Victorian Perioperative Nurses Group Meeting 13/08/2016 LIVER SURGERY. Michael Fink HPB and Liver Transplant Surgeon

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1 Victorian Perioperative Nurses Group Meeting 13/08/2016 LIVER SURGERY Michael Fink HPB and Liver Transplant Surgeon

2 Liver surgery Liver resection Liver transplantation

3 Liver resection

4 Indications Maligant Primary Hepatocellular carcinoma (= hepatoma, = HCC) Cholangiocarcinoma (hilar, peripheral) Other/rare (angiosarcoma) Metastatic Colorectal Other (neuroendocrine, renal, melanoma etc) Benign Liver cell adenoma (symptomatic or malignant risk) Focal nodular hyperplasia (symptomatic or misdiagnosis) Haemangioma (symptomatic or misdiagnosis) Cystic lesions cystadenoma, simple cyst (symptomatic more often reroofed), hydatid cyst Trauma

5 Hepatocellular carcinoma Usually arises in a diseased liver Hepatitis Cirrhosis Most commonly viral aetiology (Hepatitis B and C) Presentation Screen detected Symptomatic (late)

6 Hepatocellular carcinoma Management options Depends on Tumour Liver Patient

7 Hepatocellular carcinoma Management options Curative Resection No extrahepatic disease Resection technically feasible leaving sufficient liver volume Good liver function (normal(ish) bilirubin, albumin and INR, no ascites or encephalopathy) Patient fit for procedure

8 Hepatocellular carcinoma Management options Curative Resection Liver transplantation HCC within UCSF criteria (single tumour up to 6.5 cm diam or up to three tumours each up to 4.5 cm diam and total diam up to 8 cm) No extrahepatic tumour (CT chest, bone scan) With or without liver failure Patient otherwise suitable no significant cardiorespiratory disease, not actively drinking, adequate social supports

9 Hepatocellular carcinoma Management options Curative Resection Liver transplantation Ablation Percutaneous, laparoscopic or open Radiofrequency ablation (RFA) Microwave ablation (MWA) Percuataneous ethanol ablation (PEI)

10 Hepatocellular carcinoma Management options Palliative Transarterial chemoembolisation (TACE) Selective Internal Radiation Therapy (SIRT) Sorafenib Supportive care

11 Cholangicarcinoma Peripheral cholangiocarcinoma: liver resection if no metastatic disease Hilar cholangiocarcinoma Only curative option is radical bile duct resection + liver resection (commonly extended right hepatectomy) + porta hepatis lymph node dissection Often present late with incurable disease (Rx PTC stent)

12 Colorectal cancer metastases Commonest indication for liver resection Indications for liver resection: Primary resected/resectable No other metastases other than resectable lung metastases All liver disease resectable with adequate volume of remnant liver of sufficient quality with adequate vascular inflow and outflow and biliary drainage Volume definitions vary: e.g. for good quality liver 0.6% body weight (420 ml for 70 kg patient), 25% of liver volume

13 Colorectal cancer metastases Innovative approaches to large volume disease: Combined resection/ablation Portal vein embolisation Staged resection Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS)

14 Preoperative preparation Hx Ex (Age) Symptoms of liver failure (HCC) Jaundice Encephalopathy GI bleeding Ascites General medical status/fitness for surgery Previous treatments Signs of chronic liver disease Jaundice Anaemia Cervical lymphadenopathy (Virkhoff s node) Abdominal exam Scars Masses Hepatomegaly Spenomegaly Ascites Umbilical hernia Caput medusae

15 Preoperative preparation Ix Blood tests U&Es, LFTs, FBE, INR, Tumour markers (C/R Ca: CEA, HCC: AFP, CC: CEA + CA19.9) Imaging Cross-sectional imaging Quad phase CT (+ CT chest) Quad phase (Primovist) MRI

16 CT Hepatocellular carcinoma Precontrast Arterial phase Portal venous phase

17 CT Colorectal metastases Precontrast Arterial phase Portal venous phase

18 Preoperative preparation Ix Blood tests Imaging Cross-sectional imaging Nuclear medicine Bone scan (HCC) PET scan (CRC)

19 Liver anatomy Modified from: Blumgart: Surgery of the Liver, Biliary Tract and Pancreas, 4th ed. Saunders 2006

20 Liver anatomy Right posterior section Left lateral section 5 4 Right anterior section Left medial section Modified from: Launois and Jamieson. Surgical anatomy of the liver and associated strictures. In: Modern operative techniques in liver surgery. Churchill Livingstone 1993

