What is the liver? What is his role ?

The liver is the largest of the accessory glands of the digestive tract. It has a dual function: it excretes the bile necessary for the digestion of fats and plays a role in the metabolism of glucose, proteins and coagulation. It allows the synthesis of many proteins (having a role in coagulation and having a role in the transport of other proteins such as albumin). It has a role of detoxification, in fact the blood which arrives at the liver coming from the digestive tract and which contains the product of the digestion of food is not usable as it is. This blood (which arrives through the portal vein) must be filtered by the liver before passing into the general circulation through the supra-hepatic veins. The liver occupies the entire right side of the abdomen and weighs about 1500g. The liver is able to regenerate.

What is liver metastasis?

We speak of hepatic metastasis when a group of cancer cells has spread from its place of origin (primary colonic tumor for example) to a new part of the body (the liver).

Hepatic surgery for metastases can be a relevant therapeutic alternative in specific cases. Treatment plans are designed to meet the unique needs of each person with metastatic cancer. The treatment of hepatic metastases aimed at removing the metastases in order to prolong survival. The indication for such surgery meets specific criteria which will be explained to you by your surgeon.

In some cases, surgery is used to treat liver metastases. If the person has several liver metastases spread throughout the liver or metastases are present elsewhere in the body (lungs, peritoneum, etc.), surgery is generally not considered.

Surgical removal of a liver metastasis (hepatic resection or partial hepatectomy) may be an option in the following cases:

• The primary cancer is under control.
• In the case of colorectal cancer, the liver is the first site of spread and possibly the only place where the cancer spreads. The use of surgery to remove liver metastases can be very effective in some cases.
• Surgery is usually not an option for liver metastases when they come from more aggressive cancers like pancreatic or stomach cancer.
• There are only one or a few metastases and enough free liver.
• There is a high probability of completely removing the liver tumor while maintaining satisfactory liver function for the person.
• The person can tolerate the surgery.
• The liver is of good quality, in fact, the presence of another disease, such as cirrhosis of the liver, could make surgery impossible, because such a disease damages the liver.

The extent of the surgery depends on the size of the liver metastasis and its location in the liver. It is possible to remove up to 75 or 80% of the liver because it is an organ capable of regenerating itself. The remaining portion grows again after surgery, which may take several weeks to a few months. In addition, following the surgical removal of one lobe of the liver, the other takes over.

People with colorectal cancer have a high risk of liver recurrence following surgical removal of a liver metastasis. In some cases, surgery can be done again when doctors believe resection of the metastasis is possible, but this surgery is more difficult to perform.

The operation can be performed laparoscopically (several centimetric incisions and an incision of about 5 cm to extract the segment of liver to be analyzed from the belly), sometimes a classic incision in the abdomen (or laparotomy) may be necessary. Your surgeon will use the technique which, in your case, seems the most appropriate and the safest.

There are many types of possible operations on the liver (metastasectomies, segmentectomies, bisegmentectomies, hepatectomies). Your surgeon will discuss with you, prior to the procedure, the type of surgery he is likely to perform.

It is important to know that different doctors practicing in different disciplines (surgeon, anesthetist, gastroenterologist, cardiologist, oncologist, radiologist, radiotherapist, pathologist) practicing at the Charcot clinic (Lyon) will work as a team to ensure your treatment, this is called multidisciplinary treatment.

This guarantees the meeting of all the essential skills for your treatment to be optimal. During your treatment, you will therefore be put in contact with various doctors working at the Charcot clinic (Lyon).

The choice of the type of treatment depends on the situation and the evolutionary stage of the malignant tumour, the type of cancer, and your state of health.

To determine this, additional examinations will be carried out such as a CT scan, an MRI, a scintigraphy, a colonoscopy, a blood test, etc.

After discussion of your file by the multidisciplinary team, we will discuss with you the results of these various examinations and the follow-up for your treatment. You can bring a family member to this discussion.

