112. Adams RB, Aloia TA, Loyer E, et al. Selection for hepatic resection of colorectal liver metastases:

expert consensus statement. HPB (Oxford) 2013; 15:91–103.

113. Nordlinger B, Sorbye H, Glimelius B, et al. Perioperative chemotherapy with FOLFOX4 and surgery

versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial

40983): a randomised controlled trial. Lancet 2008;371:1007–1016.

1572

114. Jaeck D, Oussoultzoglou E, Bachellier P, et al. Hepatic metastases of gastroenteropancreatic

neuroendocrine tumors: safe hepatic surgery. World J Surg 2001;25:689–692.

115. Andreou A, Brouquet A, Bharathy KG, et al. Liver resection for liver metastases from nondigestive

endocrine cancer: Extrahepatic disease burden defines outcome. Surgery 2012;151(6):851–859.

116. Sarmiento JM, Heywood G, Rubin J, et al. Surgical treatment of neuroendocrine metastases to the

liver: a plea for resection to increase survival. J Am Coll Surg 2003;197:29–37.

117. Clark GM, Sledge GW Jr, Osborne CK, et al. Survival from first recurrence: relative importance of

prognostic factors in 1,015 breast cancer patients. J Clin Oncol 1987;5:55–61.

118. Madoff DC, Abdalla EK, Vauthey JN. Portal vein embolization in preparation for major hepatic

resection: evolution of a new standard of care. J Vasc Interv Radiol 2005;16:779–790.

119. Makuuchi M, Hasegawa H, Yamazaki S, et al. The inferior right hepatic vein: ultrasonic

demonstration. Radiology 1983;148:213–217.

120. Mise Y, Hasegawa K, Satou S, et al. Venous reconstruction based on virtual liver resection to avoid

congestion in the liver remnant. Br J Surg 2011;98:1742–1751.

121. Kubota K, Makuuchi M, Kusaka K, et al. Measurement of liver volume and hepatic functional

reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology

1997;26:1176–1181.

122. Zorzi D, Laurent A, Pawlik TM, et al. Chemotherapy-associated hepatotoxicity and surgery for

colorectal liver metastases. Br J Surg 2007;94:274–286.

123. Azoulay D, Castaing D, Smail A, et al. Resection of nonresectable liver metastases from colorectal

cancer after percutaneous portal vein embolization. Ann Surg 2000;231:480–486.

124. Ribero D, Abdalla EK, Madoff DC, et al. Portal vein embolization before major hepatectomy and its

effects on regeneration, resectability and outcome. Br J Surg 2007;94:1386–1394.

125. Shindoh J, Truty MJ, Aloia TA, et al. Kinetic growth rate after portal vein embolization predicts

posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver

metastases and small future liver remnant. J Am Coll Surg 2013;216:201–209.

126. Kawaguchi Y, Ishizawa T, Miyata Y, et al. Portal uptake function in veno-occlusive regions

evaluated by real-time fluorescent imaging using indocyanine green. J Hepatol 2013;58:247–253.

127. Hashimoto T, Miki K, Imamura H, et al. Sinusoidal perfusion in the veno-occlusive region of living

liver donors evaluated by indocyanine green and near-infrared spectroscopy. Liver Transpl

2008;14:872–880.

128. Maema A, Imamura H, Takayama T, et al. Impaired volume regeneration of split livers with partial

venous disruption: a latent problem in partial liver transplantation. Transplantation 2002;73:765–

769.

129. Shindoh J, Satou S, Aoki T, et al. Hidden symmetry in asymmetric morphology: significance of

Hjortsjo’s anatomical model in liver surgery. Hepatogastroenterology 2012;59:519–525.

130. Abulkhir A, Limongelli P, Healey AJ, et al. Preoperative portal vein embolization for major liver

resection: a meta-analysis. Ann Surg 2008;247:49–57.

131. Giraudo G, Greget M, Oussoultzoglou E, et al. Preoperative contralateral portal vein embolization

before major hepatic resection is a safe and efficient procedure: a large single institution

experience. Surgery 2008;143:476–482.

