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liver is also carefully inspected for potential bile leaks that
can be oversewn. The use of a sealant agent can be
considered to minimize postoperative biliary leaks.
Placement of a drain near the cut edge of the liver may be
considered for observation and potential treatment of a
postoperative biliary leak (Table 2).
TABLE 2. Key Steps to Laparoscopic Liver Resection
Open Resection
In general, the technique used for open resection is similar
to that of a laparoscopic resection. Placement of an
epidural for postoperative pain management should be
considered preoperatively. With the patient in the supine
position, a right subcostal incision with upper midline
extension is made. This allows adequate exposure to the
left and right lobes of the liver as well as exposure to the
suprahepatic vena cava and the lower abdomen if a Rouxen-Y hepaticojejunostomy needs to be constructed. Prior to
placing a fixed retractor, the round and falciform ligament
should be divided and any adhesions of the liver to the
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anterior abdominal wall should be mobilized to avoid
tearing of the hepatic capsule leading to bleeding. As
described in the laparoscopic approach, the abdomen and
the liver are inspected, the lobe of the liver to be resected
is mobilized, and an intraoperative liver ultrasound is
performed. The liver resection itself is performed using
similar techniques to divide the liver parenchyma.
Inspection of the cut edge of the liver is also carefully
performed to help avoid postoperative bile leaks. The
abdomen is closed in the standard fashion, and a drain
may be placed to diagnose and treat potential
postoperative bile leaks (Table 3).
TABLE 3. Key Steps to an Open Liver Resection
Special Intraoperative Considerations
Several unexpected findings or complications may be
encountered. The liver mass may ultimately be identified as
a metastasis from another primary source. In this setting,
biopsies to obtain an accurate diagnosis should be
obtained and intraoperative staging should be performed. If
appropriate, proceeding with resection of the liver tumor
along with the primary tumor can be considered. This may
be encountered in the setting of a colorectal malignancy or
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a neuroendocrine tumor. Additional hepatic lesions may
also be identified that were not identified on preoperative
imaging. If possible, consideration can be given to
resection of these lesions as well. If there is concern for
leaving an inadequate remnant, these lesions may also be
treated using radiofrequency or microwave ablation.
During resection, preparation should always be made
for unexpected hemorrhage. This includes preoperative
communication with the anesthesia team to insure that
adequate vascular access is present. Depending on the
location of bleeding, control can often be obtained with
manual compression or packing. A Pringle maneuver can
also be used. In cases of extreme bleeding, total vascular
isolation of the liver can be obtained by performing a
Pringle maneuver as well as clamping the vena cava in a
supra- and infra-hepatic position.
Postoperative Management
While most patients undergoing liver resection do not
require treatment in an ICU, a low threshold for ICU care
should be maintained if there is any concern for bleeding,
hepatic insufficiency, need for observation of renal function,
or other concerns based on the patient’s comorbidities.
The patient’s volume status, hepatic, and renal function
should be closely monitored and managed in the
postoperative period. Pain can be controlled with either
patient-controlled analgesia using intravenous opioids or
an epidural. While an ileus may occur, this is usually limited
if the majority of the surgical procedure occurred in the right
upper abdomen; therefore, a postoperative nasogastric
tube is usually unnecessary, and oral intake can be
advanced relatively quickly. If bile is not present within the
closed suction drain, the drain can be removed within
several days postoperatively. If bile is present within the
drain and is at a relatively low volume, the drain should be
left in place and can be removed as an outpatient once the
bile leak has resolved. If a high-volume leak is present,
placement of an endobiliary stent to decompress the biliary
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tree may be necessary.
Case Conclusion
The patient undergoes successful laparoscopic
resection of the largest left lobe liver mass using a
hand-assisted technique (Figure 3) and is discharged
from the hospital without complications on
postoperative day 4. The final pathology returns
confirming a giant cavernous hemangioma. Two years
later, she remains pain free.
FIGURE 3 • Laparoscopic resection of a liver mass using a hand-assisted
technique. A: Laparoscopic image of a 15-cm left lateral segment hepatic
hemangioma. B: Transection of the liver parenchyma using an ultrasonic
dissector. C: 15-cm hemangioma removed from a 7-cm laparoscopic hand
port incision.