Treatment options for liver metastases are based on the following factors:

• The original site of the cancer.
• The size and location of liver metastases.
• The number of liver metastases – single or multiple.
• The state of the healthy liver, i.e. which does not present any liver metastasis(ies).
• Symptoms and functional state of the liver.
• If other areas of the body are affected.
• The treatment already administered, if applicable.
• The age and general state of health of the person.

Depending on the type of primary cancer, other options may also be considered, including chemotherapy, targeted therapies, and radiofrequency to treat liver metastases.

Chemotherapy is sometimes given before surgery (neoadjuvant chemotherapy). For example, a person with a liver metastasis that cannot be removed surgically because it is too large may first have chemotherapy to reduce the size of the tumor and it may then be removed with surgery. .

How to prepare for liver surgery for liver metastases?

Communicate your personal treatment to your surgeon and inform yourself about the drugs which must be stopped or on the contrary continued for the intervention. Don’t forget to mention drugs as innocent as aspirin because they can increase the risk of bleeding.

If you are allergic to specific drugs (eg iodine, aspirin, antibiotics, etc.), you must report this to your surgeon and the anesthesiologist.

You will meet the anesthesiologist. He will answer all your questions about anesthesia.

How is liver surgery for liver metastases performed?

After having met your surgeon, who confirmed that this surgery had to be carried out, he will explain the procedures to you.

If you take medication on a daily basis, you should discuss this with your surgeon and your anesthesiologist, who may want you to take some of your medication on the morning of the procedure with a background of water. If you take aspirin or medication to thin your blood, tell your surgeon and your anesthesiologist. If you are diabetic say so too.

For surgery on the liver, you must be hospitalized and the operation is performed under general anesthesia.

The Charcot clinic team (Lyon) welcomes you on admission, the morning of the operation, checks the administrative formalities, ensures that there is no new information and that the instructions given before intervention (shower, fasting, etc.) have been respected.

Then you are taken to the operating room in the operating room, your surgeon, surrounded by his team, welcomes you, and carries out the usual checks (identity, compliance with instructions, etc.).

The operation can be performed laparoscopically (several centimetric incisions and an incision of about 5 cm to extract the resected liver segment from the belly and analyze it), sometimes a classic incision of the abdomen (or laparotomy) may be necessary. Your surgeon will use the technique which in your case seems the most appropriate and the safest.

There are many types of possible operations on the liver (lumpectomy, segmentectomy, bisegmentectomy, hepatectomy). Your surgeon will discuss with you before the procedure the type of surgery he is likely to perform.

During the operation, the part of the liver where the tumor is located is removed with the widest possible safety margin (passing away from the tumor).

The duration of the intervention varies from 2 to 3 hours and depends on the difficulty that your surgeon may encounter depending on the complexity of the procedure to be performed on your liver. Redons (small pipes) can sometimes be put in place in contact with the liver, and will be gradually removed.

Once awake, after a few hours in the recovery room, you return to your room. A nurse on the ward makes sure that you are not in too much pain, that you have no nausea or vomiting, that you gradually come to your senses. A snack is served. Your surgeon comes by at the end of the day to make sure that you are well, authorizes the gradual resumption of food (first a few drinks then solid foods) and gives you his findings and post-operative instructions. A hospital stay of 5 to 10 days is necessary.

There is no operation without risk. After liver surgery, there are complications such as thrombosis, postoperative bleeding, surgical site infections, damage to nearby organs or lung infections.

Your general condition can obviously have a very important influence on the progress of the operation and on the risks associated with the operation. Do not hesitate to discuss this with your doctor and do not hesitate to give him all the information that may be necessary on this subject (previous illnesses, treatments used).

