Liver short note by S.

Wichien (SNG KKU)

Liver Anatomy -1.5 kg , 2%TBW -Glisson capsule (peritonem) :Bare area--no glisson Ligament 1.round ligament -remnant of umbilical v -marker for lt portal v 2.falciform ligament -separate lt lateral seg (2/3) -along umbilical fissure -anchor liver to abdo.wall 3.lt/rt triangular ligament -anchor liver to diaphragm 4.coronary ligament -anchor liver to retroperitoneum 5.hepatoduodenal ligament -porta hepatis -deep to--epiploic F--lesser sac 6.gatrohepatic ligament Segment -cantlie line--GB to rt of IVC -couinaud system -based on portal v+hepatic v -caudate lobe--seg 1 (3subsegment) 1.spiegel lobe 2.paracaval portion 3.caudate process -quadrate lobe = seg 4 -cephalad--7,8,4a,2 -caudaul--6,5,4b,3 Hepatic a 25% of blood (75% of O2) 25% have variable rRHA--SMA 18-22% (lat to CBD) rLHA--LGA 12-15% access LHA 35% early bifurcate CHA 1-2% comp rHA--SMA 1-2% Celiac trunk 1.lt GA 2.SA 3.CHA--GDA+HAP(RGA) Portal v -75% of bood supply -valveless structure -SMV+splenic v--portal v -post to BD and HA -normal P 3-5 mmhg -lt PV : transverse part--outside liver : umbilical part--90--enter liver -caudate lobe--short br from mPV 3 Hepatic v 1.RHV=5,6,7,8 inf access RHV (15-20%) in hepatocaval lig 2.MHV=4a,4b,5,8 3.LHV=2,3 LHV+MHV--common trunk--IVC caudate lobe--drain to IVC short HV--direct to IVC Biliary system -CBD normal <10 mm in diameter -LHD longer than RHD -GB--seg 4b/5 HD confluence variant -rp+ra,lh--57% (normal bifurcation) -ra,rp,lh--12% (trifurcation) -ra or rp to CHD--4-16% -ra or rp to lh--1-5% -no HD confluence--3% -rp to cystic d--2% Neural -parasym=vagus n -symp=celiac plexus -shoulder refer pain :stretch glisson/irritate diaphragm :+ve rt phrenic n Lymphatic -perisinusoidal space of Disse periportal clefts of Mall -cystic d/CBD/HA/celiac LN

Liver short note by S.Wichien (SNG KKU)

Bile circulation -bile a+phospholipid+chol,prot,elyte -500-1000 ml/24hr -elyte in bile similar to plasma -ileum reabsorp bile salt -95% of bile acid are active transport and back to liver via portal circulation Fasting -hi portal bile acid conc -inh.choles 7-hydroxylase -downregulate bile acid synthesis Ingest food -dec.bile acid conc in portal -dec inh.of choles 7-hydroxylase -inc bile acid synthesis Synthetic fxn -coagulating factor -plasma prot--albumin -acute phase prot,cytokine Carbohydrate metabolism -storage glycogen -glc homeostasis -metabolize lactate -Cori cycle Lipid metabolism -synthesis lipoprotein,TGA,choles -gluconeogenesis from fatty a Bilirubin metabolism -heme metabolism--bilirubin :bilirubin+alb :taken up by hepatocyte--bile -Direct hyperbilirubinemia :Dubin-Johnson and Rotor synd. -Indirect hyperbilirubinemia :Crigler-Najjar T.2 :Gilbert synd Imaging Ultrasound -good for biliary tract stone/dilate -echo texture=cirrhosis/fatty liver -screen develop HCC -rare in metastatic liver -doppler u/s in tumor vascularity Microbubble contrast -uptake by RE -inc visibility of metas, HCC -inc sense 20% Intraop u/s -gold std for liver lesion -20-30% more than pre-op Ix CT -smallest detectable lesion is 1 cm -A phase 20-30s, V phase 60-70s MRI MRC -evaluate intrahepatic biliary tree MRV -extrahepatic portal vein PET -Positron Emission Tomography -fxn imaging of hi metabolism tissue :metastatic tumor :detect recurrent colorectal ca -dx w/u of potential resect liver dz Octreotide -somatostatin scan -neuroendocrine tumorcarcinoid Tc albumin scan -FNH--hot nodule -HAcold nodule

