Operations on the liver
Having a liver resection
What is going to be done at the operation?
The most common operation we perform on the liver is to remove a part of it that has developed a tumour. This is called a liver resection (or a hepatectomy). The liver is made up of two halves called the right lobe and the left lobe. If the entire right lobe is to be removed, that is called a right hepatectomy, and if the left lobe is to be removed that is a left hepatectomy. Or the surgeon may just cut away the tumour, taking with it some surrounding normal liver tissue. If the tumour is near the gall bladder, or if the gall bladder is in the way, then the gall bladder is likely to be removed as well.
How does my body cope if I lose a part of my liver?
There is a lot of spare capacity in the liver. The liver can regenerate itself, and grows back to near-normal size within six to eight weeks. If your liver is healthy, you will be able to cope with removal of up to two-thirds of your liver. If there is cirrhosis or chronic liver disease, surgeons tend not to remove large portions of the liver.
What does having this operation involve?
Let us break that up into what happens before during and after the operation.
- Before the operation
You will already have had different tests and scans. Once you are admitted for surgery, some more tests may be done, usually to confirm that you are well enough for the anaesthetic. These include blood tests, an ECG, sometimes a chest x-ray and tests of lung function. A member of the surgical team will have a discussion with you about the operation, after which you will be required to provide written consent for the operation to go ahead.
The day before your operation (or on the morning of your operation), the anaesthetist will come and see you. It is important that you ask the nurses and the doctors any questions that you may have. The doctors will have to decide whether you will need a bed on the intensive care unit (or the high dependency unit) for your recovery immediately after the operation. Be warned that the availability of such a bed can only be confirmed on the morning of the operation, and very rarely, if there is no intensive care bed on the day, your operation may get postponed.
You can usually have a normal supper the night before your operation. The last time you may eat is six hours before your operation, and you may drink water up to two hours before the operation. If you are diabetic, you will be put on a regularly monitored and adjusted dose of insulin (called a "sliding scale"). When it is time for your operation you will have to put on some stockings (which reduce the risk of blood clots forming in your leg veins), change into a theatre gown, remove any jewellery, dentures and glasses, and go to the operating theatre with a nurse or an attendant..
- The anaesthetic
In the anaesthetic room, you may first receive an epidural. This involves placing a very thin plastic tube into your back, near the spinal cord, and then inserting a drip with medication that will reduce your pain after the operation. You will have an opportunity to discuss the pro's and con's of this with the anaesthetist beforehand. If you do not have an epidural, there are other good ways of controlling pain as well. The most common is called PCA or patient-controlled analgesia where you can give yourself a dose of pain-relief through a tube in your arm when you feel pain. After the epidural, you will be given an injection that will make you go off to sleep. The anaesthetist will then place a breathing tube in your airway, place drips into your arm veins, and into a large vein in the neck, and also place a very fine needle into one of your arteries. You will have a catheter to drain your urine, and a tube into your nose draining your stomach. Then the actual operation will start.
- The operation itself
A fairly large cut (or incision) will be made in your upper abdomen. The surgeon will expose the liver, assess that it is safe to remove the tumour, temporarily block the inflow of blood into your liver to reduce bleeding, and then cut away the part that is to be removed, using a special ultrasonic scalpel. Once the procedure is finished and all bleeding has been controlled, blood flow to the liver will be restored and the wound stitched up.
- After the operation
When you wake up, you may find yourself in the intensive care or high dependency unit, or you may be back in the ward. There will be an oxygen mask on your face. In addition to the drips going into your forearms and your neck, the tube in your nose and the urinary catheter, there will be one or two plastic tubes (drains) emerging from your tummy, which will remove any unwanted ooze You will probably feel some pain and sickness, but we will give you medicine for this.
- Can something go wrong?
