If you have been detected to have a tumour in the liver, it will need a detailed evaluation (tests). The tests consist of blood tests, some specialised blood tests including tumour markers and a detailed imaging study in the form of a computerised tomography (CT scan) and / or a PET-CT scan. Sometimes a MRI of the liver may also be required for additional information. The above tests in addition to the clinical history and previous medical history will help in determining the nature of the tumour , stage and define further treatment.

Not all liver tumours need to be biopsied. Hence biopsy of the tumour is not mandatory to decide its presence. A good radiology scan is sufficient to make a diagnosis. Whether its a primary liver cancer (Hepato Cellular Carcinoma) or secondaries (Metastases - spread of cancer to the liver from other sites), biopsy may not be required. Need for a biopsy is individual and is decided by your treating physician / specialist.

Upon detection and diagnosis, the treatment will depend on the stage. Generally speaking, tumours which are restricted to part of the liver, would be eligible for potential cure through a liver operation - hepatectomy. In this procedure, the surgeon removes the part of the liver bearing the tumour with surrounding normal liver. Done in experienced centres by experienced surgeons, the procedure is safe and results in potential cure. The operation can be performed both for primary liver tumours and for secondary liver tumours also - liver metastases.

Depending on the case, a combination of chemotherapy may be required along with surgery. This is specially so in cases wherein the cancer to the liver has spread from another source (eg: intestinal {colon cancer}) . At times chemotherapy may initially be required to downstage (make the cancer smaller) prior to surgery. Chemotherapy in such patients may also be required following surgery.

Surgery, where possible is the best and defined treatment for liver tumours - whether primary or metastatic. However not all patients can have surgery. In such situations, alternative therapies including thermal ablation - burning and destroying the tumour with heat (radio frequency ablation or microwave ablation) or embolisation - instillation of chemotherapy agents into the tumour via angiography may be done. This can be combined with other treatments including chemotherapy and some patients would still qualify for surgery after these treatments.

A regular and close follow up will be required. Apart from clinical evaluation - some blood tests and periodic and regular surveillance scans will be required to monitor and see if the cancer is recurring.

The commonest reason for a liver operation is usually when the liver is affected with a tumour (cancer). The tumour in the liver can be arising within the liver : Hepato Cellular Carcinoma (HCC) or Cholangiocarcionoma - or may have reached the liver via the blood stream from outside of the liver - usually from the colon (intestines).

Cure of these cancers can only be achieved through a liver operation and variable parts of the liver will need removal depending on the location, size and number of the tumours in the liver. This information will be given to you by your treating liver surgeon.

Sometimes, even non tumour conditions of the liver will compel performing a liver operation - eg: cysts / infection in the liver.

Biliary cancers (Hilar Cholangiocarcinoma) - tumours arising in the bile duct just outside of the liver, will also need removal of the part of the liver to clear the tumour completely.

Planning for liver surgery is done based on detailed evaluation of the CT scan and MRI. on CT scan accurate depiction of the area of the liver to be removed (tumour bearing area with surrounding normal liver) is mapped out and the surgeon decides the nature of the operation. Along with removing the part of the liver - attention is also paid to the amount of liver that will be left back . Liver is an unique organ in the human body with an unparalleled capacity to regenerate. The regenerative capacity of the liver allows is to grow back to near normal size and support body function . The process of regeneration usually takes 4-6 weeks after liver surgery, when visible changes in the growth of the liver can be appreciated on imaging. Upto 65-70% of the liver can be removed in healthy individuals. However in patients wherein there is underlying liver disease, at least 40% of the liver has to be left back and lesser amount of liver therefore can be removed. Calculation of these liver volumes is vital in planning liver surgery and this is done on the basis of a very good quality CT scan.

A CT volumetric will help define the amount of liver that will be left back (remnant liver). If the volume of the liver being left back is small and would be insufficient for healthy life, there are ways to expand the size of the remnant liver prior to surgery. Since the liver has a dual blood supply, blocking blood flow to a part of the liver, diverts the same to the opposite part of the liver ( which will be left back post surgery ) , enabling it to grow (hypertrophy). This allows for the increase in the size of the remnant liver , thereby making surgery possible and safe, reducing the risk of complications. The procedure of portal vein embolisation (PVE) is usually done by the interventional radiologist and is a safe procedure (lasting about 30-40 minutes), done under local anaesthesia and involves about 2 days stay in hospital. The process of liver hypertrophy (growth) following PVE takes about 3-6 weeks thereafter and surgery for removal of tumour can usually be performed after this time (while the liver growth is achieved).