21 Liver resection Right hemihepatectomy Right hemihepatectomy Left lateral sectionectomy Extended right hepatectomy Extended right hemihepatectomy Segmental resection (segment 6)

22 Access Laparoscopic Modified lithotomy position Port sites depend on intended resection plane (tringulation) Sucker Harmonic scalpel /stapler Grasper Laparoscope Pfannenstiel (specimen removal)

23 Access Laparoscopic Open Reverse L or bilateral subcostal/rooftop/ Merc edes Benz incision Retraction/costal margin elevation (Thompson/Debergeret)

24 Liver resection Evaluate: extrahepatic disease (portal, peripancreatic, gastrohepatic, retroperitoneal nodes, peritoneum, omentum, local colorectal recurrence) liver metastases - look, feel, IOUS (site, size, relationship to portal structures, hepatic veins) volume and quality of proposed residual liver

25 Liver resection Fully mobilise liver (falciform, L triangular, gastrohepatic, R triangular and coronary) Porta hepatis dissection (divide relevant HA, PV if hemihepatectomy) Sling relevant HV if possible Mark liver along line of demarcation (Principle plane = GB fossa to IVC) Aim to maintain at least 1cm margin of normal liver between lesion and transection plane

26 Liver resection Parenchymal transection: CUSA Ligasure harmonic scalpel (Kelly clamp fracture) (finger fracture) Sheaths (PV, HA, HD radicles) and HV tributaries dealt with: diathermy Ligaclips ligation +/- transfixion Stapler

27 Liver resection Control/prevention of bleeding: Low CVP ( HV bleeding) +/- inflow occlusion ( Pringle manoeuvre ) 15 minutes on, 5 minutes off maximum of 1 hour, preferably

28 Outcome colorectal metastases Frankel and D Angelica. J Surg Oncol 2014;109:2-7

29 Outcome colorectal metastases n= day mortality = 2.8% (4.1% for lobectomy or more, 0.5% for less than lobectomy) 5 year survival = 37% median survival = 42 months factors predicting poorer survival: positive margin Clinical risk 5 yr extrahepatic disease score survival (%) > 1 tumour 0 60 CEA > 200ng/ml size > 5cm 3 20 node positive primary 4 25 disease free interval < 12 months 5 14 Fong et al. Ann Surg 1999;230(3):309-21

30 Outcome liver resection for HCC Periop. mortality and long-term (10-year) survival Gluer et al. HPB 2012;14:

31 Lap vs open liver resection for HCC Blood loss less with laparoscopic resection Blood transfusion less with laparoscopic resection Trend to larger surgical margin with laparoscopic resection Operation time equivalent Morbidity lower with laparoscopic resection Length of stay shorter with laparoscopic resection No difference in tumour recurrence or survival Yin et al. Ann Surg Oncol (2013) 20:

32 Austin experience of liver resection for all indications, N (%) Liver resections 427 Mortality 3 (0.7%) Morbidity 129 (31%) Bile leak 38 (8.8%) Bleeding 4 (0.9%) Infection 62 (14.5%) Liver failure 3 (0.7%)

33 Austin experience of liver resection for HCC 2000 Nov 2015

34 Austin experience of liver resection for HCC Morbidity, mortality and length of stay Outcome % or mean SD 90-day mortality 2% Morbidity 32% Liver failure 5% Bile leak 4% Bleeding 2% Wound infection 6% Pneumonia 4% Intra-abdominal abscess 1% Incisional hernia 2% Other 17% Postop stay Open Laparoscopic

35 Austin experience of liver resection for HCC Overall survival 65% 58%

36 Austin experience of liver resection for HCC Disease-free survival 43% 31%

37 Conclusions liver resection Liver resection is the treatment of choice for selected cases of colorectal cancer liver metastases, hepatocellular cancer and rarer primary and metastatic liver malignancies and some cases of benign disease Liver resection can be performed with a low mortality and acceptable morbidity in high volume centres Laparoscopic liver resection can achieve similar results to open surgery in selected cases, with reduced morbidity and length of hospital stay

38 Liver transplantation

39 Impact of liver disease Loss of muscle mass Debilitating lethargy Complications Portal hypertension Variceal haemorrhage Ascites, SBP Encephalopathy Renal impairment Hepatoma