Every operation carries some risks, and so will yours. A general anaesthetic carries some risk, and there is a small chance that you may develop problems relating to your heart or your breathing. If you already have heart disease or lung disease, this risk is increased. The various lines (needles) and catheters that are put in may cause some bleeding or local injury or may introduce infection. They are, however, put in with great care and with sterile precautions. If you wish to receive more information on this, do ask your anaesthetist.
Bleeding during or after the operation may happen after any surgery. Blood will be cross-matched and kept available should you need a transfusion. Transfusion itself carries some risks (reactions from a mis-match, transmission of viruses) and is not given except when absolutely necessary. Most operations on the liver do not require a blood transfusion.
Infection is another possible complication, and can involve the wound, or the inner organs. You will receive antibiotics around the time of surgery to try and prevent this from happening. The risk is increased if any bile leaks from the cut surface and collects deep to the wound.
If you have a large portion of your liver removed, sometimes you may develop a degree of liver failure in the immediate aftermath of the operation. This may make you jaundiced for a time, and interfere with your blood clotting. Such liver failure is usually short-lived and the liver makes up for the loss in a matter of days or weeks.
The pain from your wound will make coughing difficult. Patients sometimes develop chest infection from retained phlegm. Deep breathing, clearing out the phlegm in your throat and chest and working with the physiotherapist is very important after your operation. Lying still in bed can lead to the formation of clots in the legs (called deep vein thrombosis or DVT) and these can sometimes float off in the circulation and reach the lungs (called pulmonary embolism or PE). These are serious complications, and we try hard to prevent them. You will be asked to wear elastic stockings, and will receive a mild dose of an anti-coagulant to reduce the risk of clot formation. You can help by moving your legs in bed, and getting out of bed as soon as your condition will allow after the operation.
This is NOT a complete list of everything that can possibly go wrong, but a general discussion of the more common problems associated with liver surgery. If you have specific concerns or wish to receive more information about possible complications, do ask.
What are my chances of surviving the operation?
Information collected from hospitals all over the world indicates a mortality rate of less than 5% from major liver surgery. In other words, you have at least a 95% chance of surviving your operation.
Will I be cured?
If the operation is to remove a cancer, that question is difficult to answer immediately. After the operation we would have to wait and see. Liver resections for cancer are usually carried out with the intent to cure. But there will undoubtedly be a significant risk of the tumour coming back, and only time will tell if you have been cured. The pathologist's report on the pieces of tissue that are removed will give us some clues. This report usually takes seven-10 days to come through, and if it is not ready by the time you leave hospital, your surgeon will discuss it with you at your first visit to the outpatient clinic a few weeks after your surgery. He/she will also, at this time, discuss if any further treatment is required. If you wish to receive more information on this, please ask your surgeon.
Sometimes, the surgeon may find that the cancer cannot be safely removed. For example, the growth may be larger than the scans suggest, or there may be some other obstacle in the way. In such situations, the aim will be to do everything possible to relieve your current symptoms and prevent future problems. This may involve the creation of a join between the bile duct and the bowel to relieve or prevent jaundice (and this goes with an additional join between bowel and bowel). This is often referred to as a biliary bypass procedure.
Your operation may be carried out not for cancer but to relieve symptoms caused by a benign tumour. Jaundice is usually relieved quite successfully. In the case of chronic pain, it is difficult to predict how successful the operation will be in relieving pain. You would have to wait and see.
During ablation procedures, interventional radiologists directly apply extreme heat, extreme cold, or chemicals such as alcohol, to kill cancer cells. One relatively new ablation technique called radiofrequency ablation (RFA) has shown good results.
When and where is RFA used?
RFA is primarily used to treat cancer in the liver, but it is also used in the kidney, adrenal glands, lung, bone and prostate. RFA is used to treat cancers than cannot be removed by surgeons because of their number (too many) or location (too scattered or dangerously close to a major blood vessel) or because the patient is not healthy enough to have open surgery. It can also be used to treat small tumours in conjunction with surgical removal of a large mass elsewhere in the liver. It may be used to treat small tumours (HCCs) as a holding measure while the patients waits for a surgical resection or a transplant. There are limitations to the technique. It can only be used to treat tumours up to 4 cm in size, and probably not more than 3 or 4 tumours can be treated in one session. Also, if a tumour lies immediately next to a big blood vessel or bile duct it may not be safe to do RFA. We now know that RFA is a reasonably safe technique, and that it can successfully burn a tumour. But whether it destroys a tumour completely (i.e. what is the chance of tumour recurring at that site) is more difficult to tell, and there are concerns that it may not match up to surgical resection in this respect.