Liver surgery is done either through open  (cut on the abdomen) or minimally invasive  - key hole technique (laparoscopic or robotic) 

The method of performing the surgery is dependant on the location of the tumour, the type of liver operation required and preference of the operating surgeon. 

Open surgery has been the conventional method of performing these complex operations.

Recovery after liver surgery happens quickly. You will be allowed to have a diet in 1-2 days time and will slowly have removal of your tubes and lines. Usually most patients would be okay for discharge in about a weeks time following operation. Patients are usually admitted into ICU for 1-2 days following surgery, before being shifted to the regular wards.

On follow up the histology - pathology report will be reviewed by your doctor with you and any further treatment / action needed will be discussed.

In most cases, following successful surgery for liver tumours - primary or metastatic, usually no further treatment is required as surgery by itself achieves the goal of cure

Summary

• Liver surgery is safe and can be done effectively in patients where required
• The surgery needs to be planned and executed carefully after careful evaluation
• Liver surgery needs to be performed in experienced centres , with good infrastructure and by trained and specialist liver surgeons in a team approach.

Liver transplantation is required for all patients who have end stage and irreversible liver disease, for which there is no medical or any other treatment. Liver transplantation is the only treatment without which they would unfortunately succumb to their disease. End stage liver disease is referred to as Cirrhosis.

Commonest causes of Cirrhosis include

• 1. Alcohol damage to liver
• 2. Hepatitis B
• 3. Hepatitis C
• 4. NAFLD / NASH Cirrhosis : damage from fatty liver and fatty liver disease leading to cirrhosis and end stage liver disease
• 5. Primary Scelorosing Cholangitis ( PSC )
• 6. Primary Biliary Cholangitis / Cirrhosis ( PBC )
• 7. Wilson disease
• 8. Auto Immune Hepatitis ( AIH )

Liver transplantation is also done for selected cases of Liver Cancer - Hepato Cellular Carcinoma.

patients with end stage liver disease need a transplant. End stage liver disease - cirrhosis results and causes multiple complications within patients. These include

• Bleeding - gastro intestinal bleeding- vommiting of blood or passage of blood in stools
• Jaundice - yellowing of the skin
• Hepato renal syndrome - progressive cirrhosis and jaundice results in kidney damage and at times can be irreversible
• Ascitis- formation and development of water / fluid inside the abdomen
• Increased susceptibility to infections
• General deterioration in overall state of health

Patients with cirrhosis usually have multiple admissions into hospitals , due to direct or indirect complications related to cirrhosis and liver disease.

This will be done based on

• Clinical symptoms and investigations
• Based on the blood tests severity scores are calculated - MELD / MELD- NA/ Child Pugh Scores - these determine the severity of liver disease and need for transplant . generally higher the score, more severe the liver disease . this predicts the development of complications from liver disease and predict mortality from liver disease
• Ultrasound , CT scan and MRI will be required to determine the condition of the liver

A blood group match is mandatory for a recipient to receive a liver transplant from a blood group matching donor.

Blood Type Compatibility Chart
Blood Type	Can Receive liver from :	Generally can donate a liver to O, A, B, AB
O	O	O, A, B, AB
A	A, O	A, AB
B	B, O	B, AB
AB	O, A, B, AB	AB

• The liver is harvested along with other organs ( heart / lungs / kidney / pancreas ) from a brain dead donor
• The donor is identified in an ICU and once found fit his organs can be harvested
• Depending on the blood group match and size they can be implanted into an appropriate recipient
• Patients receive the entire ( full liver ) from the donor

Part of the liver ( either the right or the left side -about 50-60% ) is surgically removed from a related living donor and implanted into the recipient. The donor is carefully chosen from within the family / extended family of the recipient and after going through a series of checks , selected as being able to donate. The operative procedure involves

• Removal of the part of the organ from the donor- usually for adults the right part of the liver with its blood vessels is removed
• The remaining liver within the donor functions perfectly well
• The liver has an unparalleled and an unique regenerative capacity which quickly allows for the growth of the remainder in the donor
• The implanted liver within the recipient also grows enabling healthy liver function.