Liver short note by S.Wichien (SNG KKU)

Acute liver failure (ALF) -hepatocyte death>regeneration -without pre-existing liver ds or pHT -cause of death :IC HT (cerebral edema)--most com :sepsis/MOD FHF--HE in 8 wk of onset SubFHF--HE in>8 wk of onset Cause -viral infect--most in East -drug+toxin--most in europe -autoimmune -hpoperfusion,shock -pregnant related -wilson dz Manifestration -cerebral edema, RF, HE Coagulopathy, metabolic disturb Uncertain dx -liver bx--transjugular approach :safe (coagulopathy) Tx -ICU -fluid mx -ulcer prophylaxis -hemodynamic monitoring -elyte mx--hypophosphate :indicate spon.recovery -Tx infection -elevate head 30 -correct plt/PTonly in hmg/invasive Tx -aware ARF--renal R Tx Liver transplantation -only definite Tx -overall survival 20% to >65% King college criteria 1.acetaminophen toxicity -pH<7.3 or -PT>100 s + Cr>3.4 + gr3,4 HE 2.viral,drug -PT>100 s or -any 3 of <10 yr,>40yr Jx to encep >7d Cryptogenic/dug induced PT>50 Bili>17.5 Cirrhosis -generalize hepatic fibrous septum subdivide liver into liver nodule -w healing rxn to chronic liver inj -viral,autoim,drug,cholestasis Liver stellate cell (Ito cell) -hepatocyte necrosis--IL1/6,TNF-alpha :activate stellate cell -inc matrix metalloproteinase-1,2 :matrix degeneration -constrict sinusoid :inc portal resistance -endothelin,vasopressin,eicosanoid :dec NO of endo.cell--portal HT Classification -micronodular cirrhosis--alcohol -macronodular cirrhosis -mixed cirrhosis CT findings -rt lobe atrophy -caudate/lt lobe hypertrophy -recanalization of umbilical v. -inc portal v.caliber -splenomegaly -ascites -GE varice decompensate--manifest ESLD hepatoma--AFP+ve 60-75% Hepatic reserve and assessment of Sx risk in cirrhotic pt 1.Child Turcotte Pugh score -risk of portocaval shunt procedure -risk of intra abdo.procedure 2.MELD -mortality after TIPS -liver txn allocation

Liver short note by S.Wichien (SNG KKU)

Evaluation of hepatic reserve -pt c normal liver can tolerate resect 80% of liver volume -rt trisegmentectomy=80% -rt lobectomy=65% -lt lobectomy=35% Test 1.Indocyanine green (ICG) test -ICG clearance -bound by plasma lipoprotein -rapidly clear by liver -excrete unconjugated in bile -predict risk of LF and mortality following major resection in cirrhosis Disadvantage -not true hepatocyte fxn -depend on hepatic blood flow rate 2.Aminopyrine and phenylalanine breath test -noninvasive -ingest radiolabel aminopyrine(14C) or phenylalanine(13C) -collect expire CO2 after ingest 2 hr 3.Intravenous injection of galactose -serial serum galactose level to determine hepatic clearance of galac 4.Intravenous dose of lidocain -less expensive -metabolism lidocain to -monoethylglycinexylidide(MEGX) 2,3,4 -quantitative test -based on microsomal metabolism -not represent entire hepatic fxn -add ICG = more useful 5.SPECT -dynamic Single Photon emission CT -inject 99mTc-GSA 6.PET -use H2(15)O measure -portal v.and hepatic a.blood flow -correlate portal blood flow and severity of cirrhosis Portal hypertension PV-->systemic v 1.coronary/lt gastric v-->eso v 2.sup hemorrh v-->inf hemorrh v 3.paraumbilical v-->epigastric v 4.v.of Retzius-->intes v 5.v.of sappey-->HV Hepatic venography -most accurate dx PHT -baloon catheter direct to HV -HVPG = WHVP - FHVP (free) (represent P. in sinusoid/PV) Definition of PHT WHVP >5 mmhg than IVC (varice >12mmhg) Cause 1.Presinusoidal Extrahepatic -splenic v thrombosis -splenomegaly -splenic av fistula Intrahepatic -schistosomiasis -nodular regen hyperplasia -cong.hepatic fibrosis -chro.active hepatitis -myeloproliferative ds -sarcoidosis -graft versus host ds 2.Sinusoidal -cirrhosis -alc.hepatitis 3.Postsinusoidal Intrahepatic -alc.terminal hyaline sclerosis -vascular occlusive ds Posthepatic -budd chiari syn -inf VC web -chro.passive venous congestion Cruveillance-Baumgarten murmur :umbilical vein murmur