132. Mueller L, Hillert C, Moller L, et al. Major hepatectomy for colorectal metastases: is preoperative

portal occlusion an oncological risk factor? Ann Surg Oncol 2008;15:1908–1917.

133. Shindoh J, Tzeng CW, Aloia TA, et al. Safety and efficacy of portal vein embolization before

planned major or extended hepatectomy: an institutional experience of 358 patients. J Gastrointest

Surg 2014;18:45–51.

134. Uesaka K, Nimura Y, Nagino M. Changes in hepatic lobar function after right portal vein

embolization. An appraisal by biliary indocyanine green excretion. Ann Surg 1996;223:77–83.

135. Hirai I, Kimura W, Fuse A, et al. Evaluation of preoperative portal embolization for safe

hepatectomy, with special reference to assessment of nonembolized lobe function with 99mTc-GSA

SPECT scintigraphy. Surgery 2003;133:495–506.

136. Ijichi M, Makuuchi M, Imamura H, et al. Portal embolization relieves persistent jaundice after

complete biliary drainage. Surgery 2001;130:116–118.

137. Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ

1573

splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic

resection in small-for-size settings. Ann Surg 2012;255:405–414.

138. Makuuchi M, Hasegawa H, Yamazaki S. Ultrasonically guided subsegmentectomy. Surg Gynecol

Obstet 1985;161:346–350.

139. Ohashi I, Ina H, Okada Y, et al. Segmental anatomy of the liver under the right diaphragmatic

dome: evaluation with axial CT. Radiology 1996;200:779–783.

140. Aoki T, Yasuda D, Shimizu Y, et al. Image-guided liver mapping using fluorescence navigation

system with indocyanine green for anatomical hepatic resection. World J Surg 2008;32:1763–1767.

141. Shindoh J, Seyama Y, Umekita N. Three-dimensional staining of liver segments with an ultrasound

contrast agent as an aid to anatomic liver resection. J Am Coll Surg 2012;215:e5–e10.

142. Aloia TA, Zorzi D, Abdalla EK, et al. Two-surgeon technique for hepatic parenchymal transection of

the noncirrhotic liver using saline-linked cautery and ultrasonic dissection. Ann Surg 2005;242:172–

177.

143. El Moghazy WM, Hedaya MS, Kaido T, et al. Two different methods for donor hepatic transection:

cavitron ultrasonic surgical aspirator with bipolar cautery versus cavitron ultrasonic surgical

aspirator with radiofrequency coagulator-A randomized controlled trial. Liver Transpl 2009;15:102–

105.

144. Palavecino M, Kishi Y, Chun YS, et al. Two-surgeon technique of parenchymal transection

contributes to reduced transfusion rate in patients undergoing major hepatectomy: analysis of 1,557

consecutive liver resections. Surgery 2010;147:40–48.

145. Takatsuki M, Eguchi S, Yamanouchi K, et al. Two-surgeon technique using saline-linked electric

cautery and ultrasonic surgical aspirator in living donor hepatectomy: its safety and efficacy. Am J

Surg 2009;197:e25–e27.

146. Imamura H, Takayama T, Sugawara Y, et al. Pringle’s manoeuvre in living donors. Lancet

2002;360:2049–2050.

147. Torzilli G, Procopio F, Donadon M, et al. Safety of intermittent Pringle maneuver cumulative time

exceeding 120 minutes in liver resection: a further step in favor of the “radical but conservative”

policy. Ann Surg 2012;255:270–280.

148. Belghiti J, Guevara OA, Noun R, et al. Liver hanging maneuver: a safe approach to right

hepatectomy without liver mobilization. J Am Coll Surg 2001;193:109–111.

149. Koch M, Garden OJ, Padbury R, et al. Bile leakage after hepatobiliary and pancreatic surgery: a

definition and grading of severity by the International Study Group of Liver Surgery. Surgery

2011;149:680–688.

150. Zimmitti G, Vauthey JN, Shindoh J, et al. Systematic use of an intraoperative air leak test at the

time of major liver resection reduces the rate of postoperative biliary complications. J Am Coll Surg

2013;217:1028–1037.

151. Rees M, Tekkis PP, Welsh FK, et al. Evaluation of long-term survival after hepatic resection for

metastatic colorectal cancer: A multifactorial model of 929 patients. Ann Surg 2008;247:125–135.