Gall bladder operation – cholecystectomy is a safe and very commonly performed operation. The reported complication rate of injury to the bile duct or other major surrounding structres is reported @ 03.%( 3 in a 1000).

Some shoulder tip discomfort may be present after a key hole operation , which settles within a few hours of operation.

At discharge

You will be discharged in 1-2 days after a straightforward gall bladder operation .at discharge you would be given some basic medications and pain killer.Usually a follow up with the treating surgeon is required in 1-2 weeks time.

At discharge one would be independent and able to do ones regular activities.

A rest for 1 week is usually recommended after laparoscopic surgery following which one can usually return to work , after consultation with your treating surgeon. ( 2 weeks if you had an open operation ).

There are no long term side effects or complications of removing the gall bladder and patients return to their normal routine life as when healthy.

• It may not produce any symptoms and detection of liver cancer : HCC , may be an incidental discovery on a ultrasound or a scan done for some other reason
• Sometimes it may be detected on regular scanning on ultrasound or CT scan, in patients with cirrhosis. Hence screening ultrasonography is recommended in patients with cirrhosis.
• Abdominal pain, loss of appetite, weight loss, feeling of heaviness in the abdomen are other symptoms attributable to development of cancer within the liver

You will need some detailed investigations including blood tests such as AFP ( tumour marker ) – specific for liver cancer and liver function tests – apart from blood count and kidney functions. These give an idea about the overall health of the liver and help in planning treatment. In majority of patients with HCC – the tumour marker : Alpha Foeto Protein ( AFP ) is elevated.

Upon initial scanning - some more specific scans and investigations may be required such as MRI scan and PET-CT scan in addition to the CT scan . the purpose of these scans to precisely map out the extent of disease and stage the tumour completely which helps decide treatment . Treatment is dependant on

• Size of the tumour
• Number of tumours within the liver
• Condition of the background liver - Cirrhosis and liver function has it invaded the major blood vessels leading into the outside the liver
• Has the tumour spread anywhere else – elsewhere in the body or within the liver or
• General health / performance status of the patient.

Depending on the above –one of the following is chosen.

This is done for patients with small tumour and early disease with well preserved liver function. Surgery involves removal of the part of the liver bearing the tumour along with surrounding normal liver. Surgery can be done through the open or minimally invasive approach ( laparoscopic or robotic )The procedure is potentially curative .

Liver transplantation is offered to select patients with liver tumours- HCC , where the tumour is limited to the liver and the liver is cirrhotic. Liver transplantation removes the entire diseased liver of the patient along with the tumour. The procedure involves implanting a new healthy liver either from a deceased ( brain dead / cadaveric donor ) or a living donor (living donor liver transplant - LDLT ).

This involves destruction of the tumour with heat – and high electricity current. The tumour gets destroyed by the heat generated.

This involves injecting chemotherapy through the blood vessel supplying the liver tumour. An angiography of the liver is done and the blood vessel supplying blood to the tumour is identified and blocked . Chemotherapy is also instilled directly into the tumour. Cutting off blood supply to the tumour, results in stopping the growth of the tumour.

The procedure is similar to above , but internal radiation is delivered to the portion of the tumour bearing the tumour thereby causing tumour destruction . The procedure is specialised and can only be done in select centres.

In advanced cases, where in no other treatment is feasible / possible, usually chemotherapy is given. This includes a range of medications and usually oral chemotherapy tablets.

There are several causes of jaundice but broadly these are classified into medical causes- treated by medications / drugs and surgical causes – which need an operation .

