CTRC Liver Cancer Surgery Expertise

Liver surgery comprises various operations of the liver for different disorders. The most common operation performed on the liver is a resection or removal of a portion of the liver. The most typical indication for liver resection is a malignant tumor. Tumors can be primary (developed in the liver) or metastatic (developed in another organ, then migrated to the liver). The majority of liver metastases come from the colon. The single tumor or more than one tumor confined to either left or right side of the liver can be successfully resected with a five year survival as high as 60 percent.


Liver resection, or tumor removal patients are carefully evaluated by a multidisciplinary team to ensure the absence of the extrahepatic (outside the liver) tumor. Liver resections performed on patients with extrahepatic disease may relieve the symptoms caused by the tumor, but offer little improvement in survival.


Benign tumors of the liver can be successfully managed by liver resection as well. If the location of a benign tumor is superficial and small in size, the operation can be performed laparoscopically by making small punctures in the abdomen while viewing through a video camera.


Liver resections are also performed on people willing to donate part of their liver to a loved one (see live donor liver transplant).


A liver resection takes approximately three to five hours and can be performed without the need for blood transfusion (see bloodless surgery). Up to 75 percent of the liver tissue can be safely removed. The hospital stay is about five days and complete recovery occurs in five to six weeks. The resected liver regenerates to its preoperative size in six to eight weeks. Excellent results from liver resections are usually achieved.    

 

Liver Tumor Surgery – Malignant

Hepatocellular Carcinoma (HCC) - HCC is a form of primary liver cancer.  It tends to develop in people with predisposing diseases of the liver such as Hepatitis C and B, but can happen in anyone.  The affective treatment of HCC is best suited in a multidisciplinary setting involving multiple medical specialties.  The best outcomes still involve surgery, by either removing the affected portion of liver or even transplant surgery.  However, depending on tumor characteristics, this may involve the help of radiology directed ablations, chemoembolizations, radiation, and or chemotherapy. 


We have a large tumor board held weekly to discuss the appropriate line of therapy for each patient.  Our services include:

  • Open Liver Surgery
  • Laparoscopic Liver Surgery
  • Nanoknife Irreversible Electroporation
  • Radiofrequency Embolization
  • Chemoembolization
  • Chemotherapy
  • Radiation Therapy

Metastatic Liver Tumors – There are multiple tumors of the body that can spread to the liver.  When they arise from a primary tumor elsewhere in the body, they are thought of as secondary liver tumors.  In the past, these tumors were not resected and patients were sent to hospice, or treated as Stage IV with palliative techniques.  Today, as our medical treatments advance, we are seeing more and more patients present with secondary liver tumors, but with great control of their primary tumors.  In these patients, we address the secondary liver tumors to provide them with the best outcome possible. 


Metastatic Colorectal Tumors – Tumors of the colon and rectum can spread to the liver.  Studies have long proven that removal and ablation of these tumors can improve outcomes, especially in patients who respond to chemotherapy.  Using techniques such as laparoscopic liver surgery or Nanoknife, we can address these tumors surgically in a minimally invasive fashion.  Some people may need larger liver resections,  in which case an open technique may be utilized. 


Metastatic Neuroendocrine Tumors – There are several tumors of the GI track that can spread to the liver.  Neuroendocrine tumors are comprised of a variety of special tumors with specific characteristics that can many times make their outcomes more favorable than other types of tumors. Usually, a neuroendocrine tumor in the liver has arisen from elsewhere in the body, and can even be hard to find occasionally.  Using our sophisticated radiographic and tumor localization techniques, we will help your doctors find the primary and in most cases, remove not only the liver tumor burden, but the primary tumor as well simultaneously.  These tumors may sometimes recur, but with appropriate aggressive management, we can help prolong life expectancy and outcomes for those patients that might not be considered treatment candidates in other centers.  


 

Liver Tumor Surgery -- Benign

More than 50 percent of incidentally found tumors are one of the following three: Focal Nodular Hyperplasia, Adenomas, or Hemangiomas.  These tumors may involve a history of alcohol use or estrogen use, but are more commonly asymptomatic and are not obvious on a physical exam. 


Focal Nodular Hyperplasia (FNH) - FNH lesions are the second most common benign liver lesions.  They can occur in all age groups, but are most common in women in their 20's-30's who may have had a history of oral contraception medication.   They are usually solitary well-defined lesions that form a central scar.   Their architecture suggests a regenerative process with prominent bile duct hyperplasia and Kupffer cells (sulfur – colloid scans.) 


The majority of these lesions are asymptomatic and discovered incidentally.  The indications for resection in most series involve:

  • Rupture
  • Hemorrhage
  • Infarction

Most of these lesions are amenable to laparoscopic surgery if the indication for surgical treatment arises.  Malignant change of a true FNH has not been reported, thus lending itself to a favorable prognosis. 


