Most incidental lesions (liver cysts, haemangioma, focal nodular hyperplasia) can be diagnosed with various imaging modalities and require no surgical intervention. A hepatic abscess is treated with intravenous antibiotics in conjunction with radiological percutaneous drainage where appropriate. Surgery is rarely required. Hydatid cysts require treatments with Albendazole, followed by surgical resection.
Hepatic adenoma occurs often in patients on oral contraceptive pills (OCP) or anaebolic steroids. Cessation of OCP often leads to regression of adenoma and requires a follow up. Adenomas greater than 4-5cm pose a risk of rupture and malignant transformation, therefore usually requiring surgical resection. Adenomas in males have a high incidence of malignant transformation, thus should be considered for surgery.
Hepatocellular carcinomas (AKA, hepatoma or HCC) occur in patients with chronic liver disease from conditions such as hepatitis B, hepatitis C and alcoholic liver disease. However, fatty liver disease in obese patients is increasingly recognised as an important risk factor for HCC. CT or MRI demonstrate an arterially enhancing lesion, which “washes out” during the delayed phase in patients with evidence of chronic liver disease or other risk factors.
There are a number of treatment modalities available for HCC depending on the stage of the tumour (number, size and extra spread of disease), liver function (Child Pugh score/class - albumin, bilirubin, INR, presence of ascites and encephalopathy; presence of portal hypertension – varices, splenomegaly, ascites elevated HVPG measure), comorbidities and Eastern Cooperative Oncology Group (ECOG) performance status. Treatment strategies for HCC include laparoscopic or open liver resection (hepatectomy), ablation (microwave ablation), TACE (trans-arterial chemoembolisation), chemotherapy (sorafenib) and liver transplantation. A patient is presented in a multi-disciplinary tumour meeting and treatment strategies would be discussed and be co-ordinated. Up to date, the Barcelona Clinic Liver Cancer (BCLC) treatment guideline is generally followed where appropriate.
Colorectal liver metastases are the most common liver tumours considered for liver resection. Over the past twenty years, development of effective chemotherapy treatments and improvements in liver surgery have increased a 5-year overall survival rates in patients with liver metastases from colorectal cancers to above 50%.
A curative liver resection is performed when all liver metastases can be removed with clear margins and adequate future liver remnant (FLR). The FLR is the portion of liver left behind after liver resection, which needs adequate blood and bile inflow and blood outflow, with estimated liver volume of 30% in normal, 40% in chemotherapy affected and 50% in diseased liver.
Laparoscopic liver surgery is performed in patients with either isolated peripheral tumour or in left lateral section. A major laparoscopic liver resection is performed where appropriate. Open liver resection is often performed with intra-operative ultrasound assessment. Parenchyma preserving liver resection is performed where possible. Major hepatectomy (right or left hepatectomy) or extended right or left hepatectomy is performed where all tumours can be removed with an adequate future liver remnant (FLR). If volume for FLR is insufficient, portal vein embolisation is performed to “grow” the size of FLR prior to surgery.
Occasionally, liver resection can be performed in conjunction with colon cancer surgery when appropriate (synchronous resection), or prior to colorectal cancer surgery (liver first approach). When there is a bilobar disease, two-staged liver resection can be performed with portal vein embolisation in between resections. Neoadjuvant chemotherapy (chemotherapy first) is sometimes used to down-stage the disease if there are extensive hepatic metastases. Following liver resection, patients are followed up closely for recurrent disease. A repeat liver resection is considered in patients with limited recurrent liver metastases. Extra-hepatic liver metastases such as pulmonary metastases can be considered for resection. Selective internal radiation therapy (SIRT) is a new treatment modality available for patients with extensive liver only metastases, where surgery is not feasible.
Complex liver surgery can be performed safely and effectively but it has potential risks of morbidity and mortality. Liver surgery specific morbidities include haemorrhage, intra-abdominal infection, bile leakage and hepatic failure. A peri-operative death rate is around 1-2% depending on the type of tumour, extent and location of tumour, magnitude of liver resection, quality and volume of FLR and patient’s age and co-morbidities. An expert team of specialists will be involved in all phases of patient treatments, including pre-operative assessment, peri-operative physician and Intensive Care Unit (ICU) support and post-operative rehabilitation. A patient may require 3-7 days hospital admission following liver resection.
Post-operative Care Information
The day after your procedure you will be reviewed by Mr Choi to discuss the results of the surgery. You will be examined and the drain will be removed when appropriate. Patients are encouraged to mobilise from day 1 of their post-operative course.
Discharge from Hospital
Medications will be organised and dispensed prior to your discharge, as well as a post operative appointment in Mr Choi's private rooms, usually 2 weeks after your procedure.
Dressings will be changed to waterproof dressings prior to your discharge. The dressings should be kept intact for at least 7 days post-operatively, after which you can remove them gently yourself. You can take showers and wash with the dressings on during this time. There are usually no sutures to be removed because the surgical wounds are closed with absorbable sutures.
Time off work/school
Most people will be away from work or school for 3-4 weeks after a liver operation.
You should not drive for at least 2-3 weeks after a liver operation, especially if taking opioid pain relief such as Endone.
Light walking and light exercise can be resumed once you feel comfortable. Avoid heavy lifting (greater than 5 kilograms). Rigorous exercise such as weight training, yoga or sit ups should not be performed during the first 6 weeks post-surgery. If you have any specific questions, please do not hesitate to ask Mr Choi.
Increasing pain from your surgery after discharge from hospital
If you have any increasing, severe abdominal pain after your discharge from hospital, or vomiting or high fever, you should seek immediate medical advice, either by contacting Mr Choi through his rooms or directly. Alternatively, you could see your general practitioner or attend the Emergency Department at Epworth Hospital. If you have any specific concerns, please do not hesitate to contact Mr Choi's rooms during business hours on 03 9429 1002 or contact Mr Choi directly through Epworth Hospital on 03 9426 6666.