What does RFA involve? How is it done?
The procedure may be carried out in an operating room or in an x-ray department, and involves the administration of either intravenous sedation or a full general anaesthetic. During the technique, the doctor (who is usually an interventional radiologist or a surgeon) views the liver tumour through ultrasound (or CT). Once located, the doctor makes a small cut in the skin through which a needle is passed. Through the tip of the needle, the doctor extends several prongs into the tumour. When opened out, the prongs look like the frame of a miniature umbrella. The needle is then connected to the RFA generator (a machine the size of a briefcase), and radiofrequency energy is sent to the needle. It delivers a precise round ball of heat that kills the cancerous cells. Once the tissue is “cooked” the machine senses that, the procedure is stopped, and the needle is removed. The dead tumour tissue shrinks and later forms a scar. What can one expect after treatment?
After the procedure, the patient will experience some pain and possibly nausea. Most RFA procedures can be done as a brief overnight stay. Once home, there will be pain for one or two days and there may be a low grade fever. Most patients experience few significant side effects beyond these, but depending on the size of the tumour treated and its location, some patients may feel fatigued or tired. He/she should be able to resume all normal activities within a few days. If any symptoms recur or become worse instead of improving, a doctor should be notified.
More serious complications can develop, but they are quite rare. There may be a leak of bile or blood from the point where the liver was punctured. Infection may develop at the site of the burn, leading to an abscess (a pocket of pus) within the liver. Patients with cirrhosis may rarely develop liver failure after RFA. In the longer term, damage to any bile ducts in the vicinity of the tumour may lead to jaundice.
Follow up tests
The patient will get a follow-up CT or MRI scan, as well as blood tests, to determine the size of the treated tumour and how well the RFA worked. CT and MRI scans will continue every few months thereafter to determine how much the tumour has ultimately shrunk. RFA frequently may be repeated to treat all lesions or all parts of a larger tumour.
Are there any alternatives to RFA?
In a similar technique, called cryoablation, probes are inserted into the tumour to freeze and kill cancer cells. Laser energy and microwave energy are also being tested for use in similar fashion. Alcohol can also be injected into tumours, particularly small HCCs, to destroy them.
Portal vein embolisation (PVE)
Sometimes, the tumours are located in such a manner within the liver that a large part of the liver needs to be removed. For example the entire right lobe and part of the left lobe may need to be removed – which is called an extended right hepatectomy. But the amount of liver that will then be left behind may be too small and the patient will run a very high risk of developing liver failure. This applies particularly to situations where less than 25% of the total volume of the liver is likely to be left behind (or, in patients with chronic liver disease, less than 40% of the liver will be left behind). In such situations, it is possible to block off the portal vein inflow of blood into the parts of the liver that are going to be removed. They then start to shrink (atrophy) while the rest of the liver (the part that is going to be left behind) starts to grow. In a period of 2 to 6 weeks, substantial growth may be seen, and a surgical resection may become possible.
How is it done?
The procedure itself involves a puncture of the liver to inject glue-like material into the relevant branch of the portal vein. This done in the x-ray department by a radiologist, using ultrasound and angiography techniques to direct the needle into the correct position. It is usually done as a day case or involves an overnight stay in hospital. Alternatively the branch of the portal vein may be tied off during a surgical operation.
What are the risks?
There are some risks involved, including bleeding or bile leak from the puncture into the liver. Spillage of the glue into parts of the circulation is another small risk. It is difficult to predict exactly how much liver growth this procedure will cause in a particular patient, and one has to wait and see.
