1、 Surgical Diseases of the LiverOutlines of todays contents Surgical diseases of the liver 1.Classification 2.Surgical anatomy 3.Liver abscess bacterial abscess 4.Tumor of the liver HCC1.C1.Classification traumatic Infectious：Bacterial Abscess Tumorous:Hepatocellular Carcinoma malformed others：Intrah
2、epatic calculous parasitic 2.Surgical Anatomy of the liverLiver lies in the right upper quadrant of abdomen.The largest gland,weighs 1500g in adult.Falciform ligament Coronary ligamentTriangular ligamentGallbladderLigamentum teres hepaticusDiaphragmThree sets of ligaments1.Falciform ligament2.Anteri
3、or and posterior right and left coronary ligaments,fused to form right and left triangular ligaments at the both endings3.Gastrohepatic and hepatoduodenal ligamentsFour lobes1.Right lobe2.Left lobe3.Quadrate lobe4.Caudate lobe French segmental systemCouinaud nomenclature system 8 segments:hepatic ve
4、nous drainage and portal vein system distribution 4 in the right(segments 5-8)3 in the left (segments 2-4)1 caudate (segment 1)第一肝门第一肝门(The first porta hepatis)肝动脉肝动脉（Hepatic artery）门静脉门静脉（Portal vein）肝总管肝总管（Common hepatic bile duct）第二肝门第二肝门 The second porta hepatisrightmiddleleftHepatic Veins第二肝门第二
5、肝门(The Second Porta Hepatis)第三肝门第三肝门 The third porta hepatis Short hepatic veins Openings of short hepatic veins entering inferior vena cava第三肝门第三肝门 (the third porta hepatis)Liver Functions Bile formation：6001000ml/day/adult Metabolism of carbohydrate,lipid,protein and vitamin:glycogen;fat-soluble v
6、itamin A,D,E,K Coagulation:fibrinogen;coagulation factors;Prothrombin Metabolism of Drugs and Toxins:oxidation,reduction and hydrolysis Immunologic Function Regulation of the systemic circulationLiver Blood flow 70%to 75%of total hepatic blood flow comes from the portal vein,while the remainder come
7、s from the hepatic artery.However,40%60%oxygen supply comes from hepatic artery 3.Liver AbscessLiver abscess may be bacterial,parasitic,or fungal in origin.Bacterial abscess the most common Amebic abscess next to the most common Bacterial liver abscessEtiology:Biliary tract Hepatic artery Portal vei
8、n Lymphatic system injuryBiliary Infections Abdominal infections Generalized sepsisempyema of the gallbladder appendicitis pneumonitisprotracted cholangitis diverticulitis endocarditis biliary tractportal veinhepatic arteryLiver Abscess Clinical features Chill,hyperthermia:3940 oC Hepatalgia:persist
9、ent pain Hepatomegaly WBC B-type ultrasound:2cm,96%CT scan:positive rate 90%X-ray:elevated hemidiaphragm,blunt costophrenic angle,intrahepatic air-fluid levelDiagnosis and Treatment Correct diagnosis of pyogenic versus amebic abscess is very important,because the treatments are radically different.D
10、ifferential diagnosis between bacterial abscess and amebic abscess History:abdominal infections;diarrhea Abscess:multiple;single Symptom:fever and chill;fever without chill Blood test and culture:serologic test positive;negative Stool test Pus Diagnostic therapy:antibiotic,amebicide Therapy for bact
11、erial liver abscess Supportive treatment Antibiotics Percutaneous catheterization and drainage Open drainage Transabdominal drainage Extra-peritoneal drainage Amebic abscess Non-operative Except:rupture and secondary infectionpercutaneous drainage4.Tumor of the liverClassification Benign tumors Mali
12、gnant tumorsBenign Tumors Cavernous Hemangioma Adenoma Focal nodular hyperplasia Lipoma Teratoma Leiomyoma Malignant Tumors Primary liver cancer Secondary(metastatic)liver cancerPrimary Liver cancer(PLC)Hepatocellular carcinoma(HCC,9095%0f PLC)Cholangiocarcinoma Hepatocellular-cholangiocellular carc
