LIVER SURGERY

What is Liver Surgery?

The liver is one of the most important organs in the human body. It is located in the upper right part of the abdomen. It constitutes about 2% of the body weight, approximately 1500 grams in a 75 kilogram adult. Its absence is incompatible with life. The liver removes a large portion of the foreign substances and toxins from the body (some drugs, ammonia, etc.). Very important proteins are synthesized only in the liver (albumin and clotting factors, etc.). The organization of absorbed foods carried from the intestines to the liver and their distribution throughout the body are also among the important duties of the liver. The liver is also a very important storage center for some nutrients and minerals. Liver diseases range from simple steatosis to very serious cirrhosis.

Liver diseases requiring surgical treatment can be briefly summarized as follows:

Liver Abscess

Abdominal pain (in the upper right abdomen), high fever (39-40 C°), shivering and sweating, sometimes jaundice, loss of appetite, sepsis and related shock in delayed patients are the complaints that bring the patient to the doctor.

It is usually seen in those with any focus of infection in the abdomen (e.g. delayed appendicitis), gallbladder or main bile duct inflammation and parasitic cyst in the liver (hydatid cyst).

Following diagnosis, the abscess should be drained as soon as possible and antibiotic treatment should be started immediately. Today, non-surgical percutaneous catheter drainage (non-surgical catheter placement with ultrasound guidance) is the first step preferred in draining the abscess. In patients for whom this treatment is not sufficient and in hospitals where technical equipment is not sufficient, the abscess should be drained surgically as soon as possible.

Liver Hydatid Cyst

The causative agent of hydatid cysts is a parasite called Echinococcus Granulosus. It settles most frequently in the liver and most frequently in the right lobe of the liver. It is a public health problem in regions where animal husbandry is intense. Those who keep pets without providing appropriate conditions, those who deal with animal husbandry and do not provide the necessary hygienic conditions, and those who do not have a relationship with animals but consume foods prepared in unhygienic conditions are at risk for developing hydatid cysts.

Over time, the causative agent creates a fluid-filled cyst in the liver. In the fluid inside this cyst, there is a cyst that can form new cysts wherever it reaches if the cyst bursts. Cysts can open into the abdomen, bile ducts, and chest cavity.

Simple cysts usually do not show any symptoms, but when they do, the most common complaint is abdominal pain. When the cyst becomes infected, opens into the abdomen, chest cavity, bile ducts, or presses on other organs, it causes results ranging from symptoms such as fever, jaundice, and shivering in addition to abdominal pain to life-threatening conditions called shock.

Although patients are first started on drug treatment, since most patients do not respond to drug treatment, the main treatment is surgery. The surgical method to be chosen is determined depending on the patient's condition and the stage of the cyst. In recent years, especially in some selected and suitable patients who are diagnosed early, successful results are obtained by draining the cyst with a needle inserted through the skin under the guidance of imaging methods and injecting alcohol into it.

Alveolar hydatid cyst caused by Echinococcus Multilocularis is much more severe. The cyst has no capsule. It has the ability to grow continuously and progress to surrounding organs. The liver is filled with small and large cysts. It grows and progresses to surrounding organs and bile ducts, acting just like a malignant cancer. Untreated patients usually die within 10-15 years. The most important factor in the success of treatment is the surgical removal of the disease before it progresses to organs other than the liver and bile ducts. Surgical treatment is extremely difficult. In patients diagnosed early, the diseased area should be surgically removed. If removal is technically not possible, liver transplantation should be offered to these patients as a treatment option with successful results.

Liver Hemangioma

It is the most common benign liver tumor. It is usually seen between the ages of 30-70 and more frequently in women.

They are tumors that grow and expand like varicose veins and contain vascular structures. They are more than one in 40% of patients. They can be found all over the liver. They are usually smaller than 5 cm. Those with a diameter larger than 5 cm are called giant hemangiomas. They are encapsulated (they have a sheath).

They are often seen incidentally during surgery or in imaging methods (ultrasound, computerized tomography). Giant hemangiomas can put pressure on the organs around them and cause complaints such as early satiety and jaundice. In addition, abdominal pain may be experienced due to the tension it creates in the liver membrane. It is very rarely confused with liver cancer.

In most patients, the dimensions detected at the time of diagnosis do not change during follow-ups. However, rapid growth can be seen in some cases. Although rare, traumatic or spontaneous rupture can be seen in hemangiomas located close to the edges of the liver.

In cases where there is no suspicion of cancer, if the patient has no complaints, hemangiomas can be monitored at long intervals, regardless of their size. Those with compression symptoms and those that grow rapidly should be operated on. In addition, it is beneficial to treat individuals at risk for trauma (such as athletes) with surgery. They can usually be removed in a way that preserves the liver tissue. In giant hemangiomas that cannot be surgically removed, liver transplantation can be performed successfully.

