a About us a a
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buton Transplant Surgery
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buton Liver Surgery
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buton Pancreas Surgery
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buton Gall bladder & Bile Duct Surgery
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buton Bloodless Surgery
 
Dr Ravi Shankar Dr. Ravishankar
Liver & Transplant Surgeon

Cell: 0065-91817293
Ph: +65-64790608
24hr Svc : +65-65358833
Fax : +65 64797608

Email: diddapur@yahoo.com.sg
www.liversurgery.com.sg

Specialist Surgery Singapore Pte Ltd
#02-35, Gleneagles Hospital
6 Napier Road, SINGAPORE 258500
   
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Liver Surgery

Liver cancers
Liver cancers can arise primarily in the liver itself when they are called as hepatomas or hepatocellular carcinomas (HCC). These commonly arise in livers which are diseased with cirrhosis due to factors like Hepatitis B, Hepatitis C and or alcohol. There are other variants like intra hepatic Cholangiocarcinomas and the like. The treatment strategies are based on the severity of underlying liver disease and the location, size, multiplicity and stage of the disease.

The other group commonly known as metastatic tumours arises from other organs like colon, ovaries, breast, kidney etc and if the spread is restricted to the liver, it may be resectable, then surgery may be the best option available.

Aggressive treatment strategies can cure or significantly prolong the life of many patients with liver cancer for which surgery forms the mainstay of treatment

What are the symptoms and signs of Liver cancer?
  Early stages of cancer may go undetected for months or even years. When symptoms do develop, they are most pronounced as pain.The discomfort is usually of a moderate degree and most often in the upper or upper right part of the abdomen. In more advanced cases, symptoms of jaundice, a yellowing of the skin and eyes, may also appear.

Other symptoms may include loss of appetite, loss of weight, fever of unknown origin, general malaise, limb weakness, or sensory loss.
 
How do you stage liver cancer?
  Each type of cancer has specific staging criteria. In general the different stages can be summarized as follows:
Stage I : Localized and Resectable
    Tumor is found in one location of the liver and could be treated surgically.
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Stage II : Localized and Possibly Resectable
    Primary tumor is found in one or more locations in the liver and may be treated surgically. The decision to surgically treat the disease will depend upon the location, nature of the liver disease and the tumour.
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Stage III : Advanced
    Cancer has spread to more than one location in the liver and/or to other parts of the body. Frequently requires multiple treatment modalities for maximum benefit.
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Stage IV : Disseminated
    Cancer involves multiple sites throughout the body. Frequently, surgery is not indicated and chemotherapy is the best option.
This classification system is not standardized across all types of cancer, and each type of cancer has its own interpretation. Consult your surgeon for an exact interpretation of the stages and the letter designators as they apply to your diagnosis.
 
What are the imaging studies for staging liver cancer?
  Ultrasonography
CT-Scan
CT- Angiogram
MRI
 
What other studies are done to assess liver cancer?
  Colonoscopy
Upper GI Endoscopy
Laparoscopy
 
What are the treatment options?
 
Surgery
Radiofrequency Ablation
Alcohol Injection
Chemoembolization
Liver Transplantation
Chemotherapy
Yittrium 90 Treatment
 
When is Surgery indicated?
  Every patient with a liver tumor should be evaluated for a resection. It is the only chance for cure. Removing the tumor will rid the body of the cancer and also prevent further spread to other regions. Unfortunately, not all patients are eligible for a liver resection.

The liver is a privileged organ in that it has the ability to regenerate if part of it is removed and this allows surgeons to operate upon it successfully. In patients with colon cancer that has spread to the liver, liver resection can cure 25 - 45% of the patients. Patients may also develop metastatic colorectal cancer to both the lungs and liver. In select patients, simultaneous resection of metastases from the lung and liver can provide significant benefit.

Other indications for liver resection are metastases from other sites such as breast, kidney, lung, selected tumors of the pancreas and small intestine and sarcomas. Although these diagnoses are controversial indications, 2 year survival rates of 90% have been obtained. This improved survival occurs in patients who respond to chemotherapy and have disease only in the liver. Other indications for resection are tumors that originated in the liver, called hepatocellular cancer and cholangiocarcinoma.
A variety of liver resections can be performed. The options range from resection of a lobe (left or right) to segments (or small portions) of the liver. Resection of segments of the liver (called segmentectomy) permits a surgeon to effectively treat multiple liver tumors.
 