Liver short note by S.Wichien (SNG KKU)

1.Esophageal varice 1/3 cirrhosis--bleeding 1/3 bleeding--mortality 2/3 survive--rebleed 1 yr Prevention of variceal bleeding -stop alcohol -avoid ASA,nsaid -non selective b blocker prophylactic EVL -recommend in medium/large varice -EGD 1-3m later--q 6m Acute bleeding bleeding Tx -keep hb 8 g/dl :over volume--rebleed -replace clotting factor :vitk,FFP,plt :novo7--not recommend -short term prophylactic ATB :cef3 -vasopressin :vasoconstrictor :s/e--ischemic c/p -octreotide :splanchnic vasocons--dec bl flow :50mcg bolus--50mcg/hr -endoscope+intervention :variceal banding surgical shunt/TIPS -refractory variceal bleeding -shunt sx--child-A TIPS--child-B/C Balloon tamponade -sengstaken blakemor -refractory variceal bleeding -short term Tx (<24hr) -await definite care -c/p--aspirate/eso.perforate 2.Gastrtric varice lesser curve -extent of eso.varice -Tx as EV greater curve -assess splenic v -Tx :variceal obturation :N butyl cyanoacrylate :unavailable/fail endoscopicTIPS Surgical shunt Consider only in -MELD<15 -not candidate for L.transplant -limit access to TIPS Aims -reduce PV pressure -maintain total hepatic/portal bl.flow -avoid hi incidence of HE 1.Nonselective shunt -medical refractory bleeding -intractable ascitis -not liver transplant candidate dec portal perfusion--hi risk of HE A.end to side portocaval shunt -complete portal v.thrombosis -rarely perform--hi HE/dec perfusion B.side to side portocaval shunt -anastomosis >12mm--total shunt -use graft 8mm--Sarfeh shunt C.large diameter interposition shunt (mesocaval shunt--SMV to IVC) -dacron graft 8-10 mm :H = Drapanas shunt :C = cameron shunt -avoidance portal dissection -useful in liver transplant candidate -hi shunt thrombosis/rebleed D.Proximal/central splenorenal shunt -Linton shunt -in hypersplenism--need splenectomy 2.Selective shunt : best use A.Distal splenorenal shunt (Warren) -end splenic v --> side renal v -most effective in alcohol pt -elective tx of refractory bleeding -avoidance portal dissection -lower HE -in liver transplant candidate -exacerbate ascitis B.Inokuchi shunt -saphenous vein graft -lt gastric vIVC

Liver short note by S.Wichien (SNG KKU)

