Liver Problems

The liver is situated in the upper right side of the abdomen, just under the lower ribs and diaphragm. In the adult, it weighs between 3 to 4 pounds and is about the size (though not the shape) of a college football. Although it looks like one solid organ, it can be considered as made up of several segments, as shown below, based on the blood vessels that come in and go out. These segments form the basis upon which different surgical procedures are designed, depending on the location and size of the tumor to be removed.

Although the liver is sensitive to many things, the most common things that have a major impact are: alcohol, specific viruses (Hepatitis A, B, C, and others), certain drugs, particularly, large doses of acetaminophen (Tylenol), gallstones, particularly when they travel into the bile duct which drains bile from the liver into the intestines, and cancers, either those that originate in the liver, or those that spread from other organs.

Cancer in the original organ is called a primary tumor. Cancer that has spread to one or more organs) is called metastatic and cancer in those other organs is known as metastasis (pl. metastases). The liver is one of the organs to which cancer spreads most often. In part, this is due to the fact that the blood supply of the liver is so rich (about ¼ of our blood volume is in the liver at any given time). Another reason, as it applies to cancer that arises in abdominal organs (such as the colon, pancreas or stomach), is that all the venous blood that drains from these organs passes through the liver on the way back to the heart.

Under certain circumstances, liver metastases can be removed, either by “coring” them out, or removing larger parts of the liver (a procedure known as resection) that contain the metastases. Whether metastases can be resected (removed) depends on the nature of cancer (colon, for example), the number of metastases and the location in the liver. Each patient must be evaluated individually to determine if resection is feasible.

Normal liver regenerates, and rather quickly (weeks), so even though a large portion of the liver might be removed, you will grow some “new liver”. If the uninvolved liver has been affected by cirrhosis (scarring of the liver), too much fat, or, sometimes, chemotherapy, the remaining liver can be very slow to regenerate, or may not regenerate at all, sometimes resulting in liver failure. This possibility must be considered carefully if a liver tumor is going to be removed since a diseased liver is less able to renew itself.

Yes. Cancer that arises from the liver cells is called hepatocellular carcinoma (HCC) or hepatoma, and, in this country, it is almost always associated with chronic viral hepatitis, alcohol abuse or obesity-linked fatty liver. Cancer which arises from the bile ducts in the liver is called cholangiocarcinoma (CC). Though these unusual tumors are surprisingly common in the Orient, there are only about 2,500 cases per year in the entire USA. The high incidence of certain parasites in Oriental countries predisposes to a higher risk of this type of cancer, which typically is a very aggressive form of cancer, and is often incurable when diagnosed.

HCC (hepatoma) can be removed if relatively small and if the rest of the liver is in good enough shape to tolerate the procedure and regenerate. Often, the only possible cure is with a liver transplant, but only if certain criteria are met. CC (cholangiocarcinoma) is less amenable to resection. When cancer of the gallbladder is found prior to removal of the gallbladder (cholecystectomy), the gallbladder must be removed together with the adjacent area of the liver, or even a larger portion (known as a lobe, the procedure is called a lobectomy). When resection is not possible, chemotherapy and/or radiation may be of help, occasionally with fairly impressive results. Other modalities include the destruction of the tumor(s) with microwaves, known as radiofrequency ablation (RFA), 95% alcohol, or freezing (cryoablation).

Yes. The most common is a liver adenoma, which is often associated with oral contraceptives (although modern preparations are less likely to cause this), and focal nodular hyperplasia (FNH). Liver cysts do not usually require resection, but just drainage.

Before the use of oral contraceptives, there were almost no reports of such liver adenomas. At least 90% of cases occur in birth control users and are more common in those on birth control pills for >10 years. Patients may have either no symptoms, or they may experience pain under the rib cage, usually on the right side, and may even feel a mass. In some women, the symptoms occur suddenly, due to development of bleeding into the tumor. In these cases, the symptoms invariably bring the patient to an emergency room, and the tumor will be seen on either a CT scan or an ultrasound. If the bleeding does not stop, surgery is almost always necessary as an emergency life-saving measure.

For those women in whom a liver adenoma is diagnosed without evidence of bleeding, a planned surgical removal is the usual recommendation, particularly for the larger ones, as shown in the picture below.

Most often, liver resection is an “open” procedure, meaning that the abdomen is open wide, to ensure that there is adequate exposure of the liver and surrounding structures and that the operation is safe. Usually, the incision (cut) is under both rib margins, like an inverted “V” (also known as a chevron incision), with or without an upper extension in the midline, toward the lower end of the breastbone. There are several options for how the surgeon might actually remove the tumor. Dr. Stieber often uses a technique known as “total vascular exclusion” (TVE) (meaning that the blood supply to and from the liver is temporarily interrupted, in order to minimize blood loss), with a unique modification he has derived from his experience with liver transplantation, which helps to keep the patient’s blood pressure stable during the surgery.

It can, under very limited and strict circumstances. When laparoscopic techniques are used, the operation is most often known as “hand-assisted laparoscopic resection”, since an opening big enough to introduce a hand in the abdomen must be made, the same opening being used to remove the portion of the liver that has been resected.

The primary operative risk is bleeding. As mentioned before, the liver is a very vascular organ (meaning it has a rich blood supply), so there is always the risk of major bleeding. This is, however, not a frequent event, especially with the TVE technique. The major possible complications are a hematoma (blood clot), bile leak and infection.

Of course, if the liver has a disease, such as cirrhosis, the risks for bleeding or other complications are higher, particularly since proper blood coagulation requires the production of many factors which are produced by the liver.

If there are no complications, most patients stay in the hospital for about one week, and are back to baseline within 2 to 3 months. Recovery and return to normal activity can be shorter in some patients, even as little as 5 days in the hospital and 3–4 weeks to essentially complete recovery. It all depends on the indication for resection, the magnitude of resection, the patient’s age and general condition and his/her motivation.

To set up a consultation, or if you have other questions regarding your specific situation, you may contact our office at 404-508-4320, or email Dr. Stieber directly at drstieber@dekalbsurgical.com.