40 Impact of liver disease High mortality without transplantation: up to 1 to 2 year life expectancy for most liver transplant candidates with end stage liver disease No other rescue therapy for most candidates (cf. renal dialysis) Poor quality of life; at time of activation: 71% frequent hospital care 17% hospital-bound 6% in ICU 6% ventilated

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43 Waiting list outcome trends - Adults + children Activated Transplanted Died waiting Delisted 80 N Year Liver Transplant Unit Victoria data

44 Graft types Whole to child Standard criteria Extended criteria DCD Older donor Steatosis 6 5 Split liver Living donor liver to adult

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47 Liver transplant operation Potential for difficult operation Chronically sick, often malnourished patient Portal hypertension Thrombocytopoenia Coagulopathy Tumour Liver may be large, stiff and caudate may envelope IVC Porta hepatis may be fibrotic and full of varices

48 Liver transplant operation - Principles Good exposure Reverse L incision Adequate retractor Good lighting (headlight) Magnification (loupes) Good assistant (usually another liver surgeon/fellow) Experienced anaesthetist

49 Liver transplant operation - Cell-saver, rapid infusion system

50 Liver transplant operation - Stages Incision Portal vein clamped Reperfusion Stage I Stage II Stage III Hepatectomy Retraction Mobilisation Porta hepatis dissection Division of short hepatic veins Anhepatic Transection of PV and HVs Hepatectomy complete HV/IVC anastomosis Washout perfusion solution PV anastomosis Post-reperfusion HA anastomosis BD anastomosis Completion/closure Potential for bleeding Coagulopathy Acidosis Ischaemia/reperfusion syn. Closure completed

51 Liver transplant operation

52 Porta hepatis dissection

53 Hepatic veins

54 Hepatic veins

55 Piggyback anastomosis - Donor IVC to recipient HVs

56 Piggyback anastomosis - Donor IVC to recipient HVs

57 Portal vein anastomosis

58 Liver transplant recipient operation

59 Hepatic artery anastomosis Bile duct anastomosis

60 Liver transplant operation

61 Immunosuppression Triple immunosuppression Calcineurin inhibitor Ciclosporin (Neoral) or Tacrolimus (Prograf) Prednisolone Azathioprine or Mycophenolate mofetil

62 Complications On table mortality approx. 1% (bleeding, massive embolus, cardiac arrest) Primary non-function (1%) ReTx or death Bleeding (reoperation approx 5%) Infection (transmission from donor, reactivation, newly acquired) Hepatic arterial thrombosis (1-2%, often required re-tx) Portal venous or hepatic venous stenosis/thrombosis (rare) Biliary leak Biliary stricture Anastomotic (up to 15%) ERCP/stent Non-anastomtic (up to 25%), occassionally requires re-tx Rejection common (up to 30%), but rarely results in graft loss

63 Patient survival Liver Transplant Unit Victoria (Unit database) Australian and New Zealand Liver Transplant Registry ( 94% 92% 92% 93% 87% 86% p = % 90% 84% 82% 81% 80% 79% 76% 75% 75% 69% 64% 64% 54% 57% 57% 50% 46% (n=19) (n=107) (n=137) (n=167) (n=217) (n=314) 36% 36% USA patient survival year 3 year 5 year Survival rate 87% 78% 72% Europe patient survival (1 st transplant) 1 year 3 year 5 year 10 year Survival rate 86% 77% 73% 63%

64 Graft survival Liver Transplant Unit Victoria (Unit database) Australian and New Zealand Liver Transplant Registry ( N = % 85% 82% 76% 68% 56% 50% USA Graft Survival Rates year 3 year 5 year Survival rate 82% 72% 65% Europe graft survival (1 st transplant) 1 year 3 year 5 year 10 year Survival rate 79% 71% 66% 56%

65 Quality of life Usually excellent Most patients get back to premorbid activities (school, work) Many successful post Tx pregnancies (after male and female Tx) Often developmental delay in children Need for 3 monthly visits to Unit, regular blood tests for lifetime Immunosupression Chris Klug, Olympic bronze 2002, 18 months after liver transplant

66 Conclusion liver transplantation Liver transplantation is a life-saving therapy for selected adults and children with end-stage liver disease, fulminant hepatic failure, metabolic disease and malignancy Patient and graft survival are excellent and are improving over time Quality of life is excellent Application of liver transplantation is limited by availability of deceased donor livers Inadequate supply of deceased donor livers can be addressed to some extent by Split liver transplantation DCD liver transplantation Increasing use of extended criteria donors (increased risk of poor graft function or transmission of disease)