TIPS Transjugular IntrahepaticPortosystemic shunts -minimal invasive -nonselective shunt Indication -refractory bleed--can control>90% -refractory ascitis -Budd-chiari syn -hepatopulmo synd Procedure -metallic stent btw middle hepatic v. and portal bifurcation -using u/s,radiologic direction -needle track is dilted until -portosystemic gradient <12 mmhg Complication -post-procedure HE--25-30% -intra-abdo bleeding -infection -cardiac failure -RF -long term--stenosis of shunt Budd-chiari syndrome -1/100,000 -uncommon congest hepatopathy -obstruct HV outflow -thrombotic or non thrombotic -portal HT 1 BCS--obstr endolumi v thrombosis (30% = myeloproliferative disorder) 2 BCS--compress/outside v Asso -hypercoag--prot c,s,antithrombin3 def -anti cardiolipin ab -hyperhomocysteinemia -oral contraceptive Clinical (inc sinusoid P, dec sinusoid bl flow) -hepatomegaly--liver congest -RUQ pain -ascites -ALF--rare, most--chronic portal HT Bx -noninflam centrilobular fibrosis -hepatocyte loss U/S (sens/spec 85%) -initial ix of choice -thrombosed hepatic v. -spiderweb HV -collateral HV Hepatic venography -definite radiography -extent of HV -measure IVC P. before TIPS/sx shunt CT -caudate lobe hypertrophy -inhomo enhance in remaining liver Tx -systemic anticoagulant -asso portal HT--Tx as cirrhosis Thrombolytic Tx -acute thrombosis -benefit--unknown Sx intervention -pt who non rxn medical Tx -TIPS > sx shunt :side to side portocaval shunt -liver transplantation

Liver short note by S.Wichien (SNG KKU)

Liver abscess 1.Pyogenic liver abscess Route -asc.biliary infect--stone,stricture,tumor -biliary procedure--stent,PTC -liver trauma -HA--BE -PV--appendix,diverticulitis -direct extension--PU perforate organism -20%--c/s negative -e.coli (2/3), klebsiella, B.fragilis S+S -RUQ pain+fever+jx (1/3) Ix -u/s--hypoechoic, variable int echo -CT--hypoden, air fluid, peri enhance Tx 1.percu.abscess drainage :80-90%success :C/I--coagulopathy,ascites or vital organ 2.ATB :at least 8wk :ATB alone in multiple small abscess <1cm 3.if fail=lap/open drainage 4.liver resection :malignant tumor (central necrosis) :IHD stone+atrophy :intrahep biliarry stricture 5.Tx 1cause 2.Amebic abscess -E.histolytica -poor sanitation--fecal oral route -ingest cyst--trophozoite in colon :invade mucosa--flask shape ulcer -into PV--syst circu--liver/lung/brain abscess -proteolytic enz--liquerfactive necrosis -destroy hepatocyte--anchovy pus -sup+ant aspect rt lobe -trophozoite in cyst wall (not pus) -most c/p--2nd bact infect -fever c chill,RUQ pain,hepatomegaly Ix -Enzyme immunoassay(EIA)--most use -ELISA--false+ve in previos infect Tx 1.inconclusive Dx -metronidazole 750 mg tid 7-10d -respond rapidly within 3days -if not good--2nd bact, no ameba -pregnancy--emetine,chloroquine,diloxanide 2. I/C for aspiration -uncertain dx -metro not improve -pregnancy--cant metro -2nd bact infection -hi risk rupture-->5cm,lt lobe -pulmo/perito/pericardial extension 3.rupture -peritoneum -pleural--ICD -bronchi-- postural drain (not sx) -pericardial--subxyphoid drain 3. Parasitic liver abscess 3.1 Hydatid cyst -Echinococcus granulosus -dog--definite host -human/sheep--intermediate host -rupture--2nd infect/anaphylaxis Cycle egg in fecae--oncosphere penetrate intes.wall--hydatid cyst in liver/lung Dx -ELISA--false+ve in previos infect -Casoni skin test -CT :ring like calcifica of pericyst (typical) :heal--entire cyst calcify Tx 1.alben 5-12 mo -deep lesion <4cm 2.pericystectomy -std Tx--lap or open -aware rupture cyst -sclerosant agent before cystectomy 3.PAIR -deep lesion, close vv/bile 3.2 ascarisasis -obstr in CBD -2cholangitis abscess -biliary colic -ac.cholecystitis, ac.pancreatitis -u/s,ERCP--linear filling defect Tx -albendazole

Liver short note by S.Wichien (SNG KKU)