Adenoma – A hepatic adenoma is a benign proliferation of hepatocytes.  It occurs predominantly in women 20-40 years of age with an annual incidence of four in 100,000 in long-term users of oral contraceptive pills (OCP's).  90 percent of patients with hepatic adenomas have used OCP's.  This tumor is usually a solitary lesion with a diameter of up to 30 centimeters.  The presence of more than 10 adenomata is considered to be liver adenomatosis.


Up to two-thirds of patients with hepatic adenomas report symptoms. They can have localized upper abdominal pain and can hemorrhage.  Life threatening hemorrhage has been reported in some series to be as high as 30 percent.  Unfortunately, rupture does not correlate with tumor size, location, or number of lesions.  One series reported a malignant transformation in as many as 17 percent. 


If the diagnosis is confirmed or cannot be excluded, resection is indicated with:

  • Rupture
  • Symptoms
  • Malignant transformation
  • Prophylactic resection prior to surgery

Surgery lends itself to good outcomes in these patients.  Symptoms tend to improve after the tumors have been resected.  There has been little documented evidence of recurrence. 


Hemangiomas
Hemangiomas are the most common benign tumors of the liver with a frequency ranging from One to twenty percent.  This occurs in males and females with a mean age of 47 years.  Pedatric hemangiomas are a separate entity with a propensity for malignant transformation. 


These tumors are usually found incidentally and can present with vague abdominal pain, nausea, vomiting and early satiety.  These tumors can cause compression of large vessels, can hemorrhage, or cause thrombosis. 


Surgery for these lesions is indicated when any of the above are being caused by the tumor. Most hemangiomas can be left alone, but some are large, painful, and can compress important blood vessels to the liver.  This surgery is done under complete vascular isolation to minimize blood loss. 


Vascular Problems

Portal Hypertension – The portal vein brings nutrient rich blood from your intestines to your liver to be processed. From here, the blood then flows back into a large vein on its way to the heart to be oxygenated once again.  When the pressure in your portal vein increases, this causes significant problems in your body:


Bleeding – Increased pressure causes delicate friable veins in your GI system to enlarge.  Sometimes, these may even bleed and cause an emergency. 


Ascites – This is an accumulation of fluid in your abdominal cavity that should not be there.  This protein rich fluid causes salt imbalances, weakness, bloating, fullness, and can even get infected.


Why do people get portal hypertension?

People can develop portal hypertension in one of three ways:

  • Preliver – Less common, clotting issues in the portal vein can cause a backup of blood pressure in the system.  
  • Liver – By far the most common, with scarring of the liver and cirrhosis, blood cannot enter and leave the liver  easily.  This causes a back-up of pressure and leads to portal hypertension.  Hepatitis C, B, Alcoholic cirrhosis, and fatty liver are all examples of primary liver diseases that can cause elevated blood pressure in the portal vein.  
  • Postliver  - Problems with the hepatic veins leaving the liver, or problems with your heart can cause this rare form of portal hypertension.  This problem is more complex, but can be dealt with by our multidisciplinary team as well.

How do you fix portal hypertension?
Usually the best way to deal with portal hypertension is to fix the main disease causing it in the first place.  This is especially important in "postliver" causes.  However, once a liver has cirrhosis, this may not be possible without a liver transplant.  In most causes of "liver" causes of portal hypertension, we can mechanically help alleviate the pressure in the portal vein. 

Mesocaval Shunts – In a mesocaval shunt, the surgeon will attempt to make an unnatural connection between a branch of your portal vein (usually the superior mesenteric vein) and your large vein flowing to the heart.  In this manner, some of the blood bypasses the scarred liver or clotted portal vein system, and directly empties into the heart.  This delicate surgery is best suited for patients who have failed medical therapy.


Splenorenal Shunt – Similar to the Mesocaval shunt, the surgeon makes an artificial connection between a branch of your portal vein (splenic vein) and the renal vein (which empties into your heart eventually.)  This also bypasses your liver and is also best suited for patients who have failed medical management.  While a mesocaval shunt may lead to some confusion, the splenorenal shunt may lead to some ascites.  For this reason, you must carefully discuss your options with your surgeon. 


Trans-Internaljugular-Portal-Shunt (TIPS) – By far the most common treatment for portal hypertension is a Trans-Internaljugular-Portal-Shunt. In this procedure, a radiologist will insert a small catheter in your neck vein that will make a false connection between your portal vein within your liver, and the hepatic vein.  When blood now enters the liver from your intestines, it can bypass the scarred area of liver and enter the stent to flow directly into your venous system into the heart.  Not everyone is a candidate for this procedure, as too small a liver volume can lead to problems with worsening confusion and ascites.   


Transplant Surgery
In liver transplant surgery, a diseased liver is replaced by a whole or part of a healthy liver.  This is the treatment of choice for many diseases.  Certain liver cancers have better outcomes with transplant than with surgery alone.  Transplant surgery is only an option for a select few patients.  With the addition of this service line to our Liver and Pancreas Cancer Center, you can trust that all of your options will be completely addressed. 

Some offices may offer parts of your options, but leave transplant as a separate consultation with a separate set of physicians.  Here, you can trust that every option will be addressed in your consultation under one visit.