hepatic tumors; hydatid cyst; hepatic trauma

HEPATIC TUMORS

Anatomy and physiology

The blood supply of the liver:-the hepatic artery-the portal vein

The blood is drained from the liver by three major veins: the left, right, and middle hepatic vein

Anatomy and physiology

the intrahepatic distribution of the …

… hepatic artery, … portal vein …. and biliary tree

division of the liver in 2 lobes and 8 segments

Consequence:-there are 2 types of hepatic resections:

Anatomy and physiology

segmental resection

lobe resection

Classification

Hepatictumors

Primarytumors

Secondarytumors

(metastasis)

Maligntumors

Benigntumors

Hepatocarcinoma

Cholangiocarcinoma

Focal nodular hyperplasia

Hepatic adenoma

Cavernous hemangioma

Cystic liver masses

History

-the majority of hepatic tumours = asymptomatic

-if symptomatic:- dull right upper quadrant pain

- fullness or bloating

- nausea or vomiting

- systemic complaints:- malaise- fever- weight loss- increasing abdominal girth

Diagnosis

Anamnesis could reveal some risk factors:-hepatitis virus infection or cirrhosis-travel to areas where hepatitis B or C is endemic-alcohol use -exposure to hepatotoxins-use of oral contraceptives or hormone replacement

therapy for patients suspected of having primary liver tumors such as hepatocellular carcinoma (HCC)

-patient's history of prior malignancy for patients with suspected metastatic lesions

Diagnosis

Physical examination

± a palpable mass - depending on the stage of the lesion

-splenomegaly and ascites- frequently seen in patients with portal

hypertension (suggesting an advanced cirrhosis).

Diagnosis

Laboratory evaluation -liver function studies-coagulation parameters-hematologic parameter

-in patients with suspected metastatic disease:appropriate tumor markers should be

obtained(carcinoembryonic antigen, CA 19-9)

-in patients with HCC the serum alpha-fetoprotein (AFP) level

= the most useful laboratory test -in patients with cholangiocarcinoma

serum carcinoembronic antigen levels

Diagnosis

Computed tomography scans

=highly sensitive; rapid acquisition; three-dimensional

reconstructions-lesions: solid or cystic-the smallest detectable

lesion size: 1 cm

Diagnosis

Arterial phase of a three-phase computed tomography scan of hepatic

metastases from colorectal carcinoma

Magnetic resonance imaging

-more sensitive than CT

-usefull differentiating between a benign and a malignant liver tumor

Diagnosis

A three-fase (arterial, portal and venous) MRI of a HCC

The heterogeneity is characteristic of the lesion, which is both hypervascular and

fibrotic.

Transcutaneous ultrasonography is used

-to detect the presence of liver tumors

-to guide percutaneous biopsies of liver tumors

-to guide therapy for selected tumors(direct injection or ablation techniques)

Diagnosis

Intraoperative ultrasonography-detect the number, extent, and association of tumors

with intrahepatic blood vessels in both primary and metastatic liver tumors

-performed laparoscopically or during an open procedure

Diagnosis

Positron emission tomography

=a nuclear medicine study that

-18F-flurodeoxyglucose (FDG) is injected intravenously

-metabolically active tissues (brain, neoplastic cells) absorbs the radiotracer

-a detector and processor is used to interpret and quantify the uptake

Diagnosis

PET scan confirming hypermetabolic activity of lesions identified on

corresponding CT scans.Black arrows = hepatic metastases White arrows = portal and para-aortic lymph node metastases

Diagnostic Laparoscopy=the final step in evaluation of

a hepatic neoplasm for resectability before resection

Diagnosis

Hepatic Resection

Surgical resection remains the optimal choice for the treatment of solid tumors of the liver

– segmental rsection or lobe (right or left) resection

Treatement options

Transplantation

= an option for HCC and some selectic metastatic tumors

Criteria for selection of the patients were adopted by the United Network for Organ Sharing (UNOS)

Treatement options

Radiofrequency Ablation

= the application of a high-frequency alternating current -ultrasound is used to guide the placement of the needle

Treatement options

Alternative Ablative Techniques

-interstitial laser hyperthermic ablation-microwave coagulation therapy (MCT)

