Liver Ablation What is the Liver? The liver is the largest solid organ in the body. It is located in the right upper part of the abdominal cavity, below the breathing muscle (diaphragm), and behind the rib cage. It is surrounded by multiple vital organs, the stomach lies on its left, the gallbladder sits just below the edge of the liver, and the small and large intestines travel along its lower border. The liver is made of two parts, a bigger right lobe and a smaller left lobe. The liver is connected to the intestines through a conduit called the common bile duct. The gallbladder that has a function of storing bile is also connected to the common bile duct via the cystic duct. The liver is responsible for a plethora of vital functions, including but not limited to detoxification of body wastes, production of essential nutrients for body function, it produces bile that helps with fat digestion, it has a very important role in immunity, and it produces clotting factors to prevent bleeding. The liver is the only visceral organ that has the ability to regenerate. After liver surgery the remaining liver portion will grow in volume as to assume the function of the liver portion that was surgically removed. In healthy livers, we only need 20-25% of our liver to survive, that means that, if needed, a 75-80% of the liver can be surgically resected. That is not the case in livers that diseased, as in fatty liver and livers of cirrhotic patients per example, in which cases about 30-50% of the liver is needed for survival. External Anatomy of the Liver

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Internal Anatomy of the Liver

The liver get its blood supply though two sources: the hepatic artery and the portal vein. Blood after circulating through the substance of the liver and detoxified, drains into hepatic veins that direct blood back to the heart. These blood vessels and bile ducts divide into smaller branches that supply individual segments of the liver. There are 8 segments in a human liver. Liver surgery is mainly based on this internal liver anatomy. The aim of surgery is the remove as little liver substance as possible and maintaining adequate blood supply and adequate drainage of the remaining portion of liver.

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Common Symptoms of Liver Diseases Liver disease symptoms vary between benign diseases and cancerous diseases. Common symptoms depend on the nature of the problem but in general include: • • • •

Abdominal pain: depending on the size and location of a liver tumor, that might cause abdominal pain is different areas of the abdomen, most commonly in the right upper side. Jaundice: liver diseases can present very late where jaundice (yellowing of the skin and mucous membranes) happens. Weight loss, poor appetite and aversion to food. Fatigue, depression.

Treating Liver Diseases Liver diseases that are treated with surgery are usually tumors or masses/cysts. The are divided into three categories: 1- Benign liver lesions: these are benign and not cancerous in nature and do not progress into cancers. Examples include benign liver cysts, hemangiomas, and focal nodular hyperplasia (FNH). Surgery for these lesions is indicated if these lesions cannot be known if they are benign or malignant based on imaging studies, or causing symptoms such as abdominal pain, or compressing other surrounding organs. 2- Precancerous liver lesions: these are benign lesions at the present time but do have the risk of becoming cancers. These lesions are usually surgically removed once diagnosed. The most common example is a liver Adenoma. These usually occur in females who are taking birth control pills. Stopping these medications is the first step in treatment of these lesions, this might cause regression in their size, however they very rarely disappear and will still require surgery or close surveillance. 3- Cancerous liver lesions: these are cancerous lesions either spreading to the liver from other cancers (Colon, rectal, pancreas, breast cancers, ..), or primarily arising in the liver such as Hepatocellular Carcinoma (HCC), which is a cancer of liver cells, or Cholangiocarcinoma, which is a cancer of bile duct cells that are present in the substance of the liver. These lesions and cancers are treated in general, and the treatment is dictated by the stage of the disease and might involve surgery, transplantation, chemotherapy, or radiation therapy.

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Surgery of the Liver The extent of surgery of the liver is dictated by the location of the disease, whether benign, malignant or pre-malignant,. Liver surgery is one of the biggest and most involving surgeries in the abdomen, and that is due to the proximity of the liver to vital organs, in addition to important blood vessels. Liver ablation has become one of the most common minimally invasive methods to ablate or burn liver lesions that are too risky to be removed with old fashion open surgery. The aim of liver ablation is to burn liver lesions in patients deemed a high surgical risk or cirrhotic patients where liver surgery is contra-indicated.

