be multidisciplinary and involve primary care, public health, hepatologists, interventional radiologists, surgeons and oncologists. The management is complex and represents a significant problem for health economies around the world. Progress has been made, particularly in the pre- and postoperative management, combination drug therapies and targeted interventional radiological treatments but more clinical trials are required to ensure that progress continues.

https://wjes.biomedcentral.com/articles/10.1186/s13017-020-00302-7/ (free)

The treatment of liver injuries in trauma patients remains one of the most difficult problems and they are still responsible for significant morbidity and mortality. The management of these patients is complex and requires a rapid assessment of the anatomical injury, addressing the haemodynamic instability and frequently technically difficult surgery or safe transfer to a tertiary trauma unit. This paper presents the 2020 World Society of Emergency Surgeons guidelines, including the definitions, grading, comparison with other trauma classifications, management algorithms, diagnosis and non-operative and operative treatment, complications and postoperative care.

https://doi.org/10.1016/j.mayocp.2018.12.020/ (free)

Hepatobiliary surgery becomes significantly more complex in the presence of portal hypertension. The major complications of portal hypertension, including ascites, varices, hepatic encephalopathy and the potential for the development of hepatorenal syndrome, all have to be understood and their impact in patients in whom surgery is considered assessed and addressed. This paper presents an overview of the underlying pathophysiological processes, the associated complications and the therapeutic options.

https://doi.org/10.1016/j.lanepe.2021.100058/ (free)

Surgery for patients with colorectal cancer (CRC) liver metastases is now routinely performed but in a proportion of patients remains complex. These patients can only be appropriately managed in the setting of a specialist multidisciplinary team meeting. These meetings must be able to adequately assess patients with CRC liver metastases and have the full treatment armamentarium available. This is particularly important with recent surgical developments, including two-stage procedures, the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach, neoadjuvant chemotherapy and the attendant complications and combining surgical resection and ablation. These issues are discussed in this paper and the potential approaches in different countries are described in the context of the increasing availability of virtual meetings and the possibility of super-regional referrals.

Books

http://www.worldcat.org/oclc/491282510/

Claude Couinaud was a French anatomist and surgeon who described in detail the segmental anatomy of the liver, the concept of sheaths containing the biliary and vascular structures and performed the first ‘controlled’ hepatectomy by identifying and occluding the vascular inflow prior to parenchymal transection. His book Le Foie: Etudes Anatomique et Chirurgicales remains the most important and influential work on hepatobiliary anatomy and is an invaluable resource for hepatobiliary surgeons.

https://ascopubs.org/doi/10.1200/EDBK_200939?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed/ (free)

Hepatocellular carcinoma (HCC) is one of the most common cancers in the world and the incidence is increasing. The morbidity, mortality and burden on health economies is huge and treatment options, especially in patients where surgery is not an option, are limited. There have been few significant advances in the management of these tumours over the last four decades and the most promising strategies are approaches to disease prevention with the avoidance and treatment of hepatitis B and C infections. This overview discusses the epidemiology, prevention and management of HCC and the importance of surveillance, imaging and the identification of individuals with significant risk factors

Guidelines

https://www.sciencedirect.com/science/article/pii/S0923753419347544/ (free)

Metastatic colorectal cancer (CRC) occurs in 25% of patients and particularly in the western world is the most common indication for liver resection. Over the last 20 years, the outcome for patients with metastatic CRC has improved significantly owing to improved surveillance, a better appreciation of the benefits of surgical resection, improvements in neoadjuvant and adjuvant chemotherapy regimens and management of these patients within a multidisciplinary team setting.

https://jnccn.org/view/journals/jnccn/17/4/article-p302.xml/ (free)

This paper presents the National Collaborative cancer Network Guidelines Insights for hepatobiliary cancers. The increased incidence of hepatocellular cancer and the risk factors including viral infections, cirrhosis, metabolic disorders, and obesity are described and discussed. The complete and most recent version of the guidelines is available free of charge at NCCN.org.

https://bmjopengastro.bmj.com/content/8/1/e000592/ (free)

Benign liver tumours, particularly those that present incidentally, frequently present diagnostic and management problems, especially in patients with concomitant malignancies with the potential to metastasise to the liver. The clinical indications depend on a number of factors that have to be taken into account, including the fitness of the patient, available treatment options and the behaviour of the lesions if untreated. This paper presents an overview as a scoping document of the management of these lesions in clinical practice.

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