3 Liver Dr Fidel Copy

LIVERLIVERCelso M. Fidel, MD, Celso M. Fidel, MD,

FPSGS,FPCSFPSGS,FPCS

Diplomate Philippine Board of Diplomate Philippine Board of SurgerySurgery

Embryogenesis of the LiverEmbryogenesis of the Liver Liver premordium appear early in 4Liver premordium appear early in 4thth week at the week at the Anterior intestinal portalAnterior intestinal portal growing to Caudal sidegrowing to Caudal side of the transverse septum. The septum contains:of the transverse septum. The septum contains: Vitelline veinsVitelline veins Umbilical veinsUmbilical veins Series of inductionsSeries of inductions;; Mesodern of T SeptumMesodern of T Septum is associated w/ developing is associated w/ developing

Liver caudally.Liver caudally. Hepatic mesenchymeHepatic mesenchyme stimulates endodermal cord stimulates endodermal cord

growth and differentiation to hepatic cells. growth and differentiation to hepatic cells. Primitive endodermal platePrimitive endodermal plate becomes diverticulum. becomes diverticulum. Hepatic diverticulumHepatic diverticulum develops 2 outpocketings. develops 2 outpocketings.

Embryogenesis of the LiverEmbryogenesis of the Liver Proximal Proximal =ventral primordium of pancreas=ventral primordium of pancreas

Distal Distal = cystic duct and gall bladder = cystic duct and gall bladder

TerminalTerminal = Intrahepatic ducts, liver = Intrahepatic ducts, liver parenchymaparenchyma

Liver parenchymaLiver parenchyma appears first as solid cord of appears first as solid cord of

cells from the end of the hepatic diverticulumcells from the end of the hepatic diverticulum

that grows into the transverse Septum. that grows into the transverse Septum.

These hepatic cordsThese hepatic cords investinvest first the first the vitelline vitelline

veinsveins in the in the fifth weekfifth week and part of the left and part of the left

umbilical vein later. These vessels break-up umbilical vein later. These vessels break-up toto

plexus of plexus of thin-walled vesselsthin-walled vessels= = liver sinusoidsliver sinusoids

ANATOMYANATOMY Largest, Heaviest, Intra-abdominal Largest, Heaviest, Intra-abdominal

organ ,2%organ ,2% of total body weightof total body weight Composed of 2 lobes (right & left) and each Composed of 2 lobes (right & left) and each lobe has 2 segmentslobe has 2 segments SegmentationSegmentation 1. Morphologic Surface features1. Morphologic Surface features These lobes are divided by the These lobes are divided by the InterlobarInterlobar fissure,fissure, an invisible line between the an invisible line between the

gallgall bladder fossa anteriorly and the inferiorbladder fossa anteriorly and the inferior vena cava Posteriorlyvena cava Posteriorly

ANATOMYANATOMY SegmentationSegmentation 1. 1. Morphologic Surface featuresMorphologic Surface features Falciform ligamentFalciform ligament, the only externally , the only externally visible boundary, marks the segmentalvisible boundary, marks the segmental fissure between median & lateral fissure between median & lateral segment of the left lobesegment of the left lobe Right lobe segmental fissure has noRight lobe segmental fissure has no external landmarksexternal landmarks 2. 2. Functional vascular anatomyFunctional vascular anatomy Liver is divided into segments supplied Liver is divided into segments supplied by the by the portal triadportal triad, and drained by the, and drained by the hepatic veinshepatic veins

ANATOMYANATOMY Segments of the liverSegments of the liver

I. Caudate lobe – located posteriorly I. Caudate lobe – located posteriorly betweenbetween

right and left hepatic loberight and left hepatic lobe

II. Left II. Left

III. lateral segmentIII. lateral segment

IV. Left median segmentIV. Left median segment

V. Anterior inferior ,RightV. Anterior inferior ,Right

VI. Posterior inferior, RightVI. Posterior inferior, Right

VII. Posterior superior, RightVII. Posterior superior, Right

VIII. Anterior superior, Right VIII. Anterior superior, Right

Segments of the LiverSegments of the Liver

ANATOMYANATOMY Vascular SupplyVascular Supply ( Hepatic artery and portal ( Hepatic artery and portal

vein)vein)

