Hepatocellular carcinoma surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The feasibility of surgery depends on the stage of hepatocellular carcinoma at time of diagnosis.
Surgery
Liver transplant
Liver transplantation to replace the liver with a cadaver liver or a live donor lobe. Historically, the survival rates after liver transplantation have been low (20%-36%). Recent improvement in the survival rates (44% to 78%) due to the adoption of Milan criteria at US transplantation centers. If the tumor has metastasized, the immuno-suppressant post-transplant drugs decrease the chance of survival.[1]
Techniques
- Before transplantation, liver support therapy might be indicated ( called bridging-to-transplantation).
- Artificial liver support like liver dialysis or bioartificial liver support concepts are currently under preclinical and clinical evaluation.
- Virtually all liver transplants are done in an orthotopic fashion, that is the native liver is removed and the new liver is placed in the same anatomic location.
- The transplant operation may be conceptualized as consisting of:[2][3][4][5][6]
- Hepatectomy (liver removal) phase
- Anhepatic (no liver) phase
- Postimplantation phase
- The operation is done through a large incision in the upper abdomen.
- The hepatectomy involves division of:[7][8]
- All ligamentous attachments to the liver
- Common bile duct
- Hepatic artery
- Portal vein
- Usually, the retrohepatic portion of the inferior vena cava is removed along with the liver, although an alternative technique preserves the recipient's vena cava ("piggyback" technique).
- The donor's blood in the liver is replaced by an ice-cold organ storage solution, such as UW (Viaspan) or HTK until the allograft liver is implanted.
- Implantation involves anastomoses (connections) of the inferior vena cava, portal vein, and hepatic artery.
- After blood flow is restored to the new liver, the biliary (bile duct) anastomosis is constructed, either to the recipient's own bile duct or to the small intestine.
- The surgery usually takes between five and six hours, but may be longer or shorter due to the difficulty of the operation and the experience of the surgeon.
- The large majority of liver transplants use the entire liver from a non-living donor for the transplant, particularly for adult recipients.[9][10]
- A major advance in pediatric liver transplantation was the development of reduced size liver transplantation, in which a portion of an adult liver is used for an infant or small child.
- Further developments in this area included split liver transplantation, in which one liver is used for transplants for two recipients, and living donor liver transplantation, in which a portion of healthy person's liver is removed and used as the allograft.
- Living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver (Couinaud segments 2 and 3).
Surgical resection
If diagnosed early, surgical resection with a safety margin can be considered to remove a small or slowly growing tumors. This treatment offers the best prognosis for long-term survival. The 5 year over all survival rate for patients who undergo surgical resection is 27% to 70%.[1] Unfortunately, due to the severity of the tumor and poor liver functions, it's only possible in 10-15% of hepatocellular carcinoma cases. Resection in cirrhotic patients carries high morbidity and mortality rates.
Cryosurgery
Cryosurgery: Cryosurgery is a technique that can be used in the treatment of tumors by using sub-zero temperature to destroy cancerous tissues. The tumor is not removed and the destroyed cancer is left to be reabsorbed by the body. Initial results in properly selected patients with unresectable liver tumors are equivalent to those of resection. Cryosurgery involves the placement of a stainless steel probe into the center of the tumor and liquid nitrogen is circulated through the end of this device. The tumor and a half inch margin of normal liver are frozen to -190°C for 15 minutes, which is lethal to all tissues. The area is thawed for 10 minutes and then re-frozen to -190°C for another 15 minutes. After the tumor has thawed, the probe is removed, bleeding is controlled, and the procedure is complete. The patient will spend the first post-operative night in the intensive care unit and typically is discharged in 3 - 5 days. Proper selection of patients and attention to detail in performing the cryosurgical procedure are mandatory in order to achieve good results and outcomes. Frequently, cryosurgery is used in conjunction with liver resection as some of the tumors are removed while others are treated with cryosurgery.
Contraindications
Absolute contraindications: [6]
- Metastasis outside the liver, past the curative stage
- Hepatocellular carcinoma with metastasis (Stage 1V)
- Acute Liver Failure with persistently elevated intracranial pressure ICP >50mmHg( due to hepatic encephalopathy)
- Hemangiosarcoma
- Hilar cholangiocarcinoma with liver involvement
- Sepsis
- Active alcohol or drug abuse
- Anatomic anomalies that may be a deterrent to transplantation
- Poor adherence to medical treatment
- Absence of social support
Relative contraindications:[6][11][12][13][14][15][16][17][18][19][20]
- Infection with HIV (AIDS)
- Age >65 years
- Any serious pathologies of the lung or heart that cannot be corrected
- BMI ≥40
- Alcoholic liver disease:Only performed if abstinent for ≥ 6 months
- Presence of social support
- Participation in an alcohol abstinence and rehabilitation program
References
- ↑ 1.0 1.1 National Cancer Institute. Physician Data Query Database 2015.http://www.cancer.gov/types/liver/hp/adult-liver-treatment-pdq
- ↑ Eghtesad B, Kadry Z, Fung J (2005). "Technical considerations in liver transplantation: what a hepatologist needs to know (and every surgeon should practice)". Liver Transpl. 11 (8): 861–71. doi:10.1002/lt.20529. PMID 16035067.
- ↑ Tuttle-Newhall JE, Collins BH, Desai DM, Kuo PC, Heneghan MA (2005). "The current status of living donor liver transplantation". Curr Probl Surg. 42 (3): 144–83. PMID 15859440.
- ↑ Steadman RH (2004). "Anesthesia for liver transplant surgery". Anesthesiol Clin North America. 22 (4): 687–711. doi:10.1016/j.atc.2004.06.009. PMID 15541931.
