Partial Hepatectomy for Liver Cancer Treatment

With advances in medical treatments, many people with primary liver cancer can now regain their quality of life through surgery.

A partial hepatectomy involves removing either a small wedge of the liver or, in more extensive cases, an entire lobe. The surgery leverages the liver's remarkable ability to regenerate, enabling it to restore lost mass and compensate for the diseased tissue that has been removed.

This surgery is typically recommended for patients with liver cancer who have:

• Good functional remnant liver volume and are healthy enough to undergo surgery
• Tumors confined to one side or one area and technically removable, that have not spread into major blood vessels or outside of the liver

To determine if a patient is a good candidate for a partial hepatectomy, doctors will perform a thorough medical assessment and imaging studies, such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) with or without angiography. These imaging tests help to visualize tumor size and location and assess tumor invasion into blood vessels. Based on these scans, doctors can evaluate how much liver tissue needs to be removed.

Patients with cirrhosis present a unique challenge for partial hepatectomy. Cirrhosis causes scarring in the liver, reducing its ability to regenerate and increasing the risk of post-surgery complications. For patients with significant cirrhosis, partial hepatectomy may be possible only if we can leave at least 40-45% of liver volume and if they don’t have any symptoms of chronic liver failure (e.g., ascites, confusion, bleeding tendency).

If they have chronic liver failure symptoms or if we can’t leave adequate liver volume, other treatment options, such as non-surgical liver-directed interventions, like ablative or radiation therapy, may be considered. For selective patients with liver cancers, a liver transplant may be an option.

Surgical margin

The goal of partial hepatectomy is to remove as much of the cancerous tissue as possible while preserving enough healthy liver to maintain function. During surgery, some healthy tissue surrounding the tumor, known as the surgical margin, is removed to ensure that no cancerous cells are left behind. While the margin may appear normal to the naked eye, it will be examined under a microscope after surgery. If cancer cells are found in the surgical margin, another surgery may be needed to remove additional tissue to reduce the risk of recurrence.

Child-Pugh Score

The Child-Pugh score is a system used to assess the severity of liver disease by evaluating five factors. Each factor is assigned points based on its severity, and the sum of these points gives the Child-Pugh score.

The five factors are:

• Ascites — fluid buildup in the abdomen
• Bilirubin — a substance that builds up in the blood when the liver isn't working properly
• Albumin — a protein made by the liver
• Prothrombin time or International normalized ratio (INR) blood test — the time it takes for blood to clot
• Encephalopathy — brain function issues due to liver disease

Each of these factors is graded with points (1 to 3) based on its severity, and the sum of these points determines the Child-Pugh score:

Before surgery, several procedures are typically performed, including:

• An accurate evaluation of liver volume and function of the remnant liver (preoperative assessments)
• Portal vein embolization, in cases where the future remnant liver is found to be small, which is a procedure that shrinks the part of the liver to be removed and regenerates the part of the liver that will stay

In modern liver surgeries, preoperative assessments are a mandatory prerequisite. Along with these evaluations, meticulous surgical techniques, such as strategies to limit blood loss, are key to improving the success rate of a partial hepatectomy. Blood transfusions are usually not required, but the surgical team is always prepared, particularly when dealing with larger or more complex tumors.

Doctors may also suggest a short-term low-calorie, low-fat diet, especially for patients with higher BMIs. This makes it easier for surgeons to operate. However, such preparations should be carefully managed by a medical team consisting of the doctor and dietitians, as they are not suitable for everyone.

There are different approaches to removing liver tumors, depending on factors such as the size and location of the tumor, and whether blood vessels are involved.

• Open surgery: This traditional method involves making a large incision to access the liver directly. It is more invasive but necessary for larger or more complex tumors.
• Minimally invasive surgery: Techniques like laparoscopic or robotic resection involve smaller incisions, resulting in reduced surgical scars and a shorter recovery time. However, these options are only suitable for certain cases and are usually performed in specialized cancer centers.

The surgery may take up to six hours, depending on the complexity of the liver resection.

A partial hepatectomy offers potential benefits, but it also comes with risks.

Benefits

• Potential cure for early-stage liver cancer: If the tumor is confined to part of the liver, surgery offers long-term survival with a good quality of life.
• Liver regeneration: The liver has the ability to regenerate. After part of the liver is removed, the remaining portion can grow back and restore some function, which aids in recovery and long-term health.

Risks

• Infection: As with any major surgery, there is a risk of infection. Apart from infection at the incision wound, infection may also affect the urinary tract or lungs.
• Bleeding: The liver is an organ filled with many blood vessels, and it produces many blood-clotting factors. Significant bleeding may occur during or after surgery due to the liver’s reduced ability to clot the blood.
• Bile leakage: This may happen when the bile duct in the liver is damaged during the surgery. Bile leakage into the abdomen would require further intervention.
• Pleural effusion: Fluid buildup in the space around the lungs (pleural effusion) may occur after surgery. This can cause shortness of breath and discomfort.
• Ascites: Fluid buildup in the abdomen may occur after surgery.
• Liver insufficiency and failure: In rare cases, the remaining portion of the liver may not be able to function adequately after surgery, leading to liver insufficiency or failure.
• Tumor recurrence: Even though the tumor(s) have been removed, there is a possibility of tumor recurrence in the future.

After a partial hepatectomy, patients are monitored closely in the hospital for several days to ensure liver function remains stable and to watch for any complications, such as bleeding or infection. Recovery varies based on the approach or extent of the surgery and the patient's overall health. Most patients experience some fatigue and discomfort but can return to normal activities within a few weeks to months.

For more detailed information on post-operative care and recovery, see Recovery and Life After Partial Hepatectomy for Liver Cancer Patients.