1. 1. Arterial SupplyArterial Supply

25% of the liver blood flow25% of the liver blood flow

Common ArteryCommon Artery enters the porta hepatis enters the porta hepatis

medially to the CBD, gives up the medially to the CBD, gives up the gastro-gastro-

duodenal arteryduodenal artery to be Hepatic Artery to be Hepatic Artery properproper

Cystic ArteryCystic Artery from the right hepatic artery from the right hepatic artery

Left hepatic arteryLeft hepatic artery comes from the gastric comes from the gastric

artery in 25% of the populationartery in 25% of the population

ANATOMYANATOMY Vascular Supply ( Hepatic artery and portalVascular Supply ( Hepatic artery and portal vein)vein) Right Hepatic ArteryRight Hepatic Artery arises as a branch of arises as a branch of

the the Superior Mesenteric A in 20% of populationSuperior Mesenteric A in 20% of population 2. 2. Venous supplyVenous supply Portal veinPortal vein Lies posteriorly in the porta hepatisLies posteriorly in the porta hepatis Formed by Superior Mesenteric, InferiorFormed by Superior Mesenteric, Inferior mesenteric and coronary veinsmesenteric and coronary veins R and L branches supplies right and leftR and L branches supplies right and left hepatic lobes, provides 75% of blood flowhepatic lobes, provides 75% of blood flow

ANATOMYANATOMY Venous drainageVenous drainage Hepatic veinHepatic vein courses between segments and courses between segments and

drains drains into the inferior vena cavainto the inferior vena cava Hepatic ResectionsHepatic Resections Right Hepatic LobectomyRight Hepatic Lobectomy –transects liver thru –transects liver thru Interlobar fissure between gallbladder fossa Interlobar fissure between gallbladder fossa

and and inferior vena cavainferior vena cava Left hepatic LobectomyLeft hepatic Lobectomy Trisegmentectomy-Trisegmentectomy- R lobectomy & median R lobectomy & median

segment segment of the left, leaving L lateral segmentof the left, leaving L lateral segment L lateral Segmentectomy-L lateral Segmentectomy- Left lateral segment to Left lateral segment to the left of the Falciform ligamentthe left of the Falciform ligament Wedge resectionWedge resection

Studies of the LiverStudies of the Liver Liver function test (Synthesis)Liver function test (Synthesis) Serum proteinSerum protein Clotting factorsClotting factors CholesterolCholesterol Blood GlucoseBlood Glucose Clearance functionsClearance functions Ammonia Ammonia Indirect BilirubinIndirect Bilirubin Excretory functionExcretory function Direct BilirubinDirect Bilirubin Enzyme level( Enzyme level( Alk.Phos.,Gamma glutamyl Alk.Phos.,Gamma glutamyl

transferase)transferase)

Studies of the LiverStudies of the Liver Extent of InjuryExtent of Injury

SGOT SGOT

SGPT SGPT

Imaging Modalities of the LiverImaging Modalities of the Liver

Ultrasound Ultrasound

CT Scan and MRI CT Scan and MRI

ArteriographyArteriography

AngioportographyAngioportography

Hepatobiliary ScanningHepatobiliary Scanning

Intraoperative UltrasonographyIntraoperative Ultrasonography

Studies of the LiverStudies of the Liver Imaging Modalities of the Liver’s Sensitivity Imaging Modalities of the Liver’s Sensitivity in detecting Hepatocellular Carcinoma in detecting Hepatocellular Carcinoma Intraoperative Ultrasonography > Intraoperative Ultrasonography > 99%99%

