by Hannah Farrell
Our expert witnesses in hepato-pancreato-biliary (HPB) surgery specialise in the management of disorders affecting the liver, pancreas, and biliary tract. Our Experts in HPB surgery have a profound knowledge of managing conditions such as gallstones (cholelithiasis), cholangitis, liver failure, fatty liver disease, hepatitis, and pancreatitis. They are experts in both laparoscopic intervention and open surgery; their extensive experience in the operating theatre means they can review operation notes and assess the practical nature of the surgical procedures performed.
With a strong understanding of appropriate standards of care and NICE Guidelines, in addition to a thorough knowledge of treatment pathways, our expert witnesses in HPB surgery can advise on causation, breach of duty, current condition, and prognosis in individuals with liver, pancreatic, and biliary conditions or injury.
See below for a brief overview on HPB surgery. Alternatively, contact an expert witness in HPB surgery to see how they can help.
What is Hepato-Pancreato-Biliary Surgery?
Anatomy & Physiology
The liver, pancreas, and biliary tree form an essential part of the human digestive system. Inflammation, malignancy, infection, and trauma of these organs can have major consequence on normal bodily functions.
The liver lies below the right side of the diaphragm in the abdominal cavity. If it becomes enlarged (hepatomegaly) it will be felt on abdominal examination in the right upper quadrant.
One of the main purposes of the liver is to filter blood that passes from the small intestine and stomach via the hepatic portal vein into the liver, metabolising nutrients and drugs that have been consumed. The liver also acts as a glucose store and produces blood products, cholesterol, and immune factors.
The liver produces bile which passes via the common hepatic duct, where it is stored in the gallbladder, and secreted into the duodenum via the common bile duct. This bile is used to emulsify fats and neutralise the acidic stomach contents as they first enter the small intestine. A large component of bile is bilirubin, which is a biproduct of haemoglobin breakdown.
The pancreas is responsible for secreting digestive enzymes, water, and bicarbonate, in addition to hormones. It produces the hormone glucagon, which stimulates the release of glucose from the body stores.
Gallstones
Gallstones (cholelithiasis) can develop in the gallbladder which may block the bile ducts; this is known as cholestasis. A cholangiography is an investigation whereby a dye is injected into the body and used to illustrate the biliary tract on X-ray images. Should a blockage be detected, an endoscopic retrograde cholangio-pancreatography (ERCP) may be performed to remove it.
Jaundice
When red blood cells die, the haemoglobin is broken down into iron (which is stored in the liver), and bilirubin, which has a green/yellow colour. Should there be high levels of bilirubin circulating in the blood, an individual is said to have jaundice and will present with icteric features such as yellow whites of the eyes or yellow skin.
Jaundice can be said to have three categories of causation:
- Pre-hepatic jaundice i.e., before the liver, pathology causes increased breakdown of blood leading to high levels of bilirubin. Causes include sickle cell anaemia and haemolytic anaemia.
- Hepatic jaundice i.e., liver pathology, such as hepatitis or hepatic failure, result in abnormal metabolism of haemoglobin leading to high levels of circulating blood bilirubin.
- Post-hepatic jaundice i.e., after the liver, pathology in the bile ducts causes a backflow of bilirubin into the blood. Causes include gallstones (cholelithiasis) and pancreatic tumours.
Pancreatic Dysfunction
A glucagonoma is a rare tumour of the pancreatic alpha cells which secretes glucagon in excess. The pancreas also produces insulin in response to high levels of blood glucose, causing increased uptake of glucose by the cells, thereby lowering blood glucose levels. An insulinoma is a rare tumour of the pancreatic beta cells which secretes excess insulin; conversely, type I diabetes is an autoimmune condition which destroys the beta cells leading to a complete deficiency of insulin.
Pancreatic Cancer
Pancreatic cancer most commonly occurs in the parts of the pancreas responsible for digestive enzymes. These are known as ductal adenocarcinomas and result in digestive enzymes being secreted into the pancreas directly, rather than the duodenum. This leads to pain, pancreatitis, diarrhoea, and incomplete digestion of food.
Pancreatitis
Inflammation of the pancreas (pancreatitis) can be acute or chronic. Acute pancreatitis results in digestive enzymes being released into the pancreas and nearby organs and tissues, causing severe abdominal pain and vomiting. Acute pancreatitis can develop from excess alcohol consumption, gallbladder pathology, viral infection, and following surgeries such as ERCP (endoscopic retrograde cholangiopancreatography). Chronic pancreatitis is where there is irreversible damage to the pancreas due to ongoing (chronic) inflammation, resulting in ongoing impaired secretion of digestive enzymes and hormones.