When it comes to liver surgery, there are a few specific possible complications. A complication is bile leakage (bilioma). Other complications may occur: pain, fatigue, bleeding disorders (haemorrhage) or blood clotting (thrombosis, phlebitis, pulmonary embolism), infection of the wound (abscess), pneumonia, abnormal accumulation of fluid in the abdomen (ascites ), abscess in the region below the diaphragm (subphrenic abscess), portal hypertension and hepatic insufficiency (failure to function of the liver which no longer plays its role of detoxification and synthesis).

It is also possible that during dissection (of adhesions or when freeing the colon adhering to the liver) other organs (the colon) may be damaged. Necessary measures must be taken so that each bleeding or each breach or tear in an organ is repaired in a safe manner.

The enumeration of complications which has just been reported is not exhaustive, but it provides information on the most important and most frequent complications. Reoperation or radiological drainage may be necessary.

An operation on the liver is a serious operation for which there is a vital risk during the hospital stay. The risk of the operation is determined by various factors: the location and size of the tumour, invasion or spread into other organs, whether or not there are complications, your general condition, etc It is not easy to precisely determine the risk for each patient before the operation. On average, the mortality risk is between 3 and 5%. If an indication for surgery has been retained, unlike cosmetic surgery, it is very likely that there would be more risks in postponing an intervention (progression of the metastatic disease). If in doubt on your part, do not hesitate to ask your surgeon for clarification.

Usually, this intervention is not very painful and the pain responds well to simple analgesics (paracetamol) which will also be prescribed to you when you leave the hospital. You can get up the evening of the operation or the next day at the latest. You can drink from the evening of the operation and gradually resume a normal diet. Blood tests will be done daily to make sure the liver is working well. Redons will be phased out. Sometimes a Doppler ultrasound of the liver will be carried out after the intervention by a radiologist.

Recovery may sometimes be necessary.

Once at home, you can gradually resume your daily activities and light activity.

A work stoppage of 3 to 4 weeks will be prescribed for you (taking into account the particularities of your work)

Pain under the ribs or towards the shoulders may appear the day after the operation. They are due to the gas required for laparoscopy. These pains always disappear in 24-48 hours.

One month after the operation, you go to your post-operative consultation. Your surgeon then authorizes you to resume your physical and sporting activities.

You must absolutely contact your surgeon in case of persistent fever, appearance of jaundice, or abdominal pain that resists the medication prescribed after the operation, persistent nausea, vomiting, persistent cough, breathing difficulties or discharge through an incision.

When you leave, the documents provided by your surgeon and/or the nurses in the service include the telephone number of the surgery secretariat and the telephone number of the general practitioner on duty (7 days a week, 24 hours a day) practicing at the Charcot clinic. (Lyons). He can, if he deems it necessary, hospitalize you. Do not hesitate to contact us.

Resume very light activity, walking is allowed, avoid driving for 5 days. It is normal for the surgical area to be painful at first and will remain sensitive for some time. This should not prevent you from moving, walking and carrying out the acts of daily life.

During your recovery:

1. Precautions

• It is advisable to take showers (the bath is to be avoided for a month).
• Do not carry heavy loads (for at least one month).
• On prescription from your anesthetist: wearing compression stockings and anticoagulant.
• In case of laparotomy: an abdominal belt will be prescribed and must be worn until the next consultation.
• In case of exposure to the sun, provide protection against UV (total sunscreen cream) the best solution is to wear clean clothing to cover the scar.
• Avoid practicing sport until the next consultation.

2. Bandages

• You have to leave the scars exposed. There is no need to bring in a nurse.
• The threads on your scar are absorbable, they can get wet and will disappear on their own. After your shower, pat the scars dry with a clean towel.

3. Diet

Food can be resumed without restriction but in moderation.

The results of the microscopic examination of the surgical specimen will be communicated to you during your hospitalization or during the postoperative consultation after one month.

The results of the pathological examination provide information on the type of tumor and its extension. This does not prejudge the consequences and the evolution. Chemotherapy is sometimes used after partial liver surgery to reduce the risk of cancer recurring.

Regular follow-up with clinical examination, blood test and scanner will be organised.