13、inoma(combined type)Cellular types:Hepatocellular Carcinoma (HCC)Prevalence of HCCAge-Standardized Liver Cancer Incidence Rates Among Males Jemal A,et al.CA Cancer J Clin 2002 fifth most common cancer in men and eighth in women third leading cause of cancer death in men and the sixth among women Chi
14、na accounts for over 55%of the total hepatitis virus B or C cirrhosis aflatoxin EtiologyHepatitis B Virus 70%80%of HCC patients,HBV carrier in Asia and Africa 21%of HCC patients,HBV infection in USAHepatitis C HCV infection presents in 51%of the patients with HCC in Japan.26%with HBV infection in th
15、e same countryCoexistence of Cirrhosis and HCC 68%74%UK 70%Japan 80%86.5%China Clinical features1.Hepatalgia:upper abdominal pain,tenderness2.General and digestive:weakness,anorexia,malaise,weight loss3.Hepatomegaly:abdominal mass(14%),4.Jaundice(24%)DiagnosisSpecific marker:AFP(-fetal protein)eleva
16、tion,or=400ug/LRadioimmunoassay:positivity 6993%30%negativeMild elevation:acute hepatitis,chronic liver diseaseMarkedly increase:teratocarcinoma,yolk sac tumor,rarely metastastic tumor from pancreas or stomach B-type ultrasound:2cm;84%CT scan(computed tomography):1 cm;90%Hypoechoic lesion MRI(magnet
17、ic resonance imaging),sensitivity 95%Radioisotope scanning:99mTc red hepatic single-photon emission computed tomography,SPECT 3cm;8590%X-ray Needle biopsy:guided by ultrasound Laparoscopy:over 70%of liver surface direct assessment of abdominal spreadTreatment of HCC treatment options for HCC1.Hepati
18、c resection the most effective 2.Chemoembolization3.Chemotherapy4.Cryosurgery5.Radiofrequency Ablation6.Radiation Therapy7.Percutaneous Ethanol Injection8.Liver TransplantationHepatic Resection At present,resection is the only therapy that substantially prolongs survival.Resection has often resulted
19、 in cure,particularly in the absence of cirrhosis.*Selection of suitable patients who could tolerate a hepatic resection.The patients are required to meet the following criteria:Serum albumin 3.5gm/dl3.5gm/dl Prothrombin time Prothrombin time 3 seconds3 seconds AST normalAST normal Serum total bilir
20、ubin normalSerum total bilirubin normal ICG retention(at 15 min.)ICG retention(at 15 min.)15%15%Without ascitesWithout ascites Nontumorous liver parenchyma Nontumorous liver parenchyma 50%50%Case 1Hepatic resection Transarterial chemoembolization,TACEEmbolization is the process of injecting a foreig
21、n substance(iodized oil)into the tumor to stop the blood flow.The lack of blood deprives the tumor of needed oxygen and nutrients and eventually causes cells to die.Case 2 Regional chemotherapy Systemic chemotherapy response rate less than 25%ChemotherapyRegional drug delivery system(A subcutaneous
22、port is a small metal chamber with a rubber top that is placed under the skin of the abdomen.)Cryoablation Double freeze technique:The tumor and a half inch margin of normal liver are frozen to-190C for 15 minutes,which is lethal to all tissues.The area is thawed for 10 minutes and then re-frozen to
23、-190C for another 15 minutes.After the tumor has thawed,the probe is removed,bleeding is controlled,and the procedure is complete.5-year survival:1160%,depending on case selectionRadiofrequency ablationCoagulative necrosis from 1.6 to 3 cm Indications:fewer than three lesions each less than 3 cm in diameter,or a single recurring lesion less than 5 cm in diameter.