TAKE HOME POINTS
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• Modern imaging has led to increased detection of
incidental liver masses.
• In otherwise healthy individuals, most incidental masses
are benign.
10% of indeterminant lesions may be malignant.
• Better definition of radiologic characteristics and clinical
features has led to
Accurate radiologic diagnosis
Reduced need for biopsy
• Management ranges from observation to surgical
resection.
SUGGESTED READINGS
Buell JF, Cherqui D, Geller DA, et al. The international position on
laparoscopic liver surgery: the Louisville statement, 2008. Ann Surg.
2009;250:825–830.
Clavien PA, Petrowsky H, DeOliveira ML, et al. Strategies for safer liver
surgery and partial liver transplantation. N Engl J Med. 2007;356:1545–
1559.
Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative
outcome after hepatic resection: analysis of 1,803 consecutive cases
over the past decade. Ann Surg. 2002;236:397–406; discussion 406–
407.
Koffron AJ, Auffenberg G, Kung R, et al. Evaluation of 300 minimally
invasive liver resections at a single institution: less is more. Ann Surg.
2007;246:385–392; discussion 392–394.
Yoon SS, Charny CK, Fong Y, et al. Diagnosis, management, and
outcomes of 115 patients with hepatic hemangioma. J Am Coll Surg.
2003;197:392–402.
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28
Liver Mass in Chronic Liver
Disease
CHRISTOPHER J. SONNENDAY
Presentation
A 59-year-old man with cirrhosi s secondary to chronic
hepatitis C infection undergoes an annual screening
liver ultrasound. A 2.5-cm solid, well-circumscribed
mass in the posterior aspect of the right hepatic lobe is
identified. The liver is noted to be nodular in
appearance.
Differential Diagnosis
While the differential diagnosis of a liver mass is broad and
includes infectious lesions as well as both benign and
malignant lesions, a new mass detected in a patient with
chronic liver disease should be presumed to be a primary
hepatic malignancy until proven otherwise. Hepatocellular
cancer (HCC) is the leading cause of death in clinically
compensated cirrhotics, and individuals with cirrhosis
secondary to viral hepatitis have a 10% to 20% 5-year
cumulative risk of developing HCC. For this reason, HCC
screening has been shown to have a profound impact on
HCC-related mortality among cirrhotics. The American
Association for the Study of Liver Disease currently
recommends serial hepatic ultrasound and serum alphafetoprotein (AFP) every 6 to 12 months in at-risk
populations (e.g., any patient with cirrhosis).
While the evaluation of a liver mass in a patient with
cirrhosis is aimed at diagnosing HCC, other etiologies may
be considered. Regenerative nodules may appear masslike and may represent an early stage in the development
of hepatocellular neoplasms. Similarly, adenomas may be
diagnosed in patients with chronic liver disease. These
lesions are at high risk for malignant transformation,
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especially in this population, and imaging characteristics
alone may be insufficient to distinguish hepatic adenomas
from well-differentiated HCC. Thus, surgical resection or
ablative therapies should be considered in adenomas.
Other benign lesions that typically do not require surgical
resection include focal nodular hyperplasia (FNH) and
hemangioma.
Patients with chronic liver disease and cirrhosis are
also at increased risk for developing intrahepatic
cholangiocarcinoma, the other major primary hepatic
malignancy. While classically described in patients with
cholestatic liver disease (e.g., primary sclerosing
cholangitis), patients with cirrhosis are also more prone to
developing cholangiocarcinoma and mixed tumors that
include both HCC and cholangiocarcinoma cell types.
Workup
Any mass lesion suspected on screening ultrasound should
be further i nvestigated with contrast-enhanced crosssectional imaging, either computed tomography (CT) or
magnetic resonance imaging (MRI). MRI appears to be
slightly more sensitive and specific than CT, and particular
imaging characteristics—arterial phase enhancement with
early washout of contrast on the delayed phases of the
scan—are considered diagnostic for HCC (Fig ure 1).
Contrast-enhanced MRI may provide definitive diagnosis of
FNH and hemangioma as well. Image-guided
percutaneous biopsy is reserved for cases in which the
diagnosis is in doubt following adequate imaging or in
cases where it is thought to change management based on
clinical suspicion.