152. Nordlinger B, Guiguet M, Vaillant JC, et al. Surgical resection of colorectal carcinoma metastases to

the liver. A prognostic scoring system to improve case selection, based on 1568 patients.

Association Francaise de Chirurgie. Cancer 1996;77:1254–1262.

153. Fong Y, Fortner J, Sun RL, et al. Clinical score for predicting recurrence after hepatic resection for

metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 1999;230:309–318.

154. Wei AC, Greig PD, Grant D, et al. Survival after hepatic resection for colorectal metastases: a 10-

year experience. Ann Surg Oncol 2006;13:668–676.

155. Kato T, Yasui K, Hirai T, et al. Therapeutic results for hepatic metastasis of colorectal cancer with

special reference to effectiveness of hepatectomy: analysis of prognostic factors for 763 cases

recorded at 18 institutions. Dis Colon Rectum 2003;46:S22–S31.

156. Scheele J, Altendorf-Hofmann A, Grube T, et al. [Resection of colorectal liver metastases. What

prognostic factors determine patient selection?]. Chirurg 2001;72:547–560.

157. Brouquet A, Abdalla EK, Kopetz S, et al. High survival rate after two-stage resection of advanced

colorectal liver metastases: response-based selection and complete resection define outcome. J Clin

Oncol 2011;29:1083–1090.

158. Azagra JS, Goergen M, Gilbart E, et al. Laparoscopic anatomical (hepatic) left lateral

1574

segmentectomy-technical aspects. Surg Endosc 1996;10:758–761.

159. Croce E, Azzola M, Russo R, et al. Laparoscopic liver tumour resection with the argon beam. Endosc

Surg Allied Technol 1994;2:186–188.

160. Kaneko H, Takagi S, Shiba T. Laparoscopic partial hepatectomy and left lateral segmentectomy:

technique and results of a clinical series. Surgery 1996;120:468–475.

161. Rau HG, Meyer G, Cohnert TU, et al. Laparoscopic liver resection with the water-jet dissector. Surg

Endosc 1995;9:1009–1012.

162. Buell JF, Thomas MT, Rudich S, et al. Experience with more than 500 minimally invasive hepatic

procedures. Ann Surg 2008;248:475–486.

163. Koffron AJ, Auffenberg G, Kung R, et al. Evaluation of 300 minimally invasive liver resections at a

single institution: less is more. Ann Surg 2007;246:385–392; discussion 392–384.

164. Nguyen KT, Laurent A, Dagher I, et al. Minimally invasive liver resection for metastatic colorectal

cancer: a multi-institutional, international report of safety, feasibility, and early outcomes. Ann Surg

2009;250:842–848.

165. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804 patients.

Ann Surg 2009;250:831–841.

166. Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living donor hepatectomy for liver

transplantation in children. Lancet 2002;359:392–396.

167. Koffron AJ, Kung R, Baker T, et al. Laparoscopic-assisted right lobe donor hepatectomy. Am J

Transplant 2006;6:2522–2525.

168. Suh KS, Yi NJ, Kim J, et al. Laparoscopic hepatectomy for a modified right graft in adult-to-adult

living donor liver transplantation. Transplant Proc 2008;40:3529–3531.

169. Suh KS, Yi NJ, Kim T, et al. Laparoscopy-assisted donor right hepatectomy using a hand port

system preserving the middle hepatic vein branches. World J Surg 2009;33:526–533.

170. Faraj W, Dar F, Marangoni G, et al. Liver transplantation for hepatoblastoma. Liver Transpl

2008;14:1614–1619.

171. Kaido T, Ogawa K, Mori A, et al. Usefulness of the Kyoto criteria as expanded selection criteria for

liver transplantation for hepatocellular carcinoma. Surgery 2013;154:1053–1060.

172. Fan ST, Le Treut YP, Mazzaferro V, et al. Liver transplantation for neuroendocrine tumour liver

metastases. HPB (Oxford) 2014;17(1):23–28.

173. Le Treut YP, Gregoire E, Klempnauer J, et al. Liver transplantation for neuroendocrine tumors in

Europe-results and trends in patient selection: a 213-case European liver transplant registry study.

