Hepatic Resection

Wedge hepatic resection with lymph node dissection [Ref: Devita, Hellman & Rosenberg’s Cancer 8/e Chapter 39; Annals of Oncology 20 (Supplement 4): iv46–iv48, 2009]

The appropriate management for gallbladder cancer depends on the stage of cancer. Let’s first see the TNM staging for gallbladder cancer.

• For stage Ia:

Tla staged tumors (tumors confined to lamina propria)?

– These tumors are recognized incidentally at the time of pathologic review. No further t/t is needed. Simple cholecystectomy is sufficient for them.

– In laparoscopic cholecystectomy, recurrent cancer has been seen at the port site. Hence all port sites should be excised.

– Patients with preoperatively suspected gallbladder cancer should under go open cholecystectomy to minimize the chances of tumor dissemination.

Tlb staged tumors (tumors invading muscular layer)?

– Invasion of the muscular layer allows access to lymphatics and vessels. For Tlb staged tumors, an extended cholecystectomy is indicated, as these tumors have been reported to recur after simple cholecystectomy.

• For stage Ib, II, selected stage III tumors:

– These are managed by extended cholecystectomy. [This includes lymphadenectomy of the cystic duct, pericholedochal, portal, right celiac, and posterior pancreatoduodenal lymph nodes. Obtaining an RO resection should be the goal of surgery and results in an improved survival compared with patients who have remaining microscopic or macroscopic disease.Adequate clearance of the pericholedochal lymph nodes may be facilitated by resection of the common bile duct, but common duct resection is not always necessary; in those cases in which the

cystic duct stump margin is positive _.for malignancy, common duct resection with Roux-en-Y reconstruction is mandatory. Extension into the hepatic parenchyma is common, and extendedcholecystectomy should incorporate at least a 2-cm margin beyond the palpable or sonographic extent ^of. tumor. For smaller tumors, this goal can be achieved with a wedge resection of the liver. For larger tumors, an anatomic liver resection (extended right hepatectomy) may he required to achieve a histologically negative margin.]

• Stage IV tumors:

– Should be treated with appropriate palliation as indicated.

• No randomized data have demonstrated improved survival with either chemotherapy or radiation and its use depends on case to case basis.

Patients with solitary hepatic metastases without clinical or radiographic evidence of additional tumor involvement is treated with partial liver resection.

Eligibility criteria for hepatic resection in a case of liver metastasis includes: absence of primary tumor, absence of extrahepatic metastasis, absence of portal or celiac lymph node metastases and enough functioning of remaining hepatic tissue to ensure adequate post operative hepatocellular function.

Ref: Harrison’s Internal Medicine, 18th Edition, Chapters 91- 92; Integrated Medical and Surgical Gastroenterology By J.J.B. Van Lanschot, Page 434

“If surgical cystectomy with removal of the germinal laminated layers is not technically feasible, then liver resection can be employed”. 

Ans is ‘d’ i.e. Hepatic resection is never done 

Laparoscopic aspiration, unroofing and evacuation of the hepatic hydatid cysts can be done.

Ans. is ‘d’ i.e., Jaundice from extrinsic ductal obstruction 

• The three most critical factors related to perioperative morbidity are blood loss, the amount of normal liver resected, and the condition of the liver itself (e.g., cirrhosis).
• Classical contraindications for resection included: bilobar disease, more than four lesions, large tumors (>5 or 10 cm) and extrahepatic disease.

Ans. is ‘b’ i.e., 20%

Up to 70% to 75% of the hepatic volume may be resected with good recovery in patients with relatively normal hepatic parenchyma (without active hepatitis, cirrhosis, or metabolic defects), as long as the remnant liver has adequate portal venous and hepatic arterial inflow, adequate hepatic venous outflow, and adequate biliary drainage.