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FIGURE 1 • MRI of hepatocellular carcinoma, demonstrating characteristic
enhancement on arterial phase imaging (left panel) with washout of
contrast on delayed-phase imaging (right panel).
Once the diagnosis of HCC is established by imaging
or biopsy, the choice of appropriate therapy is made based
upon tumor burden, severity of underlying liver disease, and
patient performance status. Staging evaluation should
include measurement of serum AFP and chest CT. Bone
scan may be appropriate when clinically indicated by
symptoms or suspicion on cros-ssectional imaging.
Evaluation of underlying liver function and synthetic
reserve is critical to providing safe treatment for HCC.
While multiple clinical classification systems exist to predict
severity of liver disease, the Child-Turcotte-Pugh (CTP)
classification may be the simplest and most helpful (Table
1). Consensus exists that CTP class C patients should not
undergo hepatic resection due to excessive perioperative
mortality, and CTP class B patients should only be
considered for minor hepatic resections (resection of two
or fewer Couinaud segments) when they have excellent
performance status. The evaluation of CTP class A patients
for hepatic resection is more difficult, as these patients can
vary substantially in their risk of perioperative mortality and
postoperative liver failure.
TABLE 1. The CTP Classification of Liver Disease Severity
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CTP class A patients with overt evidence of portal
hypertension are generally considered suboptimal
candidates for hepatic resection. Clinical signs of portal
hypertension, such as a history of variceal hemorrhage,
esophageal or gastric varices on upper endoscopy, visible
upper abdominal varices on cross-sectional imaging, or
grossly apparent ascites are all contraindications to
resection. Thrombocytopenia is another critical clinical
indicator of surgical risk with hepatic resection, reflecting
the hypersplenism of advanced cirrhosis and portal
hypertension. A platelet count under 100,000 is considered
a contraindication to major hepatectomy.
A number of quantitative liver function tests have been
investigated to assess hepatic reserve prior to hepatic
resection, including indocyanine green (ICG) clearance,
galactose elimination capacity, and technetium-99m
galactosyl human serum albumin scan, among others. The
ICG clearance study is the most commonly used
internationally, though it is not commonly used or available
in the United States. Many surgeons use volumetric
assessment as a proxy for hepatic reserve. This technique
relies on the use of manual or automated serial
measurement of cross-sectional liver volumes produced
from a thin-section helical CT scan. The volume of the liver
segments to be preserved following resection is then
divided by the total estimated liver volume, which produces
a percentage of future liver remnant (FLR) volume. In
patients with normal liver parenchyma and function, an FLR
of 25% to 30% is considered adequate, if two contiguous
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Couinaud segments are preserved. In patients with
cirrhosis, an FLR of 40% to 50% is desired.
Presentation Continued
In the present case, contrast-enhanced MRI reveals
arterial phase enhancement with delayed phase
contrast washout of a 2.5-cm solitary lesion in segment
6 of the right hepatic lobe. Chest CT shows no
evidence of metastasis. The patient is active and
independent in his activities of daily living and works
full-time. He has no history of ascites or hepatic
encephalopathy. Upper endoscopy shows no
esophageal varices. Laboratory evaluation reveals an
albumin of 4.1 g/dL, total bilirubin of 1.1 mg/dL, and a
platelet count of 148,000. CT volumetry suggests that
resection of the posterior sector (segments 6 and 7)
would leave an FLR of 65%.
Diagnosis and Treatment
Treatment options for HCC are diverse and require careful
consideration of both tumor stage and liver disease
severity. Resection offers the best likelihood of survival in
select patients with resectable disease, superior to
nonsurgical therapies with 30% to 70% 5-year survival. In
patients with CTP class B or C liver disease, liver
transplantation may be the more appropriate choice of
therapy. Posttransplant survival has been shown to be
excellent (65% to 80% 5-year survival) when patients are
selected for transplant according to strict selection criteria,
known as the Milan criteria (solitary tumor under 5 cm, or 3
or fewer tumors each under 3 cm). Obviously donor organ
availability and the significant medical risks and costs
associated with liver transplantation limit its expansion to all
patients with HCC.
Among patients with more extensive tumor burden,
and/or decompensated liver disease, ablative therapies
may be considered. Radiofrequency ablation may offer
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