LIVER SURGERY 2 Med 5 Refresher Course (Surgery) 2013/14 24 Jun 2013 Dr Sunny Cheung Case 1 50/M Sudden onset of epigastric pain Abdominal distension Confused HR 120 BP 80/50 Haemocue = 8
What should you do? Shock Monitoring DDx Ix Fluid resuscitate +/- unmatched blood Blood for T&S, CBC, LRFT, Clottting Reserve FFP and Platelet (massive transfusion) SaO2 + O2 BP / pulse Foley CVP ICU Intra-abdominal bleeding AAA Ruptured HCC Massive GI Bleeding USG Contrast CT if stabilized Ruptured HCC Occurs in 3 to 15% of patients with HCC Mortality rate was high (25-75%) 12-42% patients develop liver failure during acute rupture Large and peripherally located tumor tends to rupture Postulated to be caused by vascular dysfunction Hypothesis of rupture: Rapid tumor growth and necrosis Occlusion of hepatic vein by tumor thrombi or invasion Raised intratumor pressure Lai Arch Surg 2006
Management Aim: Stop bleeding Correct coagulopathy Transfusion Transarterial Embolisation (TAE) Poor prognosis Advanced disease Poor liver function Beware of liver failure PVT increased bilirubin > 50 Algorithm Consider RFA / Surgery only in selected patient Definitive treatment after recovery from acute episode Lai Arch Surg 2006
Case 2 58/F AF on aspirin Fresh PR bleeding Increased CEA to 6 Hb 10 Colonoscopy: 3cm half-circumference sigmoid colon tumor, bx: adenocarcinoma PET-CT 4cm R lobe liver metastasis What will you do? 1) Palliative Chemotherapy 2) Colonic resection + palliative chemotherapy 3) Staged colectomy + R hepatectomy 4) Combined R hepatectomy + colectomy 5) Chemotherapy + R hepatectomy + colectomy
Is CRLM Curable Disease? Median survival in Chemo = 11.1 to 12.7 months Liver resection: 5-yr survival = 32% Untreated = 7.5 months Germany data 1980-1990 Stangl R 1994 10-year Survival is Possible Haddad AJ Int J Surg Oncol2010
Adjuvant Chemo after Hepatectomy Adjuvant 5FU / Leucovorin Median survival 62.2 months 5-yr survival = 52.8% Mitry E 2008 How to Define Resectablity? Tumorfactor Past: Unilobar < 4 tumors < 5cm Confined to liver (no extrahepatic met) Current: Size, number of tumor, bilobar disease and extra-hepatic met are no longer contraindication Able to resect all tumor with negative margin leaving adequate liver reserve (future liver remnant) Defined by what will remain Daniel H HPB 2007
Current Concepts (1) Neoadjuvant Chemo Chemo-induced liver injury Increased morbidity after hepatectomy Delay liver resection in non-responder If clearly resectable, proceed directly to resection Adjuvant Chemo Improved PFS using perioperative chemo (FOLFOX 4), but no convincing evidence in improvement in OS Pseudo-adjuvant chemo on individual basis Downstaging Chemo Reserved for initially unresectable disease Vanishing tumor tends to recur and thus need to resect the tumor bearing part Current Concepts (2) Bilobed diseases Multiple resection Combined resection + local ablation therapy If FLR too small (< 30 / 40%) Portal vein embolisation to induce hypertrophy of FLR Wait 4 weeks before surgery +/- Chemotherapy while waiting for liver hypertrophy Staged resection Combined resection + local ablation therapy Local ablation therapy (RFA) Higher recurrence and poorer survival Reserved for unresectable tumor
Synchronous CRLM + Primary Tumor Classical Approach Resect primary tumor first followed by hepatectomy Combined Approach One GA session, no delay Increased operative risk by combining 2 ultramajor operations Limited to young fit patient, preferably minor liver resection (<3 segments) Limit by surgical access Laparoscopic surgery Reverse Approach liver-first Advanced liver met, risk of progression beyond curative hepatectomy after resection of primary tumor Suitable for asymptomatic primary Consider giving peri-operative chemo Patient Selection in Synchronous Disease Symptoms and potential complications of primary tumor Location of primary tumor (colon vs rectum) Extent of metastatic disease (major vs minor resection) Example 1) T3/4 CA rectum + liver met Neoadjuvant chemort for primary tumor Liver first approach then deal with primary Disadvantage: appearance of new liver lesion after hepatectomy while waiting for resection of primary tumor 2) Obstructing primary CA Relieve obstruction first
Case 3 F/63 Painless progressive jaundice for 1 month No fever Gallbladder not palpable USG: dilated bilateral intrahepatic ducts, gallbladder normal, no gallstone, not distended Hilar Cholangiocarcinoma (Klatskin Tumor) Radiological investigation CT / MRCP Drainage ERCP / PTBD
Bismuth Classification This system only defines the longitudinal extent Does not consider vascular invasion or LN Met Criteria of Unresectability Blumgart 2007
Pre-op Investigation MDCT Look for vessels involvement (CT portogram & arteriogram) Identify lobar atrophy Allow volumetry calculation PTBD / ERCP Obtain high quality cholangiogram for operative planning Resolve cholangitis Lower bilirubin for safer hepatectomy Improve liver hypertrophy after PVE PVE in cases with inadequate FLR Principles of Surgical Treatment R0 resection of biliary tract Preserving well-functioning liver parenchyma > 30-40% Procedures: Extrahepatic bile duct resection Hepatectomy Caudate lobectomy +- L / R / central hepatectomy Depending on biliary segment(s) involved LN Dissection hepatoduodenal ligament, superior retropancreatic & common hepatic artery If portal vein bifurcation involved Vascular resection + reconstruction in expert centre Morbidity = 54%, mortality = 2% 5yr survival = 30% Nagino et al 2010
Fever Despite Drainage Known Klatskin tumor on palliative biliary stenting Fever DDx: 1. Cholangitis undrained segment, block stent 2. Liver abscess 3. Resistant bacteria 4. Cholecystitis Investigation: USG, blood c/st, LRFT, CBC, Clotting Tx: Drainage / change antibiotics Case 4 70/M RUQ pain + Fever HR 110, BP Normal WCC 16 Bilirubin 35 ALP / ALT mildly elevated
What is the differentials? DDx: Cholangitis / Cholecystitis / Liver abscess Investigation: USG / CT Hypodense leison with rim enhancement Air-filled cavity due to gas-forming organism Organisms G-negative aerobes Klebsiella, E. Coli, Enterobacter, Proteus, Citrobacter G-positive aerobes Streptococci, Staphylococcus, Enterococci G-negative anaerobes Bacteroides, Fusobacterium G-positive anaerobes Clostridium
Causes HPB: RPC, cholecystitis, infected tumor, RFA, TACE Portal: GI tract pathology - Diverticulitis, appendicitis, perianal abscess - Colonic Cancer Haematogenous: Endocarditis, ENT / dental infection Association: DM Treatment Antibiotics: 4-6 week course Percutaneous drainage Work-up for underlying cause Fasting glucose Tumor marker Hepatitis serology 3-phase contrast CT MRCP / ERCP? RPC Colonoscopy / Ba Enema Drain fluid for c/st and cytology
Summary Ruptured HCC Resuscitation, CT, correct coagulopathy, TAE Poor prognosis Colorectal liver metastasis Potentially curable with liver resection Multimodal treatment Hilar cholangiocarcinoma Bismuth classification Complex liver surgery with bile duct resection + reconstruction Liver abscess Klebsiela + DM Drainage + antibiotics Work-up