New Advances in the Treatment of Liver Tumors: Laparoscopic Resections
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This document summarizes new advances in laparoscopic resection for liver tumors. It discusses the historical challenges of open liver surgery and improved outcomes with laparoscopic techniques. Specific cases are presented of laparoscopic resection for benign cysts and tumors as well as malignant hepatocellular carcinoma and colorectal cancer metastases. The theoretical advantages and solutions for challenges of the laparoscopic approach are reviewed.
New Advances in the Treatment of Liver Tumors: Laparoscopic Resections
- 1. New Advances in the Treatment of Liver Tumors: Laparoscopic Resections Cancer Care Innovations Dorothy E. Schneider Cancer Center Mills-Peninsula Hospital April 23, 2011 Kimberly Moore Dalal, MD, FACS Surgical Oncology and General Surgery Peninsula Medical Clinic Bruce Allen, MD; Aziz Ahmad, MD; Dirk Baumann, MD; John Beare, MD; Pamela Foster, MD; Stephanie Lin, MD; Andrea Metkus, MD; John Rosenman, MD; Randolph Wong, MD; Albert Wetter, MD
- 2. Historical Perspective “… the liver is so friable, so full of gaping vessels and so evidently incapable of being sutured that it seems impossible to successfully manage large wounds of its substance.” JW Elliot 1897 Liver cancer
- 3. Historical Perspective “… 20% of patients died in the operating room because of exsanguinating hemorrhage… Another 14% died post-operatively as a direct consequence of enormous blood loss during operation…15% died of liver failure caused by technical factors other than hemostasis, including 3 bile duct injuries…” Foster JH, Berman MM. Major Problems in Clincal Surgery 1977;1-342. Liver cancer
- 4. OR Team, Bagram, Afghanistan 2007 Liver cancer
- 5. MASCAL, October 14, 2007 19 Americans injured Liver cancer
- 6. Liver Resection Today Author N Operative Mortality (%) Scheele ‘91 219 6 Rosen ‘92 280 4 Gayowski ’94 204 0 Scheele ‘95 469 4 Nordlinger ’95 568 2 Jamison, ‘97 280 4 Fong ’99 1001 3 Normal livers Liver cancer
- 7. Outline Laparoscopic liver resections for benign and malignant tumors Benign lesions Hepatocellular carcinoma Colorectal cancer metastases Liver cancer
- 9. Benign Hepatic Lesions Liver cancer Tumor Malignant Potential Spontaneous Hemorrhage Focal nodular hyperplasia No No Hemangioma No Rare Cystadenoma Yes No Adenoma Yes Yes
- 10. Case 1: Cystic Lesion of the Liver 51 year old woman 3.5 cm Liver Cyst, Seg 4, first noted on chest CT in 2001 Presented with 3 days RUQ pain RUQ ultrasound (2/07): complex cystic structure of the liver with layering Triple phase liver CT (2/07): Cystic lesion, Seg 4, 6x8x6 cm; Hounsfield units 6 (noncontrast), 11 (iv contrast) Liver cancer
- 11. Ultrasound Complex cystic structure of liver with layering Liver cancer
- 12. Triple phase liver CT: Cystic lesion, Seg 4, 6x8x6 cm Liver cancer
- 13. Case 2: Hepatic Adenoma 43 yo F with incidentally discovered right liver mass detected on CT of chest for workup of cough. AFP and CEA normal. LFTs normal. CT and MRI 4.2x2.1x2.0 cm mass, Seg 7, consistent with a hepatic adenoma. Liver cancer
- 14. Liver cancer Triple phase liver CT: Seg 7, 4x2x2 cm
- 15. Traditional Open “Chevron” Incision Liver cancer
- 16. Exposure in an Open Resection Liver cancer
- 17. Laparoscopic Port Placement for Right Liver Lesions Cho JY, et al. , Arch Surg 2009; 144(1):25-29. Liver cancer
- 18. Laparoscopic View of the Liver Liver cancer Machado MA, et al ., Surg Endosc, 2009; 23:2615-2619.