Focal Nodular Hyperplasia (FNH)

It is benign, the second most common benign liver tumor. They consist of sheathed, pale-colored nodules, usually smaller than 5 cm, most commonly seen in women aged 20-30, and are usually diagnosed incidentally. It usually does not cause any complaints. It is held responsible for vague abdominal pain in approximately 10% of patients.

If there is no increase in the diameter of FNH in regular follow-ups and it is smaller than 5 cm, they are not operated on. Lesions that are suspicious of malignant tumors, create pressure findings around them, and tend to grow should be surgically removed.

Liver Adenoma

It is a liver disease that is usually seen in women using birth control pills. Adenomas are smooth-contoured, soft tumors with areas of necrosis and bleeding on the cut surface. Histologically, they do not contain portal areas and bile ducts.

Abdominal pain is seen in approximately 50% of patients. It can cause spontaneous rupture and life-threatening intra-abdominal bleeding in approximately 30%. Patients may present with a mass in the liver or may be detected incidentally on ultrasound or tomography. Biopsy should not be performed due to the risk of bleeding.

If the birth control pill is taken, the adenoma may shrink by stopping it. However, due to the risks of turning into cancer and causing life-threatening bleeding, it should be surgically removed after diagnosis. Liver transplantation may be required in adenomatosis (presence of multiple adenomas in the liver) that is not suitable for surgical removal.

Liver Cancer

Most of the tumors seen in the liver are the spread of cancer that started in other organs (such as stomach, small and large intestine, pancreas, breast, lung) to the liver. Tumors of the liver itself constitute 10% of all tumors. Approximately 1 million people are diagnosed with liver cancer every year in the world.

Approximately 80% of liver cancers are seen in patients with cirrhosis (all causes of cirrhosis, including hepatitis B and C). In addition, some genetic diseases (trisonemia), metabolic diseases (hemochromatosis, Wilson's disease), and some toxic substances (aflatoxin, vinyl) can cause liver cancer.

There is no early specific finding of liver cancer. Therefore, when diagnosed, it is usually in advanced stages. The symptoms are extremely hidden. Fatigue, loss of appetite, weight loss and pain in the upper right side of the abdomen are the first symptoms of the disease. Since cirrhosis is usually the basis of cancer, these symptoms are usually attributed to cirrhosis. In people known to have chronic liver disease, sudden deterioration of general condition should be evaluated as the first symptom of a developing tumor and should be investigated. Jaundice and swelling of the abdomen due to fluid accumulation are symptoms of the advanced stages of this disease.

Today, it is extremely easy to detect liver cancer with advanced imaging methods. Patients at risk (especially those with cirrhosis) should be followed up with the cheapest and easiest to apply ultrasonography. In addition, computerized tomography (CT), magnetic resonance imaging (MRI), and angiography are other methods that can be used in diagnosis. Alpha fetoprotein (AFP), a tumor marker in the blood, can be determined. Although an increase is not detected in every patient, AFP monitoring is still an important parameter that helps detect tumors in the early stages in patients with cirrhosis.

The results of untreated liver cancer are very poor. 80% of tumors that become symptomatic have lost the chance of being surgically removed. While the average patient survival in tumors that can be surgically removed is 25 months, patients who cannot receive any treatment usually die within 6-9 months. Two important factors for surgical removal of cancer are that the cancer is limited within the liver, that is, it has not spread to another organ, and the stage of the underlying liver disease. Liver cancer that has spread to another organ has lost the chance of surgical treatment. In the early stages of liver disease, if the number and diameter of the cancer are suitable, surgical removal is the first step. The most important disadvantage of this is the high risk of tumor recurrence. In people who are not suitable for surgical removal, especially those with chronic liver disease, liver transplantation should be considered as the first choice, as it also treats the disease that caused the tumor. If the tumor is limited only within the liver, liver transplantation can be successfully performed regardless of its diameter and number. It has been observed that long-term survival can be achieved with liver transplantation, even in advanced-stage tumors. In patients who are not suitable for liver transplantation and surgical removal, radiological methods such as hepatic artery chemoembolization (HACE), radiofrequency ablation (RF) and alcohol injection are other interventions performed to extend the patient's survival.

Acute Liver Failure

Acute liver failure is a disease that occurs suddenly and primarily in healthy people. Both acute and chronic liver failures damage the liver cells that provide proteins and remove toxins. If acute liver failure is not treated quickly, the patient's death is inevitable.

