Liver Resection: A Patient Guide, Lecture notes of Radiotherapy

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ABOUT LIVER

RESECTION

Surgical removal of

part of the liver

A guide for patients

and relatives

This booklet has been written to provide information about the operation called a liver resection. This is a major operation and involves removal of a part of the liver. Information about the benefits and risks will help you make an informed decision about the operation.

It is important to remember that each person is different. This booklet cannot replace the professional advice and expertise of a doctor who is familiar with your condition. If you have questions that this booklet does not cover, please discuss them with your surgeon or cancer nurse specialist.

What is liver resection?

Liver resection is the removal of part of the liver during an operation.

The body can cope with removal of up to two-thirds of the liver. The liver also has the ability to grow back. Within 3 months of your operation, the remainder of your liver will have grown back to near normal size.

The operation is named depending on which portion of liver is being removed. For example, removal of the right side of the liver is called right hemi-hepatectomy. Since the gall bladder is located on the right side of the liver, it is often removed with a right hemi-hepatectomy.

Liver operations can sometimes be carried out using keyhole surgery. The surgical team at Oxford specialises in these procedures. With keyhole surgery, instruments are inserted through small cuts in the abdomen.

The surgeon can see what is happening through a narrow camera, which is also inserted into the abdomen. This avoids making a large cut on your abdomen, meaning you should have a quicker recovery from the operation. If this type of operation is suitable for you, your surgeon will discuss it in more detail.

When is liver resection recommended?

The most common reason for carrying out a liver resection is to treat cancer that has spread to the liver from a primary cancer in another part of the body.

Your specialists, including your liver surgeon, the radiologist (X-ray doctor) and oncologist (cancer chemotherapy specialist), have reviewed the results of your tests and believe that it may be possible to remove the cancer completely.

The operation is also used to treat cancers which start in the liver, the bile duct or the gall bladder. It may occasionally be needed for benign (non-cancerous) liver problems, such as liver cysts.

Occasionally, it is not possible to be absolutely sure about what is causing the problem with your liver. You may have been advised to have the operation to remove an abnormality, as this may be the best way to make a definite diagnosis.

• Selective internal radiation therapy (SIRT)

Selective internal radiation therapy (SIRT) is used to treat cancers of the liver. It is generally used with cancers that cannot be treated surgically. The treatment involves injecting microspheres (tiny beads) of radioactive material into the arteries which supply the tumour. These microspheres are carried into the tumour in the bloodstream, where they can destroy tumour cells by releasing radiation directly into the tumour.

• Stereotactic body radiotherapy (SBRT)

Stereotactic body radiotherapy (SBRT) is a new procedure for treating liver cancer. It uses high doses of radiation delivered to a precise target within the liver. This helps to avoid damaging healthy tissue nearby. The treatment is given in either a single treatment session or up to approximately five treatment sessions (each session is called a ‘fraction’).

• Portal vein embolisation

Portal vein embolisation (PVE) is a procedure which is carried out in the Radiology department. It assists with the treatment of cancer of the liver. PVE is carried out when liver cancer is suitable for surgical removal, but the remaining liver would be too small to work well afterwards. It can be done 4 to 5 weeks before the operation. PVE works by blocking the blood flow to the affected part of the liver from the bowel (portal venous flow). The blood flow from the bowel to the liver is then redirected to the healthy part of the liver, which is expected to remain after surgery. The aim of this procedure is to shrink the part of the liver affected with cancer, whilst allowing the remaining healthy liver to grow bigger.

• Staged liver surgery

Sometimes after PVE, the healthy part of the liver that is going to remain after surgery does not grow enough to carry out the liver surgery safely. If this happens, your surgeon may offer a two-step operation called an ALPPS procedure (associated liver partitioning and portal vein ligation for staged liver surgery).

In the first stage, your surgeon will tie off a branch of the portal vein that supplies the section of liver to be removed. The liver will be divided completely, in preparation for removal of the area affected by the tumour. However, the surgeon will not remove this part. Instead, the affected part of the liver will be left in place and still supplied with blood from the hepatic artery. This means it will still be able to work. The blood flow from the portal vein is then increased to the healthy part of the liver, which enables it to grow. The second stage of ALPPS is usually carried out 6-10 days after stage one. This stage involves removing the affected part of the liver. You will need a general anaesthetic for both stages. You will usually stay in hospital between both operations, although you may be able to spend a few days at home. Your surgeon may recommend an ALPPS procedure instead of trying PVE first. We will talk with you about this, if it is recommended.

What are the benefits of surgery?

The operation aims to completely remove the cancer and give you the best chance of a cure. The other non-surgical treatments help to delay the progress of the cancer, but are unlikely to cure it.

Will surgery improve my chance of

survival?

Without surgery, very few people with cancer involving the liver survive for more than 5 years. A successful operation can improve your chance of long-term survival by 25%-45%.

Despite a successful operation, there is a risk of the liver tumour recurring. This happens in at least two-thirds of people. The chance of the cancer recurring depends on the type of tumour that you have. If you wish, your surgeon can discuss the likely outcomes in your case.

