Liver Cancer Surgery

When surgery is possible

Three conditions have to be met for resection:

• the tumor is confined to the liver, with no spread beyond it;
• liver function is preserved;
• the tissue that remains after surgery is enough to live on.

The best candidates for resection are patients with a solitary tumor, without cirrhosis or with compensated cirrhosis without clinically significant portal hypertension. Size by itself is not always an obstacle: large solitary tumors in a healthy liver are also removed if the vessels and the remnant volume allow it.

Liver cancer is often confused with liver metastases. These are different diseases, and they are operated on by different rules: metastases are covered on the page “Liver Metastases Surgery”. The disease itself, its causes and tests are described on the page “Liver Cancer”.

Surgery in cirrhosis

In a healthy liver a larger part can be removed than in cirrhosis: a cirrhotic liver regenerates less well, and too large a resection risks liver failure. That is why the following are assessed before surgery:

• liver function — bilirubin, albumin, clotting tests, the Child-Pugh and MELD scores and, when needed, specialized functional tests;
• signs of portal hypertension — esophageal varices on endoscopy, platelet count, spleen size; whether resection is safe depends largely on them;
• the volume of the future remnant — CT volumetry: how much liver will remain after surgery.

If cirrhosis is compensated but resection is risky because of portal hypertension, ablation is often chosen. In decompensated cirrhosis the main option becomes transplantation, if the tumor meets its criteria.

Resection, ablation or other treatment

For a solitary tumor larger than 2 cm in cirrhosis, resection is preferred if liver function and the remnant allow it, while ablation may be an alternative for selected patients. For a solitary tumor in a liver without cirrhosis, resection is usually preferred. Sometimes after intra-arterial or systemic treatment the tumor shrinks enough for the question of resection to return, so the decision is reviewed on follow-up imaging.

How the operation is performed

The extent of resection is determined by the tumor location, its relationship with the vessels and the condition of the liver. When the tumor location and liver condition allow it, an anatomical resection may be chosen — removal of the segment or lobe supplied by the same portal vein branch as the tumor. In cirrhosis, on the contrary, the aim is to preserve as much tissue as possible, and the extent is weighed especially carefully.

During surgery the liver is examined with an ultrasound probe to find lesions not visible on imaging and to define the resection margins precisely. If the remnant volume is borderline, portal vein embolization can be performed before surgery: the part of the liver that will remain grows over several weeks.

When the tumor location and extent of resection allow it, the operation is performed laparoscopically — through a few small incisions. In patients with cirrhosis this may reduce some of the complications associated with a large incision. In other cases surgery is open; we choose the approach after reviewing the images.

Hospital stay, recovery and follow-up

Recovery follows the enhanced recovery (ERAS) protocol: early mobilization, early eating, controlled pain relief. In the first days liver function is monitored especially closely: bilirubin, blood clotting, fluid accumulation in the abdomen. The length of the hospital stay depends on the extent of resection, the approach and the condition of the liver.

The volume of a healthy liver remnant increases quickly in the first weeks, but further recovery may take months; in cirrhosis recovery is slower, and treatment of the underlying liver disease continues after surgery.

After resection the risk of a new tumor remains, because the diseased liver is still there. That is why follow-up is long: in the first years — contrast-enhanced CT or MRI and alpha-fetoprotein every few months, later less often. Treating the cause — hepatitis, alcohol-related or metabolic liver disease — is just as important. A new tumor found early can often be removed again, destroyed with ablation, or transplantation can be considered.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The main ones are:

• liver failure — especially in cirrhosis or with an insufficient remnant volume; this is why liver function, portal hypertension and volume are assessed before surgery;
• fluid accumulation in the abdomen — ascites, more common in patients with cirrhosis;
• bleeding during or after surgery;
• bile leak from the resection surface;
• infection and general surgical complications, including thrombosis.

The likelihood of each depends on the extent of resection, the condition of the liver and other conditions. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost depends on the extent of resection, the approach, whether ablation or embolization is needed before surgery, the number of days in the hospital and the tests. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

What documents are needed and how to book

• contrast-enhanced liver CT or MRI discs and the reports — the discs with the images themselves;
• blood tests: complete blood count, biochemistry, coagulation panel, alpha-fetoprotein;
• information about the liver disease — hepatitis, its treatment, hepatologist reports;
• the report of an upper endoscopy, if one was done;
• the histopathology report, if a biopsy was performed, and summaries of previous treatment.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.