Causes of acute liver failure include viruses (Hepatitis A, B, D, E and possibly C), medications (immunosuppressive therapy, chemotherapy, high doses of paracetamol, halothane, some antibiotics, heart rhythm medications, estradiol, some blood pressure medications), mushroom poisoning (especially Amanita phalloides), Wilson's disease and pregnancy.

Symptoms of acute liver failure develop suddenly and dramatically. Within 2-10 days, a completely healthy person can transition to a state of unconsciousness. The first symptoms are nausea and discomfort, but later jaundice and changes in consciousness (hallucinations, agitation) may occur. When the liver functions return to normal, consciousness usually returns to normal. Conversely, some individuals develop permanent damage. Other symptoms include sweating, feeling faint, bruising, bleeding tendency and excessive thirst.

In patients who do not respond to medical support treatments, the only life-saving treatment method is liver transplantation. The most important factor in the success of liver transplantation and treatment is the importance of timing in treatment planning. After diagnosis, these patients should definitely be referred to a center where liver transplantation can be performed.

Chronic Liver Failure or Cirrhosis

Cirrhosis or chronic liver failure can cause irreversible damage to liver cells. Although chronic liver failure is slower than acute liver failure, its external appearance is worse. Liver cells are gradually damaged and thus the liver becomes unable to function over time. The main substances produced by the liver, such as albumin and blood clotting factors, gradually decrease.

Toxic substances that need to be removed from the liver begin to accumulate in the blood. Portal hypertension (increased pressure in the main liver vein) develops as the damage to the cells prevents blood flow in the liver, and this can cause serious, life-threatening bleeding from varicose veins in the digestive system, especially in the esophagus and stomach. Cirrhosis in the liver can occur for many reasons. While the main cause in America and Europe is usually high alcohol consumption, in developing countries, including our country, viral hepatitis, especially hepatitis B and C, are the most important causes of cirrhosis. In addition, some microorganisms (bacteria, parasites), some hereditary diseases (Wilson's disease, hemochromatosis, antitrypsin deficiency), autoimmune diseases and rare allergic reactions to some drugs (such as birth control pills, isoniazid and methyldopa) can be counted among the factors that cause cirrhosis.

In chronic liver failure, patients see a doctor with fatigue, weakness, loss of appetite and exhaustion caused by weight loss. Mild jaundice is also among the symptoms. The reason for easy bleeding and bruising is that the proteins that cause blood clotting are not produced in sufficient amounts and the platelets that provide blood clotting are reduced in number. Itching, which occurs as a result of toxins not being sufficiently cleared from the body, is one of the important symptoms that restricts the person's social life. In addition, accumulated toxins cause confusion and mental changes in the person.

Due to insufficient production of albumin and increased portal pressure, fluids in the blood leak into some tissues and cause swelling, especially in the legs and fluid accumulation in the abdomen. Infection of fluid accumulated in the abdomen (peritonitis) is a life-threatening condition seen during the course of the disease.

Chronic liver failure or cirrhosis is among the diseases that cannot be reversed. Eliminating the factors that cause the disease is the first step that slows down the process and helps with treatment (such as quitting alcohol). The main purpose of other treatments is to increase the patient's quality of life. Diuretics may be recommended to reduce water retention in the body and laxatives may be recommended to accelerate the excretion of toxic substances from the large intestine through feces. The most effective treatment method for cirrhosis and related problems today is liver transplantation. Liver transplantation is successfully performed with livers provided from living or cadaver donors.

Liver Transplantation in Children

The most common cases where liver transplantation is applied in children are congenital underdevelopment of bile ducts (atresia) and hereditary metabolic diseases. Many of these diseases can be successfully treated with liver transplantation. The experience gained in liver transplantation has both given these children, who would inevitably die in a short time, the chance to live and has opened new horizons in studies on metabolic diseases. Recently, liver transplantation has also been applied in cases of familial hypercholesterolemia (high cholesterol in the blood) and hemophilia, and congenital biochemical disorders have been successfully corrected.

If the condition of underdevelopment of bile ducts is not treated in a timely manner, it definitely results in death. This disease can be treated to some extent with some special surgical interventions. However, the percentage of patients in whom these interventions yield successful results does not exceed 30-40%. The remaining 60-70% develop progressive liver failure and the child is usually lost before reaching the age of 5.

Although liver transplantation in children is technically difficult, very successful results are obtained with the level of technology reached today, the increase in surgical experience, developments in intensive care facilities and strong immune system suppressing drugs. Regardless of age and weight, the success rate in treating children with liver transplantation has increased to over 90%.

The information contained within the site is for support purposes only. It does not replace a physician's examination, diagnosis, and prognosis of a patient for medical purposes.

Copyright © 2023 Prof. Hamdi Karakayalı, M.D. All rights reserved. | Powered by Mad Men Agency, MMA