Treatement options

Cavernous hemangioma

=the most common benign tumor of the liver

-most patients are asymptomatic-symptoms: pain, early satiety, nausea, vomiting, and fever±hepatomegaly

-needle biopsy = contraindicated (risk of hemorrhage)-CT scan: precontrast hypodense mass followed by

postcontrast peripheral enhancement, centripetal filling, and delayed emptying

-the tagged red blood cell scan confirms the diagnosis with a “hot spot”

-symptomatic cavernous hemangiomas are enucleated and the feeding artery is ligated

Types of masses

Cavernous hemangioma

Types of masses

CT scan

Hepatocellular adenoma

=the most common benign liver tumor in young womenlong-term oral contraceptive use = predisposing factor

-symptomatology:abdominal pain (50%)patients may present emergently with rupture,bleeding, and shock

-resection is indicated if the mass is symptomatic, greater than 6 cm in size, shows progression in size with serial CT scans,or is associated with elevated serum AFP levels

Types of masses

Hepatocellular adenoma

Types of masses

Three-phase computed tomography scan of a hepatic adenoma. left: arterial phase; center: portal phase; right: venous phase.

Focal nodular hyperplasia

-hyperplastic response around a vascular malformation

-usually symptomatic; detected incidentally by ultrasound or CT scan

-symptomatic patients complain of abdominal discomfort

-bleeding complications and malignant transformation are rare

-treatement:asymptomatic focal nodular hyperplasia should be observed

lesions with substantial symptoms are resected

Types of masses

Focal nodular hyperplasia

Types of masses

Focal nodular hyperplasia on

cross-sectional MRI

Cystic liver masses

Solitary congenital hepatic cysts=usually asymptomatic and do not need surgery.-symptomatic cysts are treated with laparoscopic unroofing

Polycystic liver disease-occurs with polycystic kidney and may be associated with

intracranial berry aneurysms-when symptomatic, they are treated surgically with excision

or unroofing

Types of masses

Cystic liver masses

Pyogenic liver abscess=consequence of other infections

cholangitis surgerygastrointestinal sepsis bacterial endocarditis

-predisposing factors: cirrhosis HIVdiabetes metastases

-the typical presentation: right upper quadrant pain chillsfever weight loss

-treatement:-ultrasound-guided external drainage and antibiotics-laparotomy and drainage may be required in some cases

Types of masses

Cystic liver masses

Amebic liver abscess -caused by Entamoeba histolytica-the typical presentation: a single, large abscess, in the

dome of the right lobe of the liver-predisposing factors:

a history of travel to an endemic areaa history of alcoholism

-serologic tests are available to confirm the diagnosis ELISA and immunofluorescence tests

-treatement: metronidazole 750 mg three times dailylarge amebic abscesses need drainage due to the danger of intrapericardial rupture

Types of masses

Cystic liver masses

Hydatid cysts of the liver (echinococcal cysts)

arise from infestation by the tapeworm Echinococcus granulosus.

Types of masses

Hepatocellular carcinoma

-predisposing factors:hepatitis B and Ccirrhosisexposure to hepatotoxins (aflatoxin, thorotrast)

-symptomatology a long period = asymptomatic when symptomatic:painful hepatomegalyanorexiaweight losshemorrhage causes sudden, severe pain or produces shock

Types of masses

Hepatocellular carcinoma

-AFP levels are elevated-the triad:

liver mass + positive hepatitis serology + high AFP levels =hepatocellular carcinoma

MRI and CT scan-vascular involvement and extrahepatic disease

Intraoperative ultrasound-evaluation of vascular involvement to decide extent of surgical resection

Treatement:-hepatic resections (whenever possible)

often cirrhosis (with a low hepatic function) don’t allow the resection

-radiofrequency ablation-cryotherapy for central lesions-chemotherapy - indicated

for lesions greater than 5 cm and for multicentric lesions

Types of masses

Cholangiocarcinoma

-develops from the biliar epithelium

-there three types:peripheral cholangiocarcinomascholangiocarcinomas that arise from the

right or left hepatic ducthilar cholangiocarcinomas

-diagnostic and treatement-similar with HHC

Types of masses

Secondary hepatic malignancies

Metastatic cancers of the liver-more common than primary cancer

-the main primary malignancies:colorectal cancer lymphomasbreast cancer renal cell carcinomalung cancer pancreatic islet cell tumorsmelanomas carcinoid

Resection, when possible, is indicated for - primary colonic carcinoma- symptomatic carcinoid- renal cell carcinoma.