Microwave Ablation In certain tumors of the liver, the current approach is to burn the liver lesion in place instead of surgically removing it. This is a novel approach for selected liver tumors that we use nowadays, to spare some patient the morbidity and the complications of large liver resections. Liver ablation is done on patients that cannot tolerate and will not survive a major liver resection, or in some tumors that are very small and be ablated achieving similar results to liver resection. This procedure can be done through small band-aid type incisions where a camera is inserted into the belly and an ultrasound probe is used to locate the tumor in the substance of the liver, then a thin microwave antenna is inserted through the skin to target that lesion and burn it in place using microwave technology. This is a very safe and effective procedure when indicated. Patients will be discharged home the same day, or will spend one night in the hospital at the most.

Other Procedures for Chronic Pancreatitis

Microwave Antenna

There are a few other procedures done for chronic pancreatitis, and these are called drainage procedure, examples are Beger, Frey and Puestow procedures. These are usually done in certain circumstances where the aim of the procedure is the drain the pancreatic duct into the intestine as the usual drainage channel is obstructed or involved by the disease.

Ultrasound Probe

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Camera

Before Ablation

After Ablation

Tumor

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Before Ablation Surgery •

• •

Ask your doctor what to do if you take prescription blood thinners such as Aspirin, Coumadin (warfarin), Plavix, Eliquis, or others, as it is not safe to have pancreas surgery while taking these blood thinners. There is no need to stop taking ibuprofen, or naproxen. Have any tests, such as blood tests, that your doctor recommends. Don’t eat anything after midnight, the night before your surgery.

The Day of Ablation Surgery • •

Arrive at the hospital or surgery center on time. You will be given an IV to provide fluids and medication. An anesthesiologist will talk with you about the medications used to prevent pain during surgery. Liver ablation surgery is done using general anesthesia. This lets you sleep during the procedure.

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Discharge Instructions after Liver Ablation Surgery You just had liver ablation surgery and completed your hospital stay after the procedure. It is now safe to be discharged home. Your surgeon will be keeping a close eye on your progress even if are at home. Healing from a liver ablation surgery usually takes a few days. Activity: We encourage resuming walking and light activity immediately; as soon as you are sure you are not going to have issues with dizziness or lightheadedness. You may resume driving when it is comfortable to walk up and down stairs. You should be able to slam on the brakes to avoid an accident without causing any pain. Don’t plan on any strenuous activities, like sports or going to the gym, until your postop appointment. Your surgeon may have specific instructions to add to this; usually these are outlined to you before surgery. The bottom line: if it hurts, don’t do it! Eating: The basic rule is take in what your body is telling you. It takes about a week at least after liver surgery in order to resume a regular diet. Your stomach will be slow at digesting food especially after a large liver resection, certainly faster with laparoscopic or robotic surgery. Some find it easier to digest bland foods, light foods, or predominantly liquids. Make sure you stay hydrated, and avoid excessive caffeine. Also, no alcohol if you are taking prescription pain medications. We strongly recommend being on supplements like Ensure or Boost after surgery for a few weeks. Elimination: Constipation is very common after surgery. We recommend staying well hydrated, and using Miralax, prune juice, or Milk of Magnesia for a few days until things are back to normal. Do not let more than 48 hours go by without a bowel movement without starting the above medications. If they fail to help within another 24 hours, call our office. Diarrhea is common if you are taking antibiotics. If you have this problem, we would suggest either probiotics while you are on the antibiotics, or eating yogurt with active cultures. If diarrhea occurs more than 4-6 times daily for more than 48 hours, call us. Make sure your doctor is aware of any chronic difficulties with urination (like prostate trouble) before surgery. Wound care: Usually surgical wounds will have either glue or steri-strips (butterfly tapes) on them, often covered with gauze. Glue, steri-strips, or waterproof plastic dressings can all get wet the day after surgery (unless your surgeon advises differently). Wounds with visible staples or sutures can get wet in the shower after 48 hours. Do not submerge your wound (tub bathing or swimming) for one week. If you have a feeding tube, do not submerge in water until this tube is removed. If you have a surgical drain, do not submerge in water until that drain is removed. While soap will not harm the wound, do not scrub it. Do not apply peroxide or other chemicals unless you have been told to do so by your doctor. After 48 hours, change or remove gauze dressings or Band-aids. Do not leave soiled or wet dressings on the wound beyond 48 hours. Most wounds can then remain uncovered, unless you have been told otherwise. Light gauze covering to prevent chafing is acceptable if you wish. You may notice a slight drainage (usually pink or reddish in color) from the incision site. This is normal and not a cause for concern. Light pinkness immediately surrounding the incision, and not spreading over time, is normal. Bruising is Virginia Surgery Associates, P.C.

