Liver Cancer: Hepatectomy

Liver cancer is cancer that begins in the cells of your liver, the largest organ of your body that is placed in the upper right portion of your abdomen, beneath your diaphragm and above your stomach.

The most common form of liver cancer is a hepatocellular carcinoma, which begins in the main type of liver cell (hepatocyte). Other types of cells in the liver can develop cancer, but these are much less common.

Hepatectomy is the surgery used to treat liver cancers. The extent of the hepatectomy depends on the size, number, and location of cancer, and your overall health condition. The surgeon may remove a part of the liver that contains the tumor, an entire lobe, or an even larger portion of the liver. In a partial hepatectomy, the surgeon leaves a margin of healthy liver tissue to maintain the functions of the liver. If a total hepatectomy, meaning that the patient’s entire liver is removed, is performed, a liver transplantation is indicated. The removed liver is replaced with a healthy liver from a donor. A liver transplant is an option only if cancer has not spread outside the liver and only if a suitable donor liver can be found that matches the patient. While waiting for an adequate donor, the health care team monitors the patient’s health while providing other therapy.

 

Symptoms of liver cancer

Liver cancer may not show specific symptoms in early stages. In the later stages, kidney cancer signs and symptoms may include:

  • Loss of appetite
  • Weight loss
  • Pain in the upper abdomen
  • Nausea and vomiting
  • Weakness and fatigue
  • Swelling in the abdomen
  • Jaundice
  • Chalky stools

If any of these symptoms persist, try keeping a diary to record how many of these symptoms you have over a longer period. Consult your GP if you have these symptoms regularly (on most days for three weeks or more). Note that the symptoms of liver cancer may resemble other conditions or medical problems. Always consult your doctor for a diagnosis. If your doctor suspects renal cancer, you may be referred to a hepatologist or an oncologist.

 

Diagnosis of liver cancer

If your doctor suspects that you might have liver cancer based on your symptoms, he/she is likely to perform the following tests:

  • Blood and urine tests – These tests may give your doctor clues about what’s causing liver abnormalities.
  • Imaging tests – These tests are used to view a liver tumour or abnormality. Imaging tests might include ultrasound, computerized tomography (CT) scan or magnetic resonance imaging (MRI).
  • Biopsy – Based on the results of your tests, a biopsy may be conducted. A biopsy is a procedure used to remove a small sample of cells (biopsy) from a suspicious area of your liver. The sample is tested in a lab to look for signs of cancer. Your doctor may insert a thin needle through your skin and into your liver to obtain a tissue sample. The liver biopsy carries a risk of bleeding, bruising and infection.

 

Staging of liver cancer

Once you have been diagnosed with liver cancer, the doctor will determine the stage. Staging tests for liver cancer may include additional CT scans or other imaging tests your doctor feels are appropriate. The stage of the cancer is determined by the following markers:

  • Stage I – The single primary tumour (any size) has not grown into any blood vessels. Cancer has not spread to nearby lymph nodes or distant sites.
  • Stage II – The single primary tumour (any size) has grown into the blood vessels, or there are several small tumours, all less than 5 cm in diameter. Cancer has not spread to nearby lymph nodes or distant sites.
  • Stage III –  Stage III liver cancer has three subcategories:
  • Stage IIIA: There are several tumours with at least one larger than 5 cm. Cancer has not spread to nearby lymph nodes or distant sites.
  • Stage IIIB: There are several tumours and, at least, one tumour is growing into a branch of the portal vein or the hepatic vein. The liver cancer has not spread to nearby lymph nodes or distant sites.
  • Stage IIIC: A tumour has grown into a nearby organ (other than the gallbladder), Or a tumour has grown into the outer covering of the liver. Cancer has not spread to nearby lymph nodes or distant sites.
  • Stage IV – Cancer has spread to organs outside the kidney, to multiple lymph nodes or to distant parts of the body, such as the bones, liver or lungs.

Staging is extremely important because liver cancers at different stages are treated differently. If the staging is not done correctly, your doctor may not be able to decide on the best treatment.

 

Risks

Complications of liver cancer surgery depend on the procedures you choose. Complications may include:

  • Bleeding
  • Infection
  • Pneumonia
  • Blood clots in the legs
  • Urinary tract infection
  • Liver failure
  • Rejection of the new liver (if hepatectomy is followed by liver transplant)
  • Further surgery

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

 

Before the procedure

  • Your doctor will explain the surgical procedure to you. Ask any questions that you might have about the procedure – if you will need a partial or a complete hepatectomy; whether you are a candidate for laparoscopic hepatectomy; etc.
  • If you have to undergo a liver transplant, discuss the pros and cons of the procedure and the modifications you will need to make in your lifestyle post the transplant.
  • You may be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
  • Ask your doctor if you will possibly need a blood transfusion. If the doctors think a transfusion might be needed, you might be asked to donate blood beforehand.
  • Your doctor will go through your full medical history and additionally may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
  • Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anaesthetic agents (local and general).
  • Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
  • Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
  • Notify your doctor if you are pregnant or suspect pregnancy.
  • It is important that your bowels be empty when the surgery is performed. You must follow your doctor’s instructions on dietary changes and liquid intake on the days leading up to surgery.
  • A day or two before the procedure, your doctor may give you a bowel preparation that includes laxatives and enemas.
  • You will be asked to fast for eight hours before the procedure, generally after midnight.
  • You may receive a sedative prior to the procedure to help you relax.
  • You may meet with a physical therapist prior to your surgery to discuss rehabilitation.
  • Stop smoking, as smoking can delay wound healing and slow down the recovery period.