What anaesthetic will I have?

Our normal anaesthetic technique for this procedure is a combination of general and epidural anaesthesia. During general anaesthesia you are completely asleep and will have a tube put into your windpipe to help your breathing. Although this is done very gently, you are likely to have a sore throat after the operation.

You may also have a narrow tube called a catheter for giving you pain medication infusions placed into your back (epidural) or near your wound (local anaesthetic infusion). An epidural and a local anaesthetic infusion are ways of blocking the signal from the nerves in the area of the operation.

Before you go to sleep with the general anaesthetic, the anaesthetist will place the catheter in your back, next to your spinal cord nerves, or into the area around the wound. The anaesthetic will be given through this catheter during the operation and it will remain in place for 3- days after the operation.

Both the epidural and the local anaesthetic infusion will help you to breathe deeply, which can be difficult if you are in a lot of pain. You will also be able to sit and walk around more comfortably.

These types of pain relief are very safe. The chance of any permanent nerve damage from an epidural is very rare; less than 1 in 10,000.

Your anaesthetist is also responsible for replacing fluids and blood during the operation. About 1 in 6 people will need blood transfusions during or after this type of operation.

You will meet the anaesthetist and can ask any questions on the day of the operation.

What if surgical removal of the cancer

is not possible?

Sometimes, problems are discovered during the operation that could not be identified before surgery. This includes spread of the cancer to other areas of the liver or to other parts of the body. Such findings occur in 1 or 2 in 10 people.

If the cancer has spread but is still just within the liver, it may be possible to remove all the cancer by removing more of your liver than was planned. We may use ultrasound or other forms of imaging during your operation, to try to identify any other small tumours that we can safely remove.

Surgery will not be helpful if all the cancer cannot be removed. If this happens your surgeon will not remove any of the cancer.

How do I prepare for surgery?

If you are a smoker, try to stop smoking as soon as you know that you need an operation. It will also help your recovery if you are able to increase your activity levels and take part in some gentle exercise before you come in to hospital for your operation.

You will need to arrange for additional help at home whilst you recover, particularly if you live alone.

You will be given an appointment at the Pre-operative Assessment clinic before your operation. This is to check you are fit enough to safely have the operation. You will have a chest X-ray, an electrocardiogram (ECG) to check your heart, and blood tests. The appointment will be approximately 2 hours long.

Please bring a list of your medication with you, including any off the shelf or herbal remedies you might use. Our team will give you further instructions and explain what you can expect when you come in for your operation.

You will be given some written information about our Enhanced Recovery After Surgery programme (ERAS), which explains how the team caring for you will help you to recover as quickly as possible.

Will I need any other treatment for

my cancer?

Sometimes survival rate can be improved by combining other treatments with surgery, such as chemotherapy. We will discuss the option of chemotherapy with you. You may see an oncologist, who specialises in the medical treatment of cancers with chemotherapy.

Whether you receive chemotherapy or not after your operation, you will be regularly followed up, either at the Liver Clinic at the Churchill Hospital, at your local hospital, or both.

What are long-term consequences of

the operation?

There are few long-term consequences of liver resection.

You may have some numbness around the surgical scar. This is from having to divide small nerves when cutting muscles.

Occasionally, a type of hernia called an incisional hernia may develop around the scar. This is caused by a weakness in the wall of the abdominal muscles. It usually doesn’t need any treatment, but if it causes pain or becomes too large an operation may be needed to treat it.

There should be no permanent effects on your lifestyle or diet after this surgery.

Symptoms to look out for

Call your GP or specialist nurse if you develop any of the following symptoms:

• a high temperature
• a sharp or persistent pain
• being sick or not being able to eat as you would normally
• becoming jaundiced (yellowing of your skin and eyes)
• your wound becomes red and painful or has a smelly discharge.

Further information

Cancer Research UK

Website: www.cancerresearchuk.org/cancer-help

Macmillan Cancer Support

Website: www.macmillan.org.uk

Tel: 0808 808 00 00

Maggie’s Cancer Centre (Oxford)

Tel: 01865 751 882 Website: www.maggiescentres.org/oxford

Useful contact numbers:

Oxford University Hospitals’ Switchboard 0300 304 7777

Hepatobiliary Team Secretary 01865 235 668

Specialist Cancer Nurses and Specialist Dietitian 01865 235 130 (or call the switchboard and ask for bleep 1386/1891)

Pre-operative Assessment clinic (John Radcliffe Hospital) 01865 857 635

Pre-operative Assessment clinic (Churchill Hospital) 01865 226 982/

Oxford Upper GI Ward (Churchill Hospital) 01865 235 061

Intensive Care Unit (Churchill Hospital) 01865 235 084

Churchill Overnight Recovery Unit 01865 235 127

Document revised by Sue Wilner, (HPB Specialist Nurse) and Consultant Hepatobiliary and Pancreatic Surgeons, Mr. Michael Silva and Mr. Zahir Soonawalla

July 2019 Review: July 2022 Oxford University Hospitals NHS Trust www.ouh.nhs.uk/information

OMI 55947P

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