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common and may extend for up to an inch. Spreading redness, progressive swelling with bruising, and malodorous drainage are not normal and should prompt a call to our office. Drains: If you are sent home with surgical drains, you will likely be given instructions at the time of discharge for care of them, and a log sheet to record the output. It is important to note the daily output of the drain(s) so we will know when to remove them. Drains that empty into a suction bulb or attached bag can get wet in the shower. If there is gapping of the skin around the drain. Do not submerge the drain site underwater, such as tub bathing or swimming. Slight pinkish or yellowish drainage from around the tube is normal while it is in place, as is a small amount of redness at the site. Gauze over the site may help protect your clothing from staining. Foul smelling or copious drainage around the drain, or spreading redness around the drain, is not normal and should prompt a call to our office. If the drain reservoir fails to hold suction when you squeeze it, or if the drainage suddenly drops to near zero, call our office Normal care of drains includes emptying the fluid in the reservoir every 8 hours and recording the amount per 24 hour period. Bring this record to your postoperative appointment. The fluid may need to be emptied more frequently if the drainage is heavy. Fluid will often be red at first, then pink, then yellow as the wound heals. Stringy material in the tubing or reservoir is normal. Medications: Prescription pain medications are there to help you recover comfortably, but stop them as soon as you are able. Side effects of nausea, vomiting, dizziness, fatigue, poor appetite, and above all constipation, are common. If you have these issues, try to use ibuprofen and Tylenol instead (see below). Do not use alcohol or drive if you are taking prescription pain medications. Unless you are told differently by your surgeon or primary doctor, you can take 400 mg ibuprofen every 4-6 hours, or 800 mg every 8 hours, for the first 3-5 days after surgery, for a maximum dose of about 2400 mg/day (refer to the label for specific dosing based on age and weight). It is best if you can take some food with this medication. Tylenol is also acceptable in small liver surgeries, however should be avoided in large liver surgeries, or if you have cirrhosis, ask your surgeon if you can use Tylenol after your liver surgery. Blood thinners should only be restarted after surgery according to the plan discussed with you by your surgeon or prescribing doctor before surgery. If this was not made clear to you, call our office. All other medications should be resumed once you get home. Vitamins and supplements are not necessary to help you heal, unless you have a known deficiency. You may resume them after you get home if you wish. We would suggest sleep aids not be used while you are on narcotic pain medications.

If Difficulties Arise: Please call us if any problems or questions arise. We can be reached any time, including evenings and weekends, by calling our office number (703) 359-8640 and selecting to speak to the on call physician. Call your doctor if you have any of the following: • Fever over 101°F or chills • Increasing pain, redness, or drainage at an incision site Virginia Surgery Associates, P.C.

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• • • • •

Yellowing of the skin or eyes, or brown colored urine Vomiting or nausea that lasts more than 12 hours Prolonged diarrhea Chest pain or shortness of breath Inability to urinate within 8 hours of discharge

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