Saturday, June 5, 2010

Liver resection in cirrhosis

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Small HCC in cirrhotics

It is beyond debate that the best treatment for small HCC in a cirrhotic liver is liver transplantation since it achieves the best disease free and overall survival. Liver transplantation in the only modality that can remove the tumor as well as the tumor generating environment of cirrhosis. The only limitations are the paucity of availability of organs for transplantation, costs of transplantation and the risks of lifelong immunosuppression.
Small peripheral HCC in borderline or early cirrhosis who are not transplant candidates pose a dilemma to the liver surgeon to choose between one or more of the local procedures with equivalent results as resection to resection which carries a risk of post-operative decompensation of cirrhosis and mortality.
In experienced hands and in patients with good performance status with adequately sized functional remnant volumes, resection with a parenchyma sparing approach may achieve reasonable results. This may even serve as a bridge to transplantation for patients who subsequently recur within the liver without a major decline in survival.

Monday, March 22, 2010

Acute Liver Failure

Acute Liver Failure (ALF) is a syndrome characterised by deterioration in liver function in previously normal individuals over a period of 16 weeks and manifests as progressively worsening jaundice, liver function and encephalopathy (coma) . In the pre-transplant era, ALF had uniformly poor outcome with a significant number ending in death. However with better intensive care management and timely liver transplantation, many of these patients who are usually younger than those with cirrhosis, can be saved. Transplantation is considered only in patients who develop features of hepatic encephalopathy and severe deterioration in liver function or those who meet recognised criteria (King's College or Clichy). It is therefore prudent, at least in countries where transplantation is not widely accessible, that before the onset of coma and multiorgan failure ensue, patients who continue to have deteriorating liver function be shifted to facilities where transplantation can be offered . Early recognition and risk stratification followed by timely transplantation when indicated is the only way to save patients with ALF.

Friday, March 5, 2010

Liver donation by living donors...........A Necessary Evil but A Gift of Life

Taking organs from a living donor is currently the only reliable way the ever-widening gap between need for organs for transplantation and the organs available from deceased donors can be hoped to be bridged. Until promises of stem cells and other esoteric therapies are practically realised, transplantation from living donors will continue to be in the ever-growing list of 'necessary evils' in modern society. Kidney transplantation from living donors has been around for as long as kidney transplantation itself and hence gained greater acceptability as compared to liver, pancreas or intestine transplantation from living donors. It is believed (and not without some reason) that since donors have two kidneys and one is all that is sufficient, one can be easily donated. However unlike the liver, the kidney does not regain most of (if not all) the lost tissue volume, the other kidney simply adapts and becomes more efficient to take on the additional burden. Similar changes occur in the pancreas and intestine after partial donation. The liver is unique in that the remaining liver (after removal of a lobe for transplantation) is not only usually enough by itself to sustain metabolic activities but it also (demonstrably) grows in size to regain almost all the lost volume. Hence in pure metabolic and tissue mass terms, the living donor is less disadvantaged after partial liver donation than after donation of a part of pancreas, intestine or one kidney. The main concern currently is that removal of a part of one lobe is a much more complex operation than that required for removal of a kidney or a segment of intestine. Hence until a better solution to provide much needed organs for transplantation is found, rather than run down living donation , energies should be concentrated on making the process of donation transparent, simpler, safer and less demanding on the donor.

Sunday, February 21, 2010

Hepatocellular carcinoma in cirrhotic liver

Hepatocellular carcinoma (HCC) is a primary malignant tumour (cancer) of the liver. Most HCCs occur in livers that have been damaged by chronic disease processes like cirrhosis. Thus HCC is a 'tumour in a tumour generating environment'.Certain patients with liver disease eg those with tyrosinaemia, haemochromatosis or hepatitis B are at much higher risk of developing cancers than others. Once HCC develops, the chances of survival decline rapidly unless detected and managed early. Hence all cirrhotics should be under surveillance for HCC with ultrasound and alpha-fetoprotein (AFP) levels at least every 6 months. When HCC is suspected this should be supplemented by contrast axial imaging (CT/MRI) and/or biopsy. Biopsy can be hazardous in patients with advanced disease due to ascites, coagulopathy and risk of tumour spread. Without a biopsy it may be difficult to conclusively prove or disprove presence of HCC since no imaging or tumour marker is 100% accurate. If the suspicion is strong and biopsy is considered very risky, the patient should be assumed to be having HCC and treated as such.

Friday, February 19, 2010

Cirrhosis in alcohol abusers

One of the major causes of Liver Cirrhosis is alcohol. Alcohol causes liver damage through various mechanisms not necessarily in direct proportion to the amount of alcohol consumed. Moreover concurrent alcohol abuse augments the liver damage due to a host of other problems notably Hepatitis C. Many people who have alcoholic liver disease demonstrate no features of physical dependence; yet they find it difficult to stop. The first step is recognising the problem through help of medical professionals, family support and counselling. When alcoholic patients with cirrhosis stop consumption there can sometimes be a dramatic change in their condition that may help postpone the need for transplant if not totally eliminate it. To be considered for a transplant, patients who have alcoholic cirrhosis must have been abstinent for at least 6 months (under supervision) and must have demonstrated the will to be compliant and have a good family and social support. Young patients who have been abstinent for shorter periods but are seriously ill and otherwise suitable to merit a transplant can pose an ethical dilemma in the transplantation. community.