Repeat Liver Resection
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New tumors can arise after a liver resection either via open, laparoscopic, or robotic liver surgery method during the surveillance phase. New liver cancers are usually found in different locations in the liver, away from the area of prior liver resections. Each type of liver cancer is different in term of recurrent potentials. Metastatic colon and rectal cancers to the liver can recur several years after the initial liver surgery. It is important to detect an early tumor recurrence using imaging modalities such as CT scan or MRI, in addition to following the level of tumor markers. Liver biopsy is often necessary to confirm the liver cancer recurrence. A PET scan is useful to rule out other distant metastases such as brain, lung, bone or retroperitoneal lymph nodes metastasis. Once the liver cancer recurrence is diagnosed, immediate consultation with a liver surgeon or liver specialist is necessary. Liver cancer treatment should not be delayed simply because of logistics.
Management of recurrent liver cancer has evolved significantly in the last decade. Improvement in safety profile of liver resection/liver surgery and perfection in minimally invasive liver surgery technique extend the indication of repeat liver resection. Many patients with recurrent liver tumors are candidates for a repeat liver resection in combination with liver ablation and systemic chemotherapy administration. For colorectal cancer with liver metastases, repeat liver resection has been well documented to increase long-term overall survival and it is safe. Some patients achieve survival more a decade after the index metastatic diagnosis and the initial liver resection.
A preoperative evaluation for a repeat liver resection is essentially similar to one for the initial liver resection. A higher technical challenge is expected with a repeat liver resection, mainly related to volume of liver remnant and scar tissue formation around the liver, diaphragm, and intestines. However, in experienced hands of a liver surgeon, repeat liver resections can be done safely with similar short- and long-term outcomes as those of initial liver resections. The use of minimally invasive liver surgery approach during the initial liver resection facilitates easier repeat liver resections. This is secondary to the less scar tissue formation associated with minimally invasive liver surgery. The repeat liver resections can also be safely performed using the minimally invasive surgery method by experienced liver surgeons.
In our liver surgery program, we offer robotic liver resection for patients with recurrent liver tumors/liver cancers. Robotic technology allows for the repeat liver resection to be done without the need to create a large open incision, thus minimizing potentials for postoperative complications and facilitate faster recovery. Robotic liver operation also creates significantly fewer intra-abdominal adhesions, allowing for future repeat operation to be done also minimally invasively if other new tumor reoccurs in the liver. Parenchymal sparing liver surgery principal is followed in each liver resection to preserve as much non-cancerous liver parenchyma as possible. Advanced interventional radiology technique such as preoperative portal vein embolization or robotic portal vein ligation to induce hypertrophy of the future liver is also frequently applied in this circumstance. Liver transplant does not play role in patients with recurrent metastatic cancer to the liver.
Repeat liver resections may also be combined with liver tumor ablation (radiofrequency ablation or microwave ablation), depending on the tumor location, number, and proximity to major biliovascular structures. This will be determined by the liver surgeon after reviewing CT scan or MRI scan prior to the operation. Patients with metastatic liver cancers who achieve tumor-free status experience significantly longer overall survival benefits. Dr. Iswanto Sucandy has significant experience in performing minimally invasive robotic liver resection for patients who had undergone prior liver resection at other institutions, including those with open abdominal operation(s) previously.