• Infection within the liver – from viruses : Hepatitis A, B, C, non A- non B, Hepatitis E
• Liver damage from medications , chemicals and drugs
• Inborn diseases within the liver such as : Primary Biliary Cholangitis : PBC, Primary Sclerosing Cholangitis : PSC , Auto Immune Hepatitis : AIH
• Cirrhosis of the liver : when the liver is significantly damaged beyond repair it is usually referred to as Cirrhosis . A variety of conditions when not controlled can irreversibly damage the liver to cause Cirrhosis – notably among them are
  • • Hepatitis B
  • • Hepatitis C
  • • Alcohol induced liver damage
  • • Non Alcoholic Fatty Liver Disease ( NAFLD ) – this occurs due to obesity and excessive fat within the liver. In obese individuals with diabetes ( metabolic syndrome ) , excessive fat accumulates within the liver leading to a fatty liver , which causes inflammation leading to cirrhosis . In modern times this is the leading cause of cirrhosis and reason of liver transplantation .


In the above cases , jaundice settles with medical treatment of the liver , with medications and treatment of infection .

This occurs when there is an obstruction to the passage of bile from the liver to the duodenum ( intestine ) , which leads to accumulation of bile within the liver. The bile pigment ( bilirubin ) then crosses over in excess amounts into the blood stream leading to

• Yellowing of the skin
• Yellowing of the eyes
• - Dark urine ( high coloured urine ) – as extra bilirubin is eliminated by the kidneys through urine
• - Itching of the skin – since bilirubin gets deposited in the skin
• Pale stools – since bile cannot be delivered into the intestines , hence leads to pale stools.

Normal Anatomy and Physiology
In health – bile produced by the liver smoothly flows down the bile duct ( tubes which drain the bile ) into the intestine ( duodenum ) . On the way the bile is temporarily stored in the gall bladder. When food reaches the intestine , the gall bladder contracts propelling the bile into the intestine , where it mixes with the food and along with enzymes from the intestine leads to digestion.
Obstruction of the bile duct occurs due to
Gall stone disease – stone from the gall bladder can compress and impinge the bile duct resulting in obstruction of bile flow. The stone can slip into the bile duct leading to obstruction of the bile .

Other reasons for obstruction include – tumours/ cancers arising from the

• Liver - hepato cellular carcinoma
• Gall bladder
• Bile duct – cholangiocarcinoma
• Pancreas- cancer of the head of the pancreas, periampullary region or duodenum

• 1. basic blood tests – blood counts / liver function tests are required along with some other blood tests
• 2. Ultrasound/ CT scan and MRI / MRCP
  • These tests help us define and understand the reason for the blockage – whether due to stone or tumour / cancer.
  • In event of cancer they help to understand the nature of cancer, stage the cancer completely and decide and plan the treatment , which in most instances means a surgery
• 3. Endoscopy and ERCP / EUS
  • Endoscopy and ERCP will be required at times to
  • 1. Obtain further information of the blockage
  • 2. Obtain tissue for diagnosis
  • 3. Insert a plastic stent or metal stent initially to reduce the extent of jaundice before surgery
  • 4. Remove stones blocking the bile tubes and clear the passage so that removal of the gall bladder / cholecystectomy can be done

If the jaundice is due to gall stones, a cholecystectomy – removal of the gall bladder is required. This is usally done laparoscopically – key hole .the operation is straightforward and most patients are discharged within a day or two of the surgery.

• 1. Liver resection – removal of part of the liver for treatment of liver cancer, metastases ( cancer spread to the liver from elsewhere )
• 2. Removal of the liver and the bile duct – for hilarcholangiocarcinoma ( tumour blocking the confluence or union of the bile ducts ) at the base of the liver
• 3. Whipplespancreaticoduodenectomy – major surgery to remove cancers involving the head of the pancreas, bile duct , periampullary region and duodenum

• 1. metastases to the liver is not an unknown fact
• 2. almost 40-50% of all patients with cancer ( of all types ) will form metastases into the liver at some stage of their disease
• 3. metastases to the liver may be present at diagnosis of the primary cancer ( synchronous metastases ) or may come up later ( metachronous )
• 4. development of liver metastases , is dependant on the nature of the primary cancer , its biological behaviour , type, etc
• 5. the commonest sites of metastatic spread to the liver are from the lung , breast and intestine ( colorectal ) cancer

of all the types of metastatic cancer to the liver – cancer spread to the liver , from the colon and rectum has a special place , as these cancers can be very successfully and effectively treated , with potential for cure . These tumour have a potential to spread to the liver due to the portal venous circulation – the blood that is carried to the liver from the intestine via the portal vein .