CT Scan > CT Scan > 89% 89%

Preoperative Sonography > Preoperative Sonography > 88%88%

Angioportography > Angioportography > 82%82%

Surgical Conditions of the LiverSurgical Conditions of the Liver

Hepatic Abscess and CystsHepatic Abscess and Cysts

Nonviral Liver InfectionsNonviral Liver Infections

1. Bacterial, Protozoal and Parasitic1. Bacterial, Protozoal and Parasitic

2. Environmental factors, particularly 2. Environmental factors, particularly geogra-geogra-

phic location and presence of phic location and presence of endemicendemic

parasitesparasites

3. Abscess and Cysts- few localizing 3. Abscess and Cysts- few localizing signssigns

4. Similar test as used for liver tumors4. Similar test as used for liver tumors


Hepatic Abscess and CystsHepatic Abscess and Cysts

Bacterial AbscessesBacterial Abscesses

1. Most common hepatic abscess in the1. Most common hepatic abscess in the

western Worldwestern World

2. Abdominal Infections, Appendicitis, 2. Abdominal Infections, Appendicitis, Cholan-Cholan-

gitis, Diverticulitisgitis, Diverticulitis

3. Distant source= endocarditis3. Distant source= endocarditis

4. In 10-50% of cases no identifiable source4. In 10-50% of cases no identifiable source

5. Infecting organism related to primary 5. Infecting organism related to primary sourcesource


Hepatic Abscess and Cysts Hepatic Abscess and Cysts Bacterial AbscessesBacterial Abscesses 6. In Abdominal; common organisms are 6. In Abdominal; common organisms are

gram gram negative rods, anaerobic streptococcusnegative rods, anaerobic streptococcus 7. Extra Abdominal; gram + organisms7. Extra Abdominal; gram + organisms 8. Clinical picture includes:8. Clinical picture includes: Right upper quadrant painRight upper quadrant pain Liver tender or enlargedLiver tender or enlarged Sepsis may be overwhelmingSepsis may be overwhelming Hemobilia- Hemobilia- due to erosion of abscess due to erosion of abscess

intointo biliary treebiliary tree


Hepatic Abscess and Cysts Hepatic Abscess and Cysts

Bacterial AbscessesBacterial Abscesses

9. Management includes : 9. Management includes :

Percutaneous drainage Percutaneous drainage

Operative Surgical Drainage, AntibioticsOperative Surgical Drainage, Antibiotics

Amoebic AbscessAmoebic Abscess

1. 21. 2ndnd most common hepatic abscess in the most common hepatic abscess in the

western world and common than western world and common than bacterialbacterial

abscess in the 3abscess in the 3rdrd world world

2. Solitary abscess ; 90% in right lobe2. Solitary abscess ; 90% in right lobe



Amoebic AbscessAmoebic Abscess

3. Entamoeba histolytica from intestinal 3. Entamoeba histolytica from intestinal amoe-amoe-

biasis through portal veinbiasis through portal vein

4. Clinical Picture includes:4. Clinical Picture includes:

fever; hepatomegaly; R upper quadrantfever; hepatomegaly; R upper quadrant

pain; Leukocytosis; pain; Leukocytosis; liver enzymes liver enzymes

5. Management includes:5. Management includes:

Aspiration of AbscessAspiration of Abscess

Parenteral MetronidazoleParenteral Metronidazole



Hydatid Cyst of the liverHydatid Cyst of the liver

1. Dogs are definitive host1. Dogs are definitive host

2. Echinococcus granulosus2. Echinococcus granulosus

3. 2/3 occurs in the liver3. 2/3 occurs in the liver

4. Clinical picture includes:4. Clinical picture includes:

Patient exposure in an endemic areaPatient exposure in an endemic area

Liver enlargement and R upper Q painLiver enlargement and R upper Q pain

Eosinophilia present in 40% of patientsEosinophilia present in 40% of patients Serum test for parasite antigen is Serum test for parasite antigen is

diagnosticdiagnostic



Hydatid Cyst of the liverHydatid Cyst of the liver

4. Clinical picture includes:4. Clinical picture includes:

Progressive Liver enlargement Progressive Liver enlargement =Rupture:=Rupture:

into Hepatic parenchymainto Hepatic parenchyma(( daughter Cysts) daughter Cysts)

into the bile ductsinto the bile ducts

into free peritoneal cavity into free peritoneal cavity

Pericystic calcification on abdominal X Pericystic calcification on abdominal X rayray

