Alcoholism is a common is order in the North America, affecting more than 3 million people per year. Alcoholism is defined as consumption of 8 or more drinks per week for woman and 15 or more drinks per week for man. Alcoholism is a known cause of liver disease such as fatty liver, alcoholic hepatitis, liver fibrosis, and eventually liver cirrhosis. Liver is an organ with a generous regenerative capacity. Even after significant insults to the liver such as trauma, inflammation, infection, and even major surgical resection, a full functional recovery is expected. Hepatitis B and C are the two most common types of infection affecting the liver cells. Many patients are not aware of having this infectious disease until they are diagnosed with liver cirrhosis based on a CT scan or right upper quadrant ultrasound for vaque abdominal pain. With repetitive or longstanding insults such as alcoholic drinking and chronic hepatitis B/C infection, liver cells can become permanently injured and replaced by scar tissue (fibrosis). This leads to irreversible liver cirrhosis and liver failure. When advanced stage of liver cirrhosis or liver failure is reached, patients commonly present with generalized weakness, jaundice (yellowing of skin and eyes, dark urine), ascites (abdominal distention from fluid), confusion (caused by high ammonia level in the blood), and episodes of gastrointestinal bleeding (caused by portal hypertension). This is a situation where liver resection to try to remove a liver cancer can no longer be performed safely.
Liver cirrhosis can also be caused by other factors such as hemochromatosis (excessive iron deposition in the liver), nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NASH), autoimmune hepatitis, and cryptogenic (unknown cause). Liver cirrhosis is a well-known predisposing factor for development of hepatocellular carcinoma, the most common type of primary liver cancer. In about 13% of patients diagnosed with hepatocellular carcinoma, however, liver cirrhosis is not found. In our Tampa liver surgery center, we frequently see patients with hepatocellular carcinoma without liver cirrhosis (5%). The patients usually ask lot of questions of why they are getting the liver cancer without having consumed an excessive amount of alcohol during college or contacting liver cirrhosis from other causes. Dr. Sucandy typically explained, “one does not have to smoke to develop a lung cancer !”. This is a similar situation and there are still many unknown factors that play role into liver cancer development.
Hepatitis B infection and nonalcoholic fatty liver disease can also lead to the development of hepatocellular carcinoma without causing liver cirrhosis. Hepatitis B is commonly seen in Southeast Asian countries. Once hepatitis B/C is diagnosed, they should be treated by a hepatologist ‘liver doctor’ or a liver specialist. Hepatitis C once known to be a lethal infection, now is curable with 8-12 weeks of taking oral medication. A confirmatory serology (blood test) is conducted to make sure an undetectable viral load is achieved upon completion of the treatment. It is very important to see a liver specialist for any questions about hepatitis infection or signs of early liver cirrhosis. In our liver cancer program, Dr. Sucandy works collaboratively with a hepatologist to provide care for patients with liver cirrhosis, fatty liver disease, and hepatitis B/C infection.
Liver resection to remove a hepatocellular carcinoma or other forms of liver cancer in cirrhotic patients requires a complex decision making. An objective assessment of the liver function needs to be done, in addition to measuring the amount of liver to be removed and preserved. In general, at least 40% of future liver remnant volume needs to be preserved in cirrhotic patients in order to avoid postoperative liver failure. In our Tampa liver cancer center, the liver resection can be done minimally invasively using robotic liver resection with excellent outcomes. When the liver resection cannot be offered due to limited/borderline liver reserve, an alternative treatment of laparoscopic radiofrequency ablation (RFA) or microwave ablation (MWA) is utilized. Dr. Sucandy performs this procedure frequently. It is important to see an experienced liver surgeon when dealing with a liver cancer in the setting of liver cirrhosis, since the operation is usually more challenging. With the expertise of multidisciplinary team, postoperative complications after a liver surgery can be minimized.