- ↑ Park JI, Kim KH, Lee SG (2015). "Laparoscopic living donor hepatectomy: a review of current status". J Hepatobiliary Pancreat Sci. 22 (11): 779–88. doi:10.1002/jhbp.288. PMID 26449392.
- ↑ 6.0 6.1 6.2 Martin P, DiMartini A, Feng S, Brown R, Fallon M (2014). "Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation". Hepatology. 59 (3): 1144–65. PMID 24716201.
- ↑ Adam R, McMaster P, O'Grady JG, Castaing D, Klempnauer JL, Jamieson N, Neuhaus P, Lerut J, Salizzoni M, Pollard S, Muhlbacher F, Rogiers X, Garcia Valdecasas JC, Berenguer J, Jaeck D, Moreno Gonzalez E (2003). "Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry". Liver Transpl. 9 (12): 1231–43. doi:10.1016/j.lts.2003.09.018. PMID 14625822.
- ↑ Shah SA, Levy GA, Adcock LD, Gallagher G, Grant DR (2006). "Adult-to-adult living donor liver transplantation". Can. J. Gastroenterol. 20 (5): 339–43. PMC 2659892. PMID 16691300.
- ↑ Reddy S, Zilvetti M, Brockmann J, McLaren A, Friend P (2004). "Liver transplantation from non-heart-beating donors: current status and future prospects". Liver Transpl. 10 (10): 1223–32. doi:10.1002/lt.20268. PMID 15376341.
- ↑ Martinez OM, Rosen HR (2005). "Basic concepts in transplant immunology". Liver Transpl. 11 (4): 370–81. doi:10.1002/lt.20406. PMID 15776458.
- ↑ Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, Castel H, Duhamel A, Pageaux GP, Leroy V, Dharancy S, Louvet A, Boleslawski E, Lucidi V, Gustot T, Francoz C, Letoublon C, Castaing D, Belghiti J, Donckier V, Pruvot FR, Duclos-Vallée JC (2011). "Early liver transplantation for severe alcoholic hepatitis". N. Engl. J. Med. 365 (19): 1790–800. doi:10.1056/NEJMoa1105703. PMID 22070476.
- ↑ Cooper C, Kanters S, Klein M, Chaudhury P, Marotta P, Wong P, Kneteman N, Mills EJ (2011). "Liver transplant outcomes in HIV-infected patients: a systematic review and meta-analysis with synthetic cohort". AIDS. 25 (6): 777–86. doi:10.1097/QAD.0b013e328344febb. PMID 21412058.
- ↑ Mindikoglu AL, Regev A, Magder LS (2008). "Impact of human immunodeficiency virus on survival after liver transplantation: analysis of United Network for Organ Sharing database". Transplantation. 85 (3): 359–68. doi:10.1097/TP.0b013e3181605fda. PMID 18301332.
- ↑ Terrault NA, Roland ME, Schiano T, Dove L, Wong MT, Poordad F, Ragni MV, Barin B, Simon D, Olthoff KM, Johnson L, Stosor V, Jayaweera D, Fung J, Sherman KE, Subramanian A, Millis JM, Slakey D, Berg CL, Carlson L, Ferrell L, Stablein DM, Odim J, Fox L, Stock PG (2012). "Outcomes of liver transplant recipients with hepatitis C and human immunodeficiency virus coinfection". Liver Transpl. 18 (6): 716–26. doi:10.1002/lt.23411. PMC 3358510. PMID 22328294.
- ↑ Cross TJ, Antoniades CG, Muiesan P, Al-Chalabi T, Aluvihare V, Agarwal K, Portmann BC, Rela M, Heaton ND, O'Grady JG, Heneghan MA (2007). "Liver transplantation in patients over 60 and 65 years: an evaluation of long-term outcomes and survival". Liver Transpl. 13 (10): 1382–8. doi:10.1002/lt.21181. PMID 17902123.
- ↑ Prachalias AA, Pozniak A, Taylor C, Srinivasan P, Muiesan P, Wendon J, Cramp M, Williams R, O'Grady J, Rela M, Heaton ND (2001). "Liver transplantation in adults coinfected with HIV". Transplantation. 72 (10): 1684–8. PMID 11726833.
- ↑ Wreghitt T (2001). "Liver Transplantation in Adults Coinfected With HIV. Transplantation 2001; 72: 1684". Transplantation. 72 (10): 1594–5. PMID 11726816.
- ↑ Stock P, Roland M, Carlson L, Freise C, Hirose R, Terrault N, Frassetto L, Coates T, Roberts J, Ascher N (2001). "Solid organ transplantation in HIV-positive patients". Transplant. Proc. 33 (7–8): 3646–8. PMID 11750549.
- ↑ Stock PG, Roland ME, Carlson L, Freise CE, Roberts JP, Hirose R, Terrault NA, Frassetto LA, Palefsky JM, Tomlanovich SJ, Ascher NL (2003). "Kidney and liver transplantation in human immunodeficiency virus-infected patients: a pilot safety and efficacy study". Transplantation. 76 (2): 370–5. doi:10.1097/01.TP.0000075973.73064.A6. PMID 12883195.
- ↑ Neff GW, Bonham A, Tzakis AG, Ragni M, Jayaweera D, Schiff ER, Shakil O, Fung JJ (2003). "Orthotopic liver transplantation in patients with human immunodeficiency virus and end-stage liver disease". Liver Transpl. 9 (3): 239–47. doi:10.1053/jlts.2003.50054. PMID 12619020.