How long will the surgery last and what is the usual length of stay in hospital?
  A liver resection can take 4 - 6 hours to perform. In the majority of patients, a liver resection does not require a blood transfusion. The patient will be able to drink fluids on the second post-operative day and often is discharged in 8 - 10 days. The patient will be able to drink fluids on the first post-operative day and often is discharged in 4 - 6 days if the hepatectomy is performed laparoscopically as laparoscopic hepatectomy or keyhole surgery liver resection.

Dr Ravishankar performed the first in house laparoscopic hepatectomy at National University Hospital in Singapore paving the way for establishment of advanced laparoscopic hepatobiliary surgery.
 
What is Radio frequency ablation? What are the other alternatives?
 

Radio frequency ablation (RFA) is a new technique that can destroy tumors in a variety of sites in liver. RFA is the destruction of abnormal tissue using Radio frequency generated high temperatures at needle tip of about 100-110 degree Celsius. The tumor is not removed and the destroyed cancer is left to be reabsorbed by the body. Initial results in properly selected patients with unresectable liver tumors show significant survival advantage. It is performed under image guidance or as laparoscopic surgery or open surgery. Frequently, RFA is used in conjunction with liver resection as some of the tumors are removed while others are treated with RFA.

Removal of cancer of the liver by surgical means is the treatment of choice. In many patients surgery is not possible because of the extent of the tumor or the presence of cirrhosis that poses an excessive risk of liver failure after the surgery. Radiofrequency ablation (RFA) is a procedure used to destroy (kill) liver cancer. RFA is frequently an option in patients in whom surgical removal of the tumor is not an option. Radiofrequency ablation is a safe and well tolerated procedure that is associated with few complications. RFA is not currently viewed as curative procedure, rather is a procedure that could lead to increased survivability and quality of life. All patients being considered for RFA should be evaluated by an experienced liver surgeon first since surgical removal of the tumor is the best approach.

   
  Other alternatives are:
   
 

Alcohol Injection: When RFA is not appropriate due to the close proximity of tumour to vital structures like inferior vena cava, then intra tumour injection of absolute alcohol may be an option

   
 

Chemoembolization Embolization is the process of injecting a foreign substance into the tumor to stop the blood flow. The lack of blood deprives the tumor of needed oxygen and nutrients and eventually causes cells to die. The tumor blood supply is stopped with small pieces of material that have been saturated with chemotherapy drugs. Once the blood flow has stopped, the tumor is soaked in a very high concentration of drugs for a prolonged period of time thus, the tumor cells die very quickly Patients with kidney disease, blood coagulation problems, or known allergies to contrast agents are not good candidates for this procedure. People with jaundice, severe cirrhosis or kidney failure have an increased chance of complications. Studies show that patients with hepatocellular cancer undergoing this procedure may experience tumor shrinkage as well as an increased survival rate.

   
 

Liver Transplantation Milan’s criteria is used for selecting patients with hepatoma for liver transplantation. The centre can be contacted for details of criteria and also MELD scoring system

   
 

Chemotherapy A small subgroup of patients with hepatomas(HCC) may be appropriate for chemotherapy due to underlying cirrhosis. However it is commonly used in variety of metastatic liver tumours like colorectal metastasis following surgery.

   
  Yittrium 90 Microsphere injection In a small group of patients with HCC who are not candidates for surgery may be appropriate candidates for local surgery like this. For further information and evaluation please contact the centre.
 
Laparoscopic Liver Surgery
 

Benefits of laparoscopic procedures include less post operative discomfort & pain since the incisions are much smaller, quicker recovery times, shorter hospital stays, earlier return to full activities and much smaller scars. Furthermore, there may be less internal scarring when the procedures are performed in a minimally invasive fashion compared to standard open surgery.

 
Radiofrequency ablation of liver tumors
Wedge resection of the liver for liver metastasis
Removal of left half of the left lobe of the liver (in selected patients)
Removal of right half of liver ( in selected patients)
Drainage of liver abscess
Drainage or removal of liver cysts
 
Laparoscopic Liver Cyst Drainage
 

Cysts in the liver are frequently found in normal people. Liver cysts should only be treated if they are causing significant symptoms to the patient. The symptoms found with liver cysts include pain, bleeding into the cysts causing pain, and digestive complaints that are unexplained by other findings. If a liver cyst requires treatment, surgical treatment should include removal of the wall of the cyst.

Removal of the fluid only from the cyst is not recommended since the cyst fills up rapidly after the procedure. Furthermore this procedure puts the patient at risk for infection of the cyst. We offer a laparoscopic approach to patients who require treatment of liver cysts. The procedure involves removing part of the wall of the cyst so that the liquid that is in the cyst can freely drain into the abdominal cavity. The body then removes the liquid from the abdominal cavity.


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