Based on your medical condition, your doctor may request other specific tests or examinations.

 

During the procedure

Hepatectomy is the surgical removal of the liver. Procedures may vary depending on your condition and your doctor’s practices.

Generally, the surgery follows this process:

  • You will be asked to remove clothing and put on a hospital gown.
  • An intravenous (IV) line may be started in your arm or hand.
  • You will be positioned on the operating table.
  • A urinary catheter may be inserted.
  • The surgery will be performed while you are asleep under general anaesthesia. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
  • The skin over the surgical site will be cleansed with an antiseptic solution.
  • Depending on the stage of your cancer and overall medical condition, the surgeon       may perform:
  • Partial hepatectomy – The surgeon will make an incision below the ribcage, across the right side of the upper abdomen. An ultrasound device is used to find the liver tumour (s). The diseased portion of the liver is then removed, along with some adjoining healthy liver tissue.
  • Laparoscopic hepatectomy – This is a minimally invasive procedure, wherein the surgeon makes a number of small incisions (rather than one large incision as with open liver resection). A needle is inserted to expand the abdomen with carbon dioxide gas to allow room for instruments to be inserted. Your surgical oncologist uses specialized instruments, including a small telescope with a camera attached, to visualize the abdominal cavity and to remove sections of the liver that are cancerous.
  • Liver transplant – During liver transplant surgery, your diseased liver is removed and replaced with a healthy liver from a donor. Liver transplant surgery is only an option for a small percentage of people with early-stage liver cancer.
  • Regardless of the type of procedure you have, some tissue and lymph nodes will be sent to a laboratory for analysis.
  • The incision will be closed with stitches or surgical staples.
  • A drain may be placed in the incision site to remove fluid.
  • A sterile bandage or dressing will be applied.

 

After the procedure

You will spend 5–10 days in the hospital after a partial hepatectomy, and up to three weeks in hospital following a transplant. If you have a laparoscopy, the recovery time is shorter – you should allow about one week to recover before returning to your usual activities.

After the surgery, you will be taken to the recovery room for observation. The staff will monitor your blood pressure, pulse, alertness, pain or comfort level, and your need for medications and give you medicine for pain. When they are sure that you are stable, you will be transferred to a room in the hospital.

Different tubes will be in place to drain post-operative fluids, urine and bile. You will also have a drip (intravenous tube) giving you fluids and nourishment, as you may not be able to eat or drink for a few days. When you are able to eat, you will be given clear fluids at first, and then solid foods.
Although deep breathing and coughing may be painful because the incision is close to the diaphragm, breathing exercises are important to prevent pneumonia. You will probably feel quite tired and weak after the operation, but this should improve within a few weeks.
You will be encouraged and helped by the nursing staff to get out of bed on the first or second day after your operation and help you start walking soon after this.

1.1.1      At home

Once you are home, it is important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up hospital visit.

You will be given prescriptions for pain medication and possibly an antibiotic. Be sure to take only recommended medications.

Notify your doctor to report any of the following: Fever; redness, swelling, bleeding, or other drainages from the incision; increased pain near the incision; and numbness and/or tingling sensation at the surgical site.

You will have to avoid contact sports, heavy lifting or any other strenuous exercise that may put pressure on your abdomen. If you must pick something up, bend with your knees, not your waist: stoop to pick up the item. Avoid driving till you are on pain medication. Your doctor might suggest some other activity restrictions.

Your dietician will advise you on the diet if there are any changes. You will generally be advised to avoid foods that cause gas or constipation. Increase roughage in your diet. Drink plenty of fluids and pass urine regularly; this will help look after your liver. Avoid alcohol for at least one month and only drink alcohol in moderation after this time. If you have cirrhosis, you must not consume any alcohol. Your medical team will talk to you about this.

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

 

Recovery

Recovery time after this type of surgery varies but generally, you should feel improvements from between 2 to 3 weeks. This may take longer where the surgery has been more complex. The wound may be sore for this time and can take up to 8 weeks to heal fully.

The liver can repair itself easily if it is not damaged. In partial hepatectomy, the portion of the liver that remains after resection will start to grow, even if up to three-quarters of it is removed. The liver will usually be back to normal size within a few months, although its shape may be slightly changed.

If you have a liver transplant, it may take 3–6 months to recover. You will probably find it takes a while to regain your energy. You will also be given medications to reduce the chance of infection and stop the body rejecting the new liver (immunosuppressants). You will need to take immunosuppressants for the rest of your life.

Getting back to work will depend on the type of job that you do. Please ask your surgeon if you are unsure.

Walking will help your general recovery by strengthening your muscles, maintaining your blood circulation (thus preventing blood clots), and helping your lungs remain clear. However, you need to check with your doctor before you start lifting weights or doing abdominal exercises after your surgery to reduce your risk of complications.

Your doctor will give you a better idea of when you can expect to get back to your normal routine.