(condition requires no further treatment)(condition requires no further treatment)


BENIGN TUMORS OF THE LIVERBENIGN TUMORS OF THE LIVER Hemangioma:Hemangioma: 1. Most common benign hepatic tumor1. Most common benign hepatic tumor 2. Usually asymptomatic2. Usually asymptomatic 3. Can cause symptoms by compression3. Can cause symptoms by compression 4. Discovered as an incidental finding4. Discovered as an incidental finding Focal Nodular HyperplasiaFocal Nodular Hyperplasia 1. Third most common benign liver tumor1. Third most common benign liver tumor 2. Weak association w/ oral 2. Weak association w/ oral

contraceptivescontraceptives 3. Spontaneous rupture is rare3. Spontaneous rupture is rare

Surgical Conditions of the LiverSurgical Conditions of the Liver BENIGN TUMORS OF THE LIVERBENIGN TUMORS OF THE LIVER

Hepatocellular AdenomaHepatocellular Adenoma 1. Uncommon benign tumor1. Uncommon benign tumor 2. Seen in women taking oral contraceptives2. Seen in women taking oral contraceptives 3. About 25% have abdominal mass or pain3. About 25% have abdominal mass or pain 4. About 30% present w/ spontaneous rupture4. About 30% present w/ spontaneous rupture into peritoneal cavityinto peritoneal cavity 5. Suspected when mass is seen on ultrasound5. Suspected when mass is seen on ultrasound 6. Angiography useful, hypervascularity 6. Angiography useful, hypervascularity presentpresent

7. Normal liver function7. Normal liver function 8. 8. Biopsy needed to exclude malignancyBiopsy needed to exclude malignancy


BENIGN TUMORS OF THE LIVERBENIGN TUMORS OF THE LIVER Infantile HemangioendotheliomaInfantile Hemangioendothelioma 1. Benign liver tumor in children1. Benign liver tumor in children 2. May present with hepatomegaly and high2. May present with hepatomegaly and high output failure in an infant with a largeoutput failure in an infant with a large arterio-venous fistulaarterio-venous fistula PRIMARY MALIGNANT TUMORS OF LIVERPRIMARY MALIGNANT TUMORS OF LIVER Hepatocellular Carcinoma (Hepatoma)Hepatocellular Carcinoma (Hepatoma) Clinical FeaturesClinical Features 1. 80% of primary liver tumors1. 80% of primary liver tumors 2. Men are affected twice as often as 2. Men are affected twice as often as

womenwomen


PRIMARY MALIGNANT TUMORS OF LIVERPRIMARY MALIGNANT TUMORS OF LIVER

Hepatocellular CarcinomaHepatocellular Carcinoma (Hepatoma) (Hepatoma)

Clinical FeaturesClinical Features

3. About 10-15% of patients present 3. About 10-15% of patients present withwith

hemorrhagehemorrhage

4. Hepatomegaly in 88% of cases4. Hepatomegaly in 88% of cases

5. Weight loss in 85%5. Weight loss in 85%

6. Tender abdominal mass in 50%6. Tender abdominal mass in 50%

7. Associated with Cirrhosis in 60% 7. Associated with Cirrhosis in 60%

Surgical Conditions of the LiverSurgical Conditions of the Liver PRIMARY MALIGNANT TUMORS OF LIVERPRIMARY MALIGNANT TUMORS OF LIVER

Hepatocellular CarcinomaHepatocellular Carcinoma (Hepatoma) (Hepatoma) Risk FactorsRisk Factors 1. Chronic Hepatitis B Virus (HBV) infection1. Chronic Hepatitis B Virus (HBV) infection 2. Cirrhosis of the liver2. Cirrhosis of the liver 3. Hemochromatosis with iron overload and3. Hemochromatosis with iron overload and cirrhosiscirrhosis 4. Schistosomiasis & other 4. Schistosomiasis & other parasiticparasitic infestation infestation 5. Environmental Carcinogens5. Environmental Carcinogens 6. Chlorinated hydrocarbons such as Carbon6. Chlorinated hydrocarbons such as Carbon tetrachloride pesticidestetrachloride pesticides