Types of masses

Types of masses

HYDATID CYST

Hydatid disease or echinococcosis

=a zoonosis that occurs primarily in sheep-grazing areas of the world … -endemic in Mediterranean countries,

the Middle East, the Far East, South America, Australia, New Zealand East Africa

… but it is present worldwide because the dog is a definitive hosthumans contract the disease from dogsthere is no human-to-human transmission

Etiology

Etiology

Echinococcus granulosus= a tapeworm that live into the bowel of the dog or other canide

Eggs are passed (up to thousands of ova daily) and deposited with the dog’s feces

eggsOther species of this tapeworm:

E. multilocularisE. oligartus

Etiology

Echinococcus granulosus= a tapeworm that live into the bowel of the dog or other canide

Eggs are passed (up to thousands of ova daily) and deposited with the dog’s feces

The biologic cycle of Echinicoccus

-the definitive host = the dog

the adult tapeworm is

attached to the villi of the ileum

-the worm’s eggs are deposited in the dog’s feces

-sheep are the usual interme-diate host

-humans are an accidental intermediate host

The biologic cycle of Echinicoccus

The biologic cycle of Echinicoccus

In the human duodenum, the parasitic embryo releases an oncosphere containing hooklets that penetrate the mucosa, allowing access to the bloodstream of portal vein. In the blood, the oncosphere reaches the liver (most commonly) or lungs, where the parasite develops its larval stage known as the hydatid cyst.

Consequence of infestation

in the duodenum the parasitic embryo is released

humans (incidentaly)

contaminated water or food

eggs eliminated by dog

the parasitic embryo pass trrough the intestinal wall into the portal bloodstream

Liver Hidatid cyst of the liver

right atrium

pulmonary circulation Hydatid cyst of the lung

left atrium

sistemic circulation any otherlocation

50-60%

20-30%

10-20%

The structure of the hydatid cyst

-three weeks after infection a hydatid cyst begin to develop-the cyst grows slowly (2 cm diameter/year) in a spherical manner-the pericyst develops around the hydatid cysta fibrous capsule derived from host tissues-the cyst wall itself has two layers:

an outer gelatinous membrane (ectocyst)an inner germinal membrane (endocyst)

-the content of the hydatid cyst:the hydatid fluid

(clear like water – if the cyst is uncomplicated)brood capsules scoleces (hydatid sand)

The structure of the hydatid cyst

The structure of the hydatid cyst

the pericyst

The structure of the hydatid cyst

the ectocyst

The structure of the hydatid cyst

a fragment of the

endocyst

daughter cysts

Evolution of the hydatid cyst

The cyst grows slowlyRupture into …

… the biliary tree… bronchial tree… the peritoneal cavity… pleural cavity… pericardial cavity

Free ruptures can result in disseminated echinococcosis and/or a potentially fatal anaphylactic reactionInfection of a hydatid cyst can occur pyogenic abscessCalcification of the cyst = seldom (in years, if the parasite die)

Symptomatology

-asymptomatic until complications occur

-the most common symptomsabdominal paindyspepsiavomiting

-hepatomegaly = the most frequent sign-jaundice and fever - seldom

Diagnosis

-serologic tests evaluate antibody response-ultrasound

= the most commonly used

splitting of the cystic wall parasitic membrane into the cyst

Diagnosis

-ultrasound

comb the honey tumor-like hidatid cyst

Diagnosis

-ultrasound

calcified cyst

Diagnosis

CT or MRI-similar findings like ultrasonography-detailed hepatic anatomic relationships to the cyst

Endoscopic retrograde cholangio-pancreatographyPercutaneous transhepatic cholangiography

-in patients with suspected biliary involvement

Treatement

-the treatment of hepatic hydatid cysts is primarily surgical

-the abdomen is explored, the liver mobilized and the cyst exposed

-packing off of the abdomen to prevent the diffuse seeding

-the cyst is aspirated and flushed with a scolicidal agent (hypertonic saline)