Liver cyst 1.Congenital cysts -simple cyst -most common benign lesion -most asymptomatic -f:m 4:1 -Ix--thin wall,homo,fluid fill Tx I/C--severe symptoms,intracyst hmg 1.Percu.Aspir.Instillaton of alc. and Reaspirate (PAIR) 2.lap or open cyst fenestration 2.biliary cystadenoma -benign--slow growing -large lesion rt lobe -can malignant transform Ix -thicker wall -cyst septation enhance Tx -resection+frozen section -if malignant--hepatectomy 3. PCLD (>3 cyst) -ADPCLD--AD (congen PCLD--AR) -mutation of PKD1/2 -50% have PCKD -Number of cyst asso :female/inc age/severity of renal cyst -cyst : paren ratio >1 have symptom -fullness,early satiety,pain -massive cystic cyst--decompente L. 3 type T1.large cyst >10cm T2.multiple medium cyst 5-7cm T3.small/medium cyst <5cm Lab elevate gamma GT CT most useful imaging Asso -cerebral aneurysm (T3) -diverticulosis, MVP, inguinal hernia C/p -intracyst.hmg, infection -posttraumatic rupture Tx : in mass effect, c/p -open/lap cyst fenestration -partial hepatic :if remnant <2 seg=OLT 4.calori disease 5.Traumatic cyst Benign liver tumor 1.Hemangioma -most common benign tumor -MRI (best Ix)--hyperdense in T2 -CT--delay central fill+delay wash out Sx -enucleation or liver resection I/C for Sx -rapid enlarge -symptom r/o other cause -cant r/o ca -Kasabach Merritt synd Embolization -hi risk pt, children -multiple extensive hilar involve -before sx in large lesion -spon.bleeding 2.Focal nodular hyperplasia -2nd most common benign tumor -women, asso pill < HA -CT rapid enhance+rapid wash out -2/3 have central scar -rarely symtomatic/rupture -no malignant transform -sx resection--symptomatic -enucleation 2.Hepatic adenoma -reproductive women, 20-40 yr -used OC -lack bile duct/kuffer cell -congest/vacuolated hepatocyte -75% abdo.pain -25% can rupture -malignant transform--HCC -CT/MRI as FNH -Tc albumin scan--cold nodule (FNH--hot nodule) Tx <4cm, normal AFP, hx pill -observe+stop pill >4cm, c/p, cant stop pill -resection margin 1cm (Std Tx) Hi risk pt -RFA Rupture -embolize then sx -cant embolize--2 stage Adenomatosis (>4) -resect large lesion+RFA small lesion

Liver short note by S.Wichien (SNG KKU)

Hepatoma risk factor -cirrhosis,alfa1 trypsin def PBC,wilson,alcohol,hepatotoxin AFP -cirrhosis--rising 75% -no cirrhosis--rising 30% Staging Okuda Tumor >50% <50% Ascitis +ve -ve alb >3 <3 TB <3 >3 Hepatoma Tx 1.LT Criteria -child B C -no vv invasion -no extrahepatic metastasis -single <5cm or 3+<3cm/each 2.RFA -mass <3cm, deep to liver 1 cm -not hilar -not major blood vv--from vv >2 cm 3.cryotherapy--liquid N2 -EL--direct contact -mass <3cm, peripheral superficial lesion 4.percu.ethanol injection--PEI -mass <3cm, peripheral superficial lesion 5.TACE IC -unresectable -insuff FLV CI -complete PV thrombosis -child's C -severe RF -biliary obstruction -extrahepatic metas 6.Target tx -sorafenib 400 mg bid -prolong durvival 4.5m--6.5m Ruptured hepatoma CT signs -hypervascular mass -mass closed to liver capsule -protusion mass -subtle rim enhancement -extravasation of contrast -free fluid Tx 1.unstable Conservative Tx -morribund pt -malignant cachexia -terminal liver failure -extrahepatic metas Transarterial embolization EL+swab packing/sesection--not HA ligation 2.stable -elective Sx

1 0 1 0 1 0 1 0

0=stage1, 1-2=stage2, 3-4=stage3 BCLC stage 0 a b c d PST 0 0 0 1-2 3-4 T single<2cm single<=5cm 3,<3cm/each large,multi vv invade extrahepatic any child a a-b a-b a-b c