Hepatocellular CarcinomaHepatocellular Carcinoma (Hepatoma) (Hepatoma)

Diagnostics:Diagnostics:

1. Alpha-fetoprotein 1. Alpha-fetoprotein elevated elevated in in 70-90%70-90% of of casescases

2. Hepatic Ultrasound2. Hepatic Ultrasound

3. Arterioportography3. Arterioportography

4. CT Scan4. CT Scan

5. MRI5. MRI

TreatmentTreatment

Resection of the lesionResection of the lesion


HepatoblastomaHepatoblastoma Almost exclusively a childhood tumorAlmost exclusively a childhood tumor 66% of malignant hepatic tumor in children66% of malignant hepatic tumor in children Occurs in the first 5 years mostly under 2 yrsOccurs in the first 5 years mostly under 2 yrs Associated with Wilms’ tumor, GlycogenAssociated with Wilms’ tumor, Glycogen storage disease, Low birth weight, talipes, storage disease, Low birth weight, talipes, Cleft palate, Down’s syndrome, mutations of Cleft palate, Down’s syndrome, mutations of the Adenomatous polyposis coli (APC) gene.the Adenomatous polyposis coli (APC) gene. Linked to maternal oral contraceptive use &Linked to maternal oral contraceptive use & total alcohol syndrometotal alcohol syndrome



HepatoblastomaHepatoblastoma

Clinical featuresClinical features

1. Failure to thrive, weight loss and a rapidly1. Failure to thrive, weight loss and a rapidly

enlarging abdominal massenlarging abdominal mass

2. Serum AFP is invariably high and correlates2. Serum AFP is invariably high and correlates

with tumor burdenwith tumor burden

3. It is an aggressive neoplasm that invades3. It is an aggressive neoplasm that invades

locally & spreads to regional lymph nodes,locally & spreads to regional lymph nodes,

adrenals, Lungs, Brain and Bonesadrenals, Lungs, Brain and Bones


HepatoblastomaHepatoblastoma TreatmentTreatment 1. Adjuvant and Neo-adjuvant chemotherapy1. Adjuvant and Neo-adjuvant chemotherapy and Chemo-embolization has improved theand Chemo-embolization has improved the resection rate and overall survivalresection rate and overall survival 2. Transplantation in selected cases2. Transplantation in selected cases PrognosisPrognosis 1. 50-80% long term survival1. 50-80% long term survival 2. Patients with pure fetal type have a better2. Patients with pure fetal type have a better outcome if completely resectedoutcome if completely resected



CholangiocarcinomaCholangiocarcinoma

5-30% of primary Hepatic Malignancy5-30% of primary Hepatic Malignancy

The 2The 2ndnd most frequent Carcinoma after HCC most frequent Carcinoma after HCC

Some arise w/in congenitally dilated ducts,Some arise w/in congenitally dilated ducts,

1. after thorium dioxide( Thorotrast ) &1. after thorium dioxide( Thorotrast ) &

anabolic steroidsanabolic steroids

2. in Intrahepatic lithiais2. in Intrahepatic lithiais

3. primary sclerosing cholangitis3. primary sclerosing cholangitis

4. ulcerative colitis4. ulcerative colitis




5. Choledochal cyst5. Choledochal cyst

6. parasitic infections w/ Clonorchis and6. parasitic infections w/ Clonorchis and

opistorchisopistorchis

Peripheral type arises from smaller bile ductsPeripheral type arises from smaller bile ducts

Hilar type (Klatskin tumors arises from majorHilar type (Klatskin tumors arises from major

duct in the hepatic Hilar areaduct in the hepatic Hilar area

K- ras and p 53 mutations can occur inK- ras and p 53 mutations can occur in

primary sclerosing Cholangitis,primary sclerosing Cholangitis,





1. Patients older than 60 in both sexes1. Patients older than 60 in both sexes

2. Symptoms includes:2. Symptoms includes:

HepatomegalyHepatomegaly

Abdominal painAbdominal pain

Weight lossWeight loss

MalaiseMalaise

AnorexiaAnorexia





3. Hilar CC presents w/ painless jaundice and3. Hilar CC presents w/ painless jaundice and

prurituspruritus

4. CEA and CA 19-9 are sometimes elevated4. CEA and CA 19-9 are sometimes elevated

5. Most of Intrahepatic CC are at an advanced5. Most of Intrahepatic CC are at an advanced

stage w/ involvement of LN & stage w/ involvement of LN & distant distant organsorgans