Although the procedure is not a cure for liver cancer, studies have shown that patients may experience improvement and possibly, in some instances, live longer. Chemoembolisation also may relieve pain and other symptoms, make patients more comfortable and improve the quality of their lives. Another advantage is that the procedure may be repeated multiple times.
Explaining the procedure
An angiogram, a real-time X-ray that highlights where blood flows, is performed to help the interventional radiologist look in the liver at the tumour without the need for an open incision. The interventional radiologist uses the x-ray images on the TV monitors to insert the catheter (which is a soft, thin, long plastic tube) through a small nick in the skin at the groin and guide it through to the artery that feeds the tumour. A combination of chemotherapy drugs and tiny particles, as small as grains of sand, are then injected directly into the tumour.
At the end of the procedure, the catheter is removed and pressure is applied to the entry point to prevent bleeding and a dressing is applied. Patients remain in bed for six to eight hours and leave the hospital usually within two-three days.
Chemoembolisation can be performed repeatedly on a patient. Typically, patients wait ten to twelve weeks, or even longer, between treatments. This procedure can also be used in conjunction with other cancer therapies.
Chemoembolisation may not be appropriate for patients who have blockages of the veins that supply blood to the liver, cirrhosis of the liver or blockage of the bile ducts.
How chemoembolisation works
The liver has two blood supplies. The portal vein provides 75% of the liver’s blood supply and the hepatic artery supplies the remaining 25%. Tumours that grow in the liver typically receive their blood supply from the hepatic artery, making chemoembolisation possible. The drugs can be injected into the artery feeding the tumour while sparing most of the healthy liver tissue that feeds from the portal vein.
As the chemotherapy is delivered directly to the tumour and doesn't spread throughout the body, stronger doses of cancer-killing drugs can be administered compared to the doses used for standard systemic chemotherapy which is injected through a vein in the arm. Secondly, the tiny particles embolise, or block, the artery and decrease the flow of blood to the tumour causing it to shrink. Finally, by blocking the artery, the particles help contain the chemotherapy keeping it in direct contact of the tumour for a longer period of time.
This technique also may reduce some of the side effects of standard chemotherapy because the drugs are trapped in the liver instead of circulating throughout the body.
What you can expect afterwards
After the procedure, you will receive prescriptions for oral antibiotics, pain-killers, and medications to control nausea. Once home, you may experience a fever for the first few days. For the first two weeks, fatigue and loss of appetite are common. These are all normal. However, if your fever suddenly becomes higher or your pain changes in intensity or character, contact your physician. A majority of patients can resume their normal activities within a week, and most are back to their usual state of health in about one month.
Eventually, you will get a follow-up CT or MRI scan, as well as blood tests, to determine the size of the treated tumour and how well the chemoembolisation has worked. CT and MRI scans will continue every few months thereafter to determine how much the tumour ultimately shrunk.
What are the risks and benefits?
- Chemoembolisation can help slow down the growth of a tumour, and even make it shrink in some cases, while preserving liver function and a relatively normal quality of life.
- Chemoembolisation can be used in conjunction with other cancer treatments including tumour ablation, radiation and chemotherapy.
- Emboli (tiny particles) can lodge in the wrong place and deprive normal tissue of its blood supply.
- Even if antibiotics are given, there is always a risk of infection after embolisation.
- There is a risk of an allergic reaction to the dye used in the x-ray and occasionally kidney damage in patients with diabetes or other pre-existing kidney disease.
- Nausea, hair loss, decreases in white blood cells and platelets, and anaemia may occur due to the chemotherapy drug.
- Very rarely, serious complications occur and these typically include damage to the liver. Liver failure is usually the cause of the 1 in 100 deaths related to this procedure.
These treatment options are described here in a very general sense, and individual patients should discuss their treatment with their own medical team. It is important that a patient with a liver tumour is seen by a medical team that specialises in the treatment of liver disease.