TNM T1-single <2cm T2-single <2cm+vv invade single >2cm+no vv invade multi 1 lobe <2cm+no vv invade T3-single >2cm+vv invade multi 1 lobe <2cm+vv invade multi 1 lobe >2cm T4-multi >1 lobe+HV/PV invade N1-LN+ve 1 2 3a 3b 4a 4b T1 T2 T3 T1-3 T4 anyT N0 N0 N0 N1 anyN qnyN M0 M0 M0 M0 M0 M1

Liver short note by S.Wichien (SNG KKU)

HCC variant 1.Fibrolamellar variant of HCC -f=m -20-40 yr (25yr) -not asso HBV/HCV -no cirrhosis -well circumscribe -CT--central scar+calcification -AFP+ve 5% -better prognosis Tx 1.sx resection--resectibility 95% 2.CMT--5FU+IF alpha 2b 2.angiosarcoma -tumor of liver blood vv -60-70yr -chemical carcinogen--vinyl chloride -aggressive--6 mo -muli foci,bilat 3.hepatoblastoma -2yr -most common 1liver tumor in child -AFP+ve Hepatic resection Rt trisegmentec--80% 4 5 Rt hepatectomy--65% 5 6 Rt ant sectionectomy 5 8 Rt post sectionectomy 6 7 Lt trisegmentec 23 Lt hepatectomy--35% 2 3 Lt lat sectionectomy 23 Lt medial sectionectomy 4 Central hepatectomy 45 Hepatic resection 1.pre-op assess A.pt asses -ECOG 0-5 B.tumor assess Resectability -no extrahepatic metas -anatomical resect--no bilobe -no main PV,IVC thrombus -adequate liver fxn reserve C.liver assessment FLR 20% (if cirrhosis >40%) -fxn--child C--not sx -CT volumetry -ICG clearance :normal residual <10% at 15m ICG15<10%--3segment ICG15 10-19%--2segment ICG15 20-29%--1segment ICG15 30-39--free margin ICG>40%--enucleation 2.intraop assessment IOUS -detect tumor<0.5 cm -vv involved -confirm line of resection Liver mobilization Inflow control 1.pringle maneuver--clamp 15m/5m 2.selective intermittent clamp (dissect rt/lt PV,HA) 3.total hepatic vascular occlusion (Heaney technic--inflow+outflow) Outflow control--HV Low CVP -keep CVP 5 cmH2o -stable BP,Uo Liver hanging maneuver -dissect between RHV--MHV -cord tape Parenchymal transection -low tech--tip suction -hi tech :CUSA,harmonic,ligature,waterjet Raw surface mx -complete hemostasis+bilostasis Bile leak testing Drainage -2 drain--rt subphrenic, subhepatic 3.post op care -aware hypogly ,hypoalb, jx

678 78 458 4 8

Liver short note by S.Wichien (SNG KKU)

CHCA -adenoca arising from epi. lining of biliary tree including both intra-extra HD -but from the GB and ampulla are exclude Srinagarind Male - 135:100,000 Female - 43:100,000 Classification -IHD/peripheral CHCA -EHD hilar(43%),middle(12%),distal(20%) LN station1-gr.12 Station2-gr.8,13,17 Gross type 1.mass forming--nodular type 2.infiltrating/sclerose--periductal type 3.intraductal--papillary type 4.mix mass forming/infiltrating (nodular infiltrating type) Symptom -jx(60%) -liver mass (90%of mass=CHCA) Risk -caroli dz -clonorchiasis -choledochal cyst -primary sclerosing cholangitis -nitosamine+OV Staging Intrahepatic CHCA T1-solitary tumor without vv invade T2a-solitary tumor with vv invade T2b-multiple tumor w/wo vv invade T3-perforate visceral peritoneum/ direct invade extrahepatic structure T4-tumor with periductal invasion N1-regional node 1-T1N0M0 2-T2N0M0 3-T3N0M0 4a-T4N0M0, anyTN1 4b-anyT anyN M1 Extrahepatic CHCA T1-confined to bile duct T2-beyond bile duct T3-liver,GB,pancreas unilat.v/a.in liver T4-colon,stomach,duodenum Bilat.v/a.in liver N1-regional node 1a-T1N0M0 1b-T2N0M0 2a-T3N0M0 2b-T1-3N1M0 3-T4N0M0 4-M1