Prognosis =PoorPrognosis =Poor

Treatment =Resection when feasibleTreatment =Resection when feasible



AngiosarcomaAngiosarcoma


1. Most common primary Mesenchymal liver 1. Most common primary Mesenchymal liver

tumor in Adultstumor in Adults

2. 1% of Liver tumors found in men in their2. 1% of Liver tumors found in men in their

55thth and 6 and 6thth decade of life decade of life

3. Latency period of 20-35 years3. Latency period of 20-35 years

4. Local spread to the spleen in 80% of cases4. Local spread to the spleen in 80% of cases





5. Related to exposure to:5. Related to exposure to:

Thorotrast Thorotrast Vinyl Chloride Vinyl Chloride

Arsenic Arsenic Androgenic Androgenic SteroidsSteroids

Copper Sulfate Copper Sulfate Estrogen Estrogen

Radiotherapy Radiotherapy Chemotherapy Chemotherapy

6. Hemochromatosis6. Hemochromatosis





7. Symptoms includes:7. Symptoms includes:

Abdominal pain Abdominal pain Anorexia Anorexia

weight loss weight loss Fatigue Fatigue

8. PE findings8. PE findings

Hepatomegaly w/ or w/o Hepatomegaly w/ or w/o splenomegalysplenomegaly

ThrombocytopeniaThrombocytopenia




Diagnostic tool-Diagnostic tool- Angiography and Angiography and contrastcontrast

enhanced CT scan of the liverenhanced CT scan of the liver

Prognosis-Prognosis- Grave ; Most patients die Grave ; Most patients die within within

6 months6 months

Deaths are due to Hepatic failure andDeaths are due to Hepatic failure and

intra abdominal bleedingintra abdominal bleeding


METASTATIC TUMORS OF LIVERMETASTATIC TUMORS OF LIVER

OverviewOverview

Liver is the 2Liver is the 2ndnd most common site of mets. most common site of mets.

Over 2/3 of all colorectal cancer ultimatelyOver 2/3 of all colorectal cancer ultimately

involve the liverinvolve the liver

Up to 50% of cancers outside the abdomenUp to 50% of cancers outside the abdomen

metastasize into the livermetastasize into the liver

May be difficult to detect because liverMay be difficult to detect because liver

metastasis are asymptomaticmetastasis are asymptomatic

Surgical Conditions of the LiverSurgical Conditions of the Liver METASTATIC TUMORS OF LIVERMETASTATIC TUMORS OF LIVER

OverviewOverview Metastatic disease to the liver depends onMetastatic disease to the liver depends on type of primary tumor .type of primary tumor . Chemotherapy for liver metastasis fromChemotherapy for liver metastasis from colorectal cancer colorectal cancer Radiation therapy is poorly tolerated by theRadiation therapy is poorly tolerated by the liver but may be palliative for painful liverliver but may be palliative for painful liver metastasismetastasis Hepatic Artery ligationHepatic Artery ligation Surgical resectionSurgical resection

Surgical Conditions of the LiverSurgical Conditions of the Liver TRAUMATRAUMA

Liver is 2Liver is 2ndnd commonly injured organ commonly injured organ High blood flow and in proximity to IVC High blood flow and in proximity to IVC Vital structure and propensity to developVital structure and propensity to develop infectioninfection The overall mortality of liver trauma remainsThe overall mortality of liver trauma remains about 10-20 %about 10-20 % Abdominal pain and symptoms of shockAbdominal pain and symptoms of shock Abdominal paracentesis for blunt abdominalAbdominal paracentesis for blunt abdominal traumatrauma Packing and Pringle’s maneuver (Packing and Pringle’s maneuver (porta porta

hepatis)hepatis)

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