1. Third Lecture of Hepatobiliary Lectures Dr. Noori H. Jassim Assistant Professor and Consultant General and GI Surgeon 1.Liver Tumors 2.Liver transplantation

2. Liver tumours :. I - Benign tumour. II - Malignant tumour. I - Benign : A – Haemangioma : (vascular lesion) - Most common. - Often multiple of cavernous type. - symptomless. - If too large → mass – compressible. -They have little if any malignant potential. Dx: -U/S …diagnostic… abnormal plexus of vessels. -CT… delayed or slow contrast enhancement due to small vessel uptake. - P/c biopsy should be avoided → may bleed profusely Rx : - If small & asymptomatic → No Rx - If large and symptomatic → Rx is controversial (Embolization, Lobe or segmental resection or DXT to ↓ size). Indication of Rx : 1)Arterio venous shunting embarrass heart function. 2)Misdiagnosis of malignant vascular tumour.

3. B – Hepatic adenoma : -premalignant -Women with contraceptive pills. -Develops in otherwise normal liver tissue. Dx: -U/S &CT → well circumscribed solid tumours. But, unfortunately difficult to differentiate from malignant tumours radiologically. So → -Angiography → well developed peripheral arterialisation of the tumours Rx. Lobe or segmental resection is Rx of choice. (premalignant) C – Focal nodular hyperplasia (FNH): -Focal overgrowth of functioning liver tissue supported by fibrous tissue stroma (hepatocytes & kupffer cells) - Middle age female with no association with underlying liver disease -Unusual & Unknown aetilogy. Dx -U/S → solid tumour, CT → central scarring & well-vascularised lesion (not specific) -Sulphur colloid liver scan →FNH +ve (kupffer cells) but adenoma & primary or metastatic tumours -ve (↓ ↓ kupffer cells )

4. II – Malignant liver tumours : Primary cancer : 1- Hepatocellular carcinoma ( HCC ) : - one of the commonest tumour in the world specially UK - Association with chronic liver disease HBV & HCV → screening by U/S and AFP. -Middle age. - 80% of primary liver malignancy. - May be multicentric. - ά Fetoprotein (AFP) ↑. Clinical features : -S&S of CLD: malaise and weakness, jaundice, ascites, portal hypertension. - S&S of Cancer : Mass ; wt. ↓, anorexia,,. Dx : US., CT and biopsy. Rx: 1. surgical resection (lobe or segment/s) 2. Liver transplantation (size, site and availability of donors)

5. 2- Cholangiocarcinoma : - Elderly age. – Patients with PSC - Fibrotic tumors → stricture often fibrous at the confluence of R&L hepatic ducts→ jaundice. - Distal b.d. CC → polypiod obstruct the lumen of b.d. Clinical features : -Painless obstructive jaundice -Enlarged tender liver, ↓ wt., fever, asthenia Dx -U/S → dilated intrahepatic but not extra-hepatic b.d. -Cholangiography (ERCP) → hilar stricture → Brush cytology → tissue dx (2/3). -CT → ? Mass ( if infiltration liver parenchyma) - Angiography → (local spread to PV or HA). Rx Surgical resection

6. Secondary liver tumours : Much more common -Multiple usually Sources : Intra abdominal : - GIT (colorectal), -Pancreas -Uterus & ovaries Extra abdominal: - Melanoma, Carcinoid tumours, Breast & Sarcoma. Dx: 1.Dx of liver tumours as described before (U/S, CT….etc) 2.Dx the primary- clinical exam, chest CT, bone scan, colonoscopy…. etc. Rx: 1.Surgical resection 2. If not resectable – systemic chemo (5 FU & folinic acid) Px: The 5-year survival rate after resection of solitary colorectal metas. is 35%

7. Liver Transplantation Starzl 1963 USA Calne 1968 Cambridge UK Indications : 4 groups of indications 1.Cirrhosis and chronic liver failure example: Alcoholic liver dis, Viral liver dis (hepatitis B and C), non-alcoholic steatohepatitis, primary biliary cirrhosis, biliary atrasia in children 2. Acute liver failure e.g: Acute fulminant liver failure usually viral or drug induced (e,g, paracetamol overdose 3. Metabolic liver diseases e.g: Wilson’s disease, oxalosis and familial amyloid polyneuropathy 4. Primary hepatic malignancy which is more common predisposed by L. cirrhosis especially in virally induced

8. Technical complications 1.Haemorrhage treated by packing peritransplant area 2-3 days, correction of coagulo- pathy and may be evacuation 2. Vascular Complications: hepatic artery thrombosis most commonly spontaneously or due to acute rejection ( in pediatric recipient), primary Schlorising Cholangitis. Dx: Doppler UlS or Angiography….Rx: retransplantation. 3. Biliary Complications: most commonly biliary stenosis, biliary leaks Rx: endoscopic dilatation and stenting or surgical correction Outcome of liver transplantation: It depend on underlying diseases: 1.The best outcome is in chronic L. diseases 2.Whereas in acute L. diseases there is higher mortality rate in early post transplantation because of multiple organ failure. 3.While patients with liver tumor have very good early outcome but ultimately fare much less well because tumor malignancies 4. Patients with hepatitis B or C may develop graft failure due to recurrent viral infections

9. Management of intraoperative blood loss ( it can be very considerable) Management of perioperative coagulopathy : assessment repeatedly and correction with appropriate clotting factors, many centres use rationale thromboelastography Thromboelastography in Theatre Technique

10. 3.Primary sclerosing cholangitis (PSC) : Young adults. Progressive fibrous stricture & obliteration of both intra & extra hepatic bile ducts. Etiology : unknown but genetics that is likely attributed to association with ulcerative colitis. Dx : 1.Cholangiography (MRCP or ERCP)…. irregular narrowing of BD…. If equivocal then → 2. liver biopsy …………fibrous obliteration of biliary tracts. Outcome : - obstruction → jaundice - liver failure - cholangiocarcinoma →Dx … biliary brush cytology by ERCP Rx : - Follow up & monitoring. - Biliary stenting by ERCP → temporary relief of obstructive jaundice - Liver transplantation →the only useful treatment modality