- 19. Case 2: Hepatic Adenoma, Segment 7 Laparoscopic Resection…9 Months Later Liver cancer
- 20. Established Diagnosis/Staging Fenestration of Simple Cysts Evolving Minor resections (≤ 2 segments) for tumor Major hepatic resections Tumor ablation Laparoscopic Liver Surgery Liver cancer
- 21. Laparoscopic Liver Resection Theoretical Advantages Less post-operative pain Less post-operative morbidity Shorter hospital stay Improved cosmesis Quicker return to normal activity Quicker initiation of adjuvant therapies Liver cancer
- 22. Laparoscopic Liver Resection Theoretical Disadvantages Loss of tactile sense Margins Staging Limited access/instrumentation Exposure Control of major pedicles/hepatic veins Time and money Liver cancer
- 23. Laparoscopic Liver Resection Solutions Loss of tactile sense Margins Staging Laparoscopic Ultrasound Hand-assisted techniques Liver cancer
- 24. Laparoscopic Liver Resection Solutions Limited access/instrumentation Exposure Control of major pedicles/hepatic veins Fear of major hemorrhage Hand-assisted techniques Ligaments intact Improved retractors Harmonic Scalpel Vascular Stapler Ligasure Device Tissuelink Argon Beam Coagulator Water Jet Liver cancer
- 25. Laparoscopic Liver Resection Solutions Time and money Comparison to open surgery in trials Liver cancer
- 26. Segmental resection: 27 pts (61%) 2 7 8 5 3 1 segment: 17 pts (38%) >1segment: 10 pts (22%) Left lateral: 6 pts (13%) Laparoscopic Hepatectomy MSKCC Results (n=44) D’Angelica, MD, et al ., AHPBA 2006 Liver cancer
- 27. 23 pts: Negative margins (100%). No local recurrence. Laparoscopic Hepatectomy MSKCC Results (n=44) Liver cancer D’Angelica, MD, et al ., AHPBA 2006 Benign 21 pts (47%) Malignant 23 pts (53%) 1 tumor 36 pts (81%) > 1 tumor 8 pts (18%)
- 28. Operative Outcome Laparoscopic Hepatectomy MSKCC Results: Comparison to Open Liver cancer D’Angelica, MD, et al ., AHPBA 2006 LLR (n=44) OLR (n=91) p OR time (minutes) 199 161 0.01 Pringle time (minutes) 31 22 0.04 Pringle 45% 75% <0.01 EBL (ml) 161 521 <0.01 Transfusion 2.2% 26% <0.01
- 29. Laparoscopic Hepatectomy MSKCC Results: Comparison to Open Post-operative Outcome Liver cancer D’Angelica, MD, et al ., AHPBA 2006 LLR (n=44) OLR (n=91) p Length of stay (days) 5.1 6.7 <0.01 Morbidity 13% 28% 0.08 Regular diet (days) 3 3 0.7 Oral analgaesia (days) 3.1 3.5 0.1 Mortality 0% 0% 0
- 30. For well-selected patients, laparoscopic liver resection is safe and does not compromise operative or oncologic outcomes. While laparoscopic liver resection is associated with some benefits, these can only be definitively proven in randomized controlled trials. Summary Liver cancer
- 31. Outline Laparoscopic liver resections for benign and malignant tumors Benign lesions Hepatocellular carcinoma Colorectal cancer metastases Liver cancer
- 32. Epidemiology of Hepatobiliary Cancer Estimated U.S. incidence in 2010: 24,120 cases/year 1 Annual incidence of HCC with Hepatitis C cirrhosis is 2-8%, Hepatitis B cirrhosis 2.5%. 18,910 deaths in men and women Jemal A, et al ., CA Cancer J Clin, 2010; 60:27-300. Liver cancer
- 33. Diagnosis and Workup for HCC Often asymptomatic. Nonspecific symptoms: anorexia, weight loss, malaise, upper abdominal pain. Paraneoplastic syndromes: hypercholesterolemia, erythrocytosis, hypercalcemia, hypoglycemia. Physical signs: jaundice, ascites AFP>200 ng/mL + liver mass =HCC Liver cancer Zhang BH et al ., J Cancer Res Clin Oncol. 2004; 130:417-422.
- 34. Child-Pugh Class A Patients are Candidates for Resection Liver cancer Class A = 5-6 points Good operative risk Class B = 7-9 points Moderate operative risk Class C = 10-15 points Poor operative risk 1 2 3 Encephalopathy None 1-2 3-4 Ascites None Slight Moderate Albumin (g/dL) >3.5 2.8-3.5 <2.8 Prothrombin time (sec) 1-4 4-6 >6 Bilirubin (mg/dL) 1-2 2-3 >3
- 35. Case 3: Hepatocellular Carcinoma 74 yo M with Hepatitis C x 30 years from a blood transfusion, treated with interferon for one year Developed pneumonia and asked PCP to investigate for cirrhosis. AFP: 4690. Abd US: 3.4 x 2.4 x 3.1 cm mass, left lateral segment of liver. Triple phase Liver CT: 3.5 x 2.5 cm mass, segment 3. (CT of abdomen and pelvis 3 months earlier negative). Liver cancer
- 36. Triphasic Liver CT: Segment III 3.5 cm mass Liver cancer
- 37. Principles of Surgery for HCC Mortality <5% Five-year survival rates > 50% 70% in patients with early stage HCC and preserved liver function. Recurrence at 5 yrs>75% Careful patient selection: Comorbidities Tumor characteristics Size and function of future liver remnant Liver transplantation for patients meeting UNOS criteria Single lesion < 5cm 2 or 3 lesions < 3 cm Liver cancer
- 38. Case 3: Hepatocellular Carcinoma Laparoscopic resection of segment III Length of stay 5 days Bone metastasis @ 7 mos Liver cancer
- 39. Epidemiology of Colorectal Cancer Estimated U.S. incidence of colorectal cancer: 142,570/year 1 51,370 deaths 50% of patients will be diagnosed with liver metastases Liver resection->long-term survival 5 year survival: 25-58% Surgical techniques Chemotherapy Unresectable->resectable 1 Jemal A, et al ., CA Cancer J Clin, 2010; 60:27-300. 2 http://www.hopkinsmedicine.org. Liver cancer
- 40. Determinants of Outcome for CRC Liver Metastases: Fong Score Extrahepatic disease Positive margins Node (+) colorectal primary Disease-free interval < 1 year More than 1 hepatic tumor Largest hepatic tumor > 5 cm CEA > 200 ng/mL Fong et al Ann Surg 1999;230:309 Liver cancer Fong Y, et al ., Ann Surg. 1999 Sep;230(3):309-318.
