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HEALTH

Liver Surgery : Lagging Behind

by Dr Mohammad Ali
***It will be unfortunate to remain yet much behind even of our regional neighbours in treatment of such vital organ as liver. Something must be done for the suffering humanity in the country.***
THE modern era of biver Surgery (Hepatobiliary) is ever evolving and has revealed a new horizon in the rapidly advancing surgical sphere. Liver Is the largest internal organ of the body. It has a difficult and extraordinary anatomy and complex physiology. Since long it is regarded as a mystical organ full of blood and fearsome to operate upon. It has a difficult location under cover of the lower ribs which is unfavourable for diagnostic imaging and surgical exposure. Due to all these facts the liver became the last organ in the human body to be acquired by the surgeons.
In the past twenty years the world has witnessed a tremendous development in the field of imaging and surgical techniques. Liver was not exempted from that. Scientists of the world have understood the complex and vascular segmental anatomy and invented many methods and manoeuvres to control the haemorrhage from liver. Physiological concept has revealed that about 75 per cent of the liver could be resected safely and a healthy liver regenerated close to its original weight. Advanced techniques have allowed not only preoperative imaging but also imaging during operation which exposes the real anatomy and the exact extent of the diseased condition of liver. Different modalities of technical tools and methods for managing the liver conditions also have been added to the modern surgical armamentarium. Lastly, liver transplantation is added to the management of endstage liver disease. This has been possible due to the better understanding of organ preservation, donor and recipient selection and development of immunosuppression protocols. Various types of liver transplantation have given a new hope to the sufferer of the deadly disease.
Dedicated and well versed knowledgeable surgeons of different developed countries have organised many specialised centres for liver surgery and its study and research. More research has given a momentum to the new advancement in this complicated field. Now-a-days the Hepatobiliary surgery is one of the most fast advancing surgical field in the medical discipline.
The leading countries in this field are United States of America. Japan. France. United Kingdom and Australia. Apart from organising the centre for thefr own country they also have set up training programme for other countries so that the technical expertise could be transferred to different parts of the world. This is highly humanitarian attitude and thus the technology is being transferred in a very rapid manner. Our regional countries like Singapore. Malaysia. Thailand, and India have started such centres after completion of training of their fellows in the
developed countries. These newly formed centres are in turn providing training to their own doctors and paramedics in this very special branch.
It is very unfortunate that in our country. Bangladesh, there is no such centre to manage the surgical conditions of liver, biliary tree, and pancreas. The sufferers do not get any well planned guideline for treatment of the complicated disease conditions. Most of them remain untreated or improperly treated, except a fortunate few who could afford to go abroad for the treatment. Even going abroad also may not solve their problem properly. Most of the time they are not aware of the facilities and expertise of that centre. Again only some fortunate ones get proper treatment, others not. This is another setback which renders much financial involvement and endless physical suffering.
Liver surgery (Hepatobiliary surgery) doesn't mean to cut the liver only. It is a highly organised team-work which deals with all the management modalities of the surgical conditions. In addition, it also deals with the liver transplantation if the facilities and expertise permit. The concept of a Hepatobiliary centre may be expressed in the following manner:
1) This centre organises the diagnostic procedures of the liver disease. This includes the modern imaging, endoscopy, and laboratory facilities. The
surgical conditions of the liver, biliary tract and the pancreas could be diagnosed properly.
2) Proper planning of the surgical condition; so that surgical intervention should be well planned, safe and adequate in manner. There are certain conditions which are completely curable by the surgery alone but other conditions may require Involvement of more many and other modalities of treatment like interventional radiological interference, endoscopic involvement, percutaneous technique, radiotherapy, chemotherapy, and immunotherapy.
3) Liver transplant is a very fast developing aspect of Hepa-toblllaiy surgery. This is needed for those developed endstage liver diseases, that is, when liver is badly damaged by disease and thus is beyond the scope of any medical treatment or surgical intervention.
Liver is transplanted from brain death patients (after proper consent of the relatives), or part of the liver of a living donor can also be transplanted? Most of the patients get their life back with newly trans-[ilanted liver but it needs a llfe-ong follow-up. Liver transplantation needs established centres and highly skilled experts and financial involvement. The financial situation is not ripe enough to start liver transplant right now in Bangladesh. But the endstage liver disease patients could be assessed properly and sent to a
suitable centre if the patient can afford expenses, so that the patient is in the right hand, in the right centre and at the right time.
4) The training of the doctors and the paramedics in the modalities of management system; this will help proper functioning of the centre.
5) The concept of modern surgeon at work is the academic surgeon. He should be involved in some research activities, in addition to the surgery; clinical and patient oriented research activities is possible in Bangladesh.
6) Contact with other established centres in the developed countries will help the centre to exchange technology. opinions, and suggestions. Doctors and paramedics can be sent to those centres from time to time to update their experience.
There should be follow up protocols of the patients involved in the management. Community should be advised regarding the risk factors of the Hepatobiliary disease, which will be helpful to early reporting of the conditions and treatment, accordingly. The high risk groups should be under regular observation.
Overall surgical conditions of the liver biliary tree and pancreas could be divided in two categories. One group could be managed by the experienced general surgeon. Another group which constitutes complex, complicated and advanced patients need management by the experienced personnel in well equipped centre. The expertise and equipment should be organised in that centre to deal with the specific problem adequately and efficiently.
Problems of liver disease is very common in our country. Some are linked to medical conditions and others to the surgical conditions. Some conditions develop out of complication of medical condition. Most of the surgical conditions are curable by adequate surgery: some conditions need longterm follow-up and management.
As we know, the financial situation and health facilities are very limited in Bangladesh. Even with the existing facilities one Hepatobiliary surgical centre could be opened in here. But it will need organisational support and cooperation of the health authorities concerned. Support from other countries and centres could be expected only when a centre is formed and functioning. We are far behind of the medical devel«p-inent in the developed wofcl, eVen from that in our regional neighbours. It will be unforfM-nate to remain as such. Softiething effective and fruitful should be done for the suffering humanity in Bangladesh.
The writer, an FCPS. FRCS. is working as a Fellow in the Hepatobiliary Surgery and Liver Transplant Unit of the Princess Alexandra Hospital. Brisbane. Australia.