• 1. This is usually detected on regular scanning that patients with cancer undergo. Eg: a patient who had had a bowel operation for cancer – needs a scan every few months / regular basis . The spread of the cancer is visible and picked up on the scan either Ultrasound or CT scan
• 2. Patients may present with some symptoms – pain , swelling and this leads to detection of tumour spread into the liver through a scan which is subsequently done
• 3. Blood tests eg : CEA – which is specific blood test for patients with colon cancer . the level of CEA may show an increasing trend during the follow up period for patients with colon cancer. Subsequent investigations can show the presence of tumour spread into the liver ( liver metastases )

Upon initial scanning - some more specific scans and investigations may be required such as MRI scan and PET-CT scan in addition to the CT scan . the purpose of these scans to precisely map out the extent of disease and stage the tumour completely which helps decide treatment . Treatment is dependant on

• Size of the tumour
• Number of tumours within the liver
• Condition of the background liver
• Has the tumour spread anywhere else – elsewhere in the body or within the liver or has it invaded the major blood vessels leading into the outside the liver
• General health / performance status of the patient.

Depending on the above –one of the following is chosen

1. Surgery :- HEPATECTOMY - removal of the liver SURGERY IS POTENTIALLY CURATIVE FOR PATIENTS WITH LIVER METASTASES ESPECIALLY LIVER METASTASES FROM INTESTINAL ( COLON AND RECTAL CANCER ) AND SHOULD BE DONE WHEREVER POSSIBLE. Surgery involves removal of the part of the liver bearing the tumour along with surrounding normal liver. Surgery can be done through the open or minimally invasive approach ( laparoscopic or robotic )The procedure is potentially curative.

The amount of liver that requires removal may be small – minor hepatectomy or large- major hepatectomy . This is dependant on the extent of disease and location within the liver.

2. Ablation –Radio frequency Ablation : RFA or Microwave Ablation : MWA This involves destruction of the tumour with heat – and high electricity current. The tumour gets destroyed by the heat generated.

3. TransarterialChemoEmbolization : TACE Chemotherapy is an intergral and a very important part of management of metastatic cancer.

Chemotherapy is very effective and successful in the management of liver metastases.

Chemotherapy

• 1. Allows for reduction of tumour burden in the liver
• 2. Prevents further spread of the tumour elsewhere
• 3. Makes unresectable and borderline tumours in the liver resectable and amenable to surgery
• 4. Chemotherapy is either given prior to surgery or may be given after surgery as well
• 5. Chemotherapy is not always required .in cases where the tumour is small , and amenable to straight liver surgery , chemotherapy may not be required.

• 1. Jaundice - yellowing of the skin , secondary to a tumour in the head of the pancreas . the tumour causes obstruction to the bile duct , causing obstruction to the flow of bile into the intestine leading to jaundice
• 2. weight loss
• 3. loss of appe3te
• 4. abdominal pain
• 5. vommiting and general disturbance of health

You will need some detailed investigations including blood tests such as CEA , CA19-9 ( tumour marker ) – specific for pancreas cancer and liver func3on tests – apart from blood count and kidney functions. In majority of patients with pancreas cancer– the tumour marker : Ca 19-9 is elevated.

Upon initial scanning - some more specific scans and investigations may be required such as MRI scan and PET-CT scan in addition to the CT scan . the purpose of these scans to precisely map out the extent of disease and stage the tumour completely which helps decide treatment . Treatment is dependant on

• Size of the tumour
• exact location of the tumour
• relationship of the tumour to the surrounding structures specifically the vital blood vessels in the close vicinity of the pancreas
• Has the tumour spread anywhere else – elsewhere in the body or to the liver or has it invaded the major blood vessels in the vicinity of the pancreas
• General health / performance status of the patient.

Upon initial scanning - some more specific scans and investigations may be required such as MRI scan and PET-CT scan in addition to the CT scan . the purpose of these scans to precisely map out the extent of disease and stage the tumour completely which helps decide treatment . Treatment is dependant on

• Size of the tumour
• Number of tumours within the liver
• Condition of the background liver
• Has the tumour spread anywhere else – elsewhere in the body or within the liver or has it invaded the major blood vessels leading into the outside the liver
• General health / performance status of the patient.