- 41. Preoperative Portal Vein Embolization Can Increase the Future Liver Remnant PVE Percent Resection FLR/TLV 0.20 (20%) 1 >40% for cirrhotics, Child’s A 1 Chun YS, et al ., J Gastrointest Surg. 2008 Jan;12(1):123-8. Liver cancer
- 42. >1 cm Margins are Preferred, but > 1 mm Margins are Favorable Multivariate analysis (n=1019) > 1 tumor Size > 5 cm Node positive primary Bilateral resection Margins Margin N (%) Median survival (mo) P Involved/<1mm 112 (11) 30 mos Ref 1 – 10 mm 563 (55) 42 mos <0.01 > 10 mm 344 (33) 55 mos <0.01 1 Are C, et al ., Ann Surg. 2007 Aug;246(2):295-300. Liver cancer
- 43. Summary Laparoscopic liver resections are safe and oncologically sound in highly selected patients in the hands of surgeons with a laparoscopic skill set. Patients with malignant liver tumors (primary or metastatic) can be considered for resection based on tumor characteristics, future liver remnant size and function, and patient comorbidities. Liver cancer
- 45. Radiofrequency Ablation High-frequency alternating current flows from electrical probe through tissue to ground Ionic agitation results in frictional heating and coagulation of surrounding tissue Liver cancer Probe insertion Extension of prongs RF current application
- 46. Radiofrequency Ablation Liver cancer
- 47. Radiofrequency Ablation Pre-ablation 3-days post 2 months post Liver cancer
- 48. Radiofrequency Ablation Advantages Performed percutaneously, laparoscopically, or at laparotomy Low complication rate May be related to size of ablation (<3 cm) Disadvantages Poor performance near blood vessels One probe Many tumors require multiple, overlapping ablations Slow Liver cancer
- 49. Microwave Ablation Theoretical advantages over RFA Larger zone of active heating Possibly better performance near blood vessels Hotter temperature Use of multiple probes Liver cancer
- 50. Microwave Ablation Liver cancer
- 51. Factors Determining Resectability of CRC Mets Fong Score (CRC mets) Fong et al. Ann Surg 1999 • Functional hepatic reserve Child-Pugh score MELD score Volumetric calculations
- 52. Resectability of Colorectal Cancer Metastases Liver cancer
- 53. After portal vein embolization, left liver hypertrophied and right liver atrophied Metastases resected Staged Resections
- 54. Hepatocellular Carcinoma Risk Factors Hepatitis B viral infection Asia and Africa Hepatitis C viral infection Europe, Japan, North America Inherited errors of metabolism Hemochromatosis, alpha 1-antitrypsin deficinecy, Wilson’s disease Autoimmune hepatitis Primary biliary cirrhosis Excessive alcohol intake Aflatoxin exposure Non-alcoholic fatty liver disease Liver cancer
- 55. Margins and HCC Randomized prospective trial 169 patients randomized 2 cm vs 1 cm margin Actual margin 1.9 vs 0.7 cm Well matched Improved survival in wide margin Shi M, et al ., Ann Surg 2007, 245(1):36-43. Liver cancer
- 56. Local Recurrence Rates for RFA Mulier S, et al ., Ann Surg. 2005 Aug;242(2):158-71. Liver cancer
- 57. Liver cancer
Editor's Notes
- #18: Hassan technique- initial supraumbilical port RUQ and LUQ ports to take down omental adhesions Divide gastrohepatic ligament with ligasure Left gastric artery was identified and retracted in an anterior location. Base of celiac plexus was visualized. A 22 g needle was sheathed in a plastic sheath and inserted. Area was aspirated, then injected 15 cc of 50% alcohol on either side of the celiac pelxus. No evidence of hypotension or blood aspiration.
- #27: Technique- do we isolate vasculature or go through parenchyma
- #28: Divide into groups based on margins width- how may > 1cm and how many < 1 cm
- #29: OPERATIVE DETAILS
- #30: SHORT TERM OUTCOME
- #33: Hepatobiliary cancers are highly lethal cancers. 4 million Americans with Hepatitis C 1.5 million Americans with Hepatitis B
- #40: Hepatobiliary cancers are highly lethal cancers. 4 million Americans with Hepatitis C 1.5 million Americans with Hepatitis B
- #51: 5 probes