-the cyst is then unroofed

-then …

Treatement

-then … a number of possibilities:pericystectomydrainage of the cystomentoplastyor even liver resection

-sometimes major biliary repairs or approaches through the common bile duct may be necessary-laparoscopic techniques for drainage and unroofing are possible for the uncomplicated cyst-after operation: antiparasitic agents (albendazole or mebendazole)

Treatement

In the past, aspiration of hydatid cysts was contraindicated

-risk of rupture and uncontrolled spillage

In recent years percutaneous aspiration and injection of scolicidal was reported with a good rate of success (70%)

HEPATIC TRAUMA

Mechanism of injury

-compressive injuries from the overlying ribs-penetrating wounds in the right thoracoabdominal area

laceration of the liver in a car accident

hemorrhage

Diagnosis

-in hypotensive patients who have suffered blunt abdominal or multisystem trauma

an ultrasonography visualization of fluid (blood!) or a hepatic injury

a diagnostic peritoneal lavage reveals blood into the peritoneal cavity(the most likely sources of hemorrhage are

injuriesto the liver, spleen or mesentery)

Diagnosis

-in hemodynamically stable patient and without peritonitis - a spiral contrast CT

intraperitoneal fluid (blood)magnitude of injury to the liver or other organthe presence or absence of active

hemorrhage

nonoperative or operative management is chosen

-penetrating wounds to the abdomen in patients with peritonitis, hypotension or evisceration mandate laparotomy.

Classification

Grade Description of injuryIHaematomaLaceration

Subcapsular, non-expanding, less than 10 percent of surface areaCapsular tear, non-bleeding, parenchymal depth less than 1 cm

IIHaematomaLaceration

Subcapsular, non-expanding, 10–50 per cent of surface area; or intraparenchymal, non-expanding, less than 2 cm in diameterCapsular tear, active bleeding, parenchymal depth 1–3 cm, less than10 cm in length

IIIHaematoma

Laceration

Subcapsular, more than 50 per cent of surface area or expanding;ruptured subcapsular haematoma with active bleeding;intraparenchymal haematoma larger than 2 cmParenchymal depth more than 3 cm

IVHaematomaLaceration

Ruptured intraparenchymal haematoma with active bleedingParenchymal disruption of more than 25–50 percent of hepatic lobe

VLacerationVascular

Parenchymal disruption of more than 50 per cent of hepatic lobeJuxtahepatic venous injuries

VIVascular Hepatic avulsion

The Liver Injury Scale

Treatement

Nonoperative management-80-85% of patients with hepatic trauma are hemodinamic stable -nonoperative management is appropriate after a contrast CT-patients are kept at bed rest-the vital signs are monitored-in stable patients a repeat spiral CT is appropriate at 5 to 7 days to evaluate the evolution of lesion

Laparotomy could become necessary if …-a falling hematocrit-continuing need for transfusion -new onset peritonitis and/or hypotension

Treatement

Operative management

Simple techniques of hemostasis-5 min of compression-application of topical hemostatic agents

cellulosemicrofibrillar collagen hemostatfibrin sealant

-simple suture hepatorrhaphy

Treatement

Operative management

Advanced techniques of hemostasis•extensive hepatorrhaphy•hepatotomy with selective vascular ligation•viable omental pack•resectional debridement with selective vascular ligation•absorbable mesh compression•formal resection•selective hepatic artery ligation•intrahepatic balloon tamponade•perihepatic packing

Treatement

Operative management

The Pringle maneuver controls arterial and portal vein hemorrhage from the liver. Any hemorrhage that continues must come from

the hepatic veins.

Treatement

Operative management

Manual compression of large hepatic injuries

temporarily controls blood loss in hypovolemic

patients until the circulating blood volume

can be restored.

Treatement

Operative management

Perihepatic packing is often effective in managing

extensive parenchymal injuries.

Treatement

Operative management

intrahepatic balloon tamponade

Treatement

Operative management

Hepatotomy with selective ligation

Treatement

Operative management

Resection and suture of the

hepatic parenchima

Treatement

Operative management

Hepatic resection and perihepatic packing