Ann Surg 2013;257:807–815.

174. Mazzaferro V, Pulvirenti A, Coppa J. Neuroendocrine tumors metastatic to the liver: how to select

patients for liver transplantation? J Hepatol 2007;47:460–466.

175. Grossman EJ, Millis JM. Liver transplantation for non-hepatocellular carcinoma malignancy:

Indications, limitations, and analysis of the current literature. Liver Transpl 2010;16:930–942.

176. Hagness M, Foss A, Line PD, et al. Liver transplantation for nonresectable liver metastases from

colorectal cancer. Ann Surg 2013;257:800–806.

177. Wu Y, Johlin FC, Rayhill SC, et al. Long-term, tumor-free survival after radiotherapy combining

hepatectomy-Whipple en bloc and orthotopic liver transplantation for early-stage hilar

cholangiocarcinoma. Liver Transpl 2008;14:279–286.

178. Schule S, Altendorf-Hofmann A, Utess F, et al. Liver transplantation for hilar cholangiocarcinoma–a

single-centre experience. Langenbecks Arch Surg 2013;398:71–77.

1575

Chapter 61

Calculous Biliary Disease

David A. Kooby, Joshua H. Winer, and Kenneth Cardona

Key Points

1 Gallstones are classified by their cholesterol content as either cholesterol (70% to 80%) or pigment

(20% to 30%), with pigment stones further classified as black or brown.

2 Biliary sludge refers to a mixture of cholesterol crystals, calcium bilirubinate granules, and a mucin

gel matrix and is thought to serve as the nidus for gallstone growth.

3 The pathogenesis of cholesterol gallstones is clearly multifactorial but essentially involves four

factors: (a) cholesterol supersaturation in bile, (b) crystal nucleation, (c) gallbladder dysmotility,

and (d) gallbladder absorption/secretion.

4 Prophylactic cholecystectomy is generally not indicated in patients with asymptomatic gallstones,

because studies show that under 30% of patients will become symptomatic within 20 years and only

1% to 2% will develop gallstone-related complications, such as cholecystitis, per year.

5 Elective laparoscopic cholecystectomy is associated with a mortality rate of less than 0.3% and an

overall complication rate of 10%, with less than 5% of patients requiring conversion to an open

procedure.

6 Randomized trials have shown that laparoscopic cholecystectomy performed for acute cholecystitis

(AC) during initial hospitalization can be performed safely resulting in a lower morbidity rate and

shorter overall hospital stay when compared to delayed cholecystectomy during a separate

admission.

7 Common bile duct (CBD) stones, similar to gallbladder stones, can have an asymptomatic course and

pass spontaneously without clinical consequence. When symptomatic, the presentation of CBD stones

can vary between mild biliary colic to fulminant sepsis from acute cholangitis, biliary pancreatitis, or

hepatic abscesses.

8 ERCP with stone extraction is effective in removing stones in 85% to 95% of cases but is associated

with postprocedural complications (pancreatitis and cholangitis) in 5% of cases.

9 Endoscopic cholangiography with sphincterotomy allows for the diagnosis of CBD stones in the vast

majority of cases. The primary advantage of endoscopic retrograde cholangiopancreatography

(ERCP) is that it allows for therapeutic intervention if stones are identified.

10 Acute cholangitis results from the combination of significant bacterial concentration in bile and

increased biliary pressure associated with biliary obstruction.

INTRODUCTION

Cholelithiasis (gallbladder stone disease) is both a substantial healthcare problem and financial burden

for the US healthcare system, with more than 20 million Americans afflicted, resulting in expenses of

more than 6 billion dollars annually.1 A recent report demonstrates that cholelithiasis and cholecystitis

were the second most common gastrointestinal problems listed as the discharge diagnosis in 2009 with

approximately 750,000 gallbladders removed.2 Surgeons treating patients with gallstones and their

associated conditions should have an understanding of biliary physiology and of the pathophysiology of

gallstone formation. This chapter reviews the physiology and surgical management of calculous biliary

disease.

BILIARY PHYSIOLOGY

An understanding of normal bile composition, synthesis, and metabolism is pertinent to the

1576