Liver short note by S.Wichien (SNG KKU)

Hilar CHCA Modified Bismuth Corette class I--CHD II--CHD+porta IIIa--CHD+porta+RHD IIIa+--CHD+porta+RHD(2nd br) IIIb--CHD+porta+LHD IIIb+--CHD+porta+LHD(2nd br) IV--CHD+RHD+LHD IVa--CHD+RHD(2nd br)+LHD IVb--CHD+RHD+LHD(2nd br) V--IVa+IVb rt hepatic d. shorter than lt Radical sx -extended hepatectomy -caudate lobectomy -bile duct resection--gross 1 cm -sys.lymphadenectomy 12/8/13 -+/-vascular resection and recons Unresectable Pt factor -unfit,unable tolerate major OR -hepatic cirrhosis Tumor related factor -encase main portal v proxi.bifurcate -extend to bilat 2nd biliary -extend to unilat 2nd biliary +contralat portal v.encase +contralat atropy Metastasis -lung,liver,peritoneal -metas to LN beyond hepatoduo lig Pre-op percu transhepatic biliary drain -dec bilirubin -tx cholangitis -inc liver hypertrophy when PVE -assess proximal margin -inc resectable -easier sx Pre-op PVE -normal liver--can remnant 20% -OJ--can remnant 40% 1.transileocolic PVE(TIPVE) 2.percu transhepatic PVE(PTPVE) CHCA Tx Principle of Tx -complete anatomical liver resection -remove all regional LN Sx curative resection Hilar lesion -hilar resect + hepatectomy + sys.lymphadenectomy 12/8/13 -caudate lobe resection Distal lesion -pancreaticoduodenectomy + sys.lymphadenectomy 12/8/13/17 Diffuse lesion -hepaticopancreaticoduodenectomy + sys.lymphadenectomy 12/8/13/17 Free sx margin -Rules of thumb=1cm -frozen section free -anatomical liver resection Post op c/p -hemorrhage -pleural effusion -intra abdo collection/abscess -liver insuff/failure -bile leakage -biliary sepsis Prognosis Factor -tumor staging -sx resection (R0>1>2) -tumor free margin -gross pathology (intraductal--good prognosis) 80% recurrence in 1yr almost recurrence in 2yr F/u -after sx 2 wk -q 1mo until 6 mo -q 3 mo until 2 yr -q 6-12 mo

Liver short note by S.Wichien (SNG KKU)

Liver metastasis 1.colorectal liver metas I/C -complete resection of 1ds -metas nodule = R0 resection -liver remnant >30% or 2 segment -no extrahepatic ds, except :resectable/ablatable lung metas :resectable/ablatable isolate extrahepatic--spleen, adrenal :local direct extent of liver metas diaphragm,adrenal that can resect C/I -liver remnant <30% -celiac node +ve -can't be clear all metas ds 2.neuroendocrine liver metasNELM Ix=CT/MRI,SRS No extrahepatic ds resectable -hepatic resection -pre-op chemoembolize if large T unresectable carcinoid,small,favor feature -liver transplantation non-carcinoid,large,unfavor feature -chemoembolize large T -radiofrequency ablation (<3cm) -systemic therapy c somatostatin Extrahepatic ds -chemoembolize large T -radiofrequency ablation (<3cm) -systemic therapy c somatostatin Milan criteria of NELM for LT -confirm carcinoid histo -1tumor drain by portal v -<50% hepatic replace by tumor metes -good rxn/stable ds in pretransplant -absence of extrahepatic ds 3.non-colorectal,non-neuroendocrine -no extrahepatic ds -single nodule -ds free interval >1yr