This hypothetical consultation about liver surgery is presented for purposes of general information. Please see your doctor to discuss your individual case and the exams and treatments that are best for you.
Tumors of the liver can be primary, meaning that they form first in the liver, or secondary, meaning that the tumor forms from a cancer that originates elsewhere in the body. Most liver tumors are secondary tumors. In our example, the patient is a 55-year-old man who has had surgery for colorectal cancer in the past, and now has a tumor in his liver that is suspected to be a metastasis or spread from the original cancer.
Doctor: Hello. How are you?
Patient: I’m all right, thank you.
Doctor: I have been looking at your records, and see that a tumor has been found in the right lobe of your liver and your doctor has referred you to me for surgery.
Doctor: Let’s begin by talking about what’s been happening. Please tell me how this all started and what has been going on with you.
Patient: A few weeks ago I began to have pain in my upper abdomen. I went to my primary care doctor and she did an examination and ran some blood tests, and the liver function tests came back abnormal. She had me go for an ultrasound scan, which showed a mass in my liver. Then I had a CT scan that showed a 7-centimeter tumor in the right lobe.
Doctor: And your records show that you have had abdominal surgery before, that you had cancer.
Patient: Yes, I was diagnosed with colon cancer three years ago.
Doctor: What happened at that time?
Patient: I had gone to the emergency room with terrible pain. It turned out that I had a bowel obstruction. They took me right in for surgery, and they found the tumor in the large bowel. They removed the tumor and did a bowel resection.
Doctor: Did you have any other treatment for the cancer at that time
Patient: We discussed chemotherapy, but I decided not to undergo this at that time.
Doctor: And your GI doctor has been following you since the surgery.
Patient: Yes. I’ve had a colonoscopy every year and it’s been clear. So it looked like they got it all when they did the bowel resection, but my primary care doctor feels it’s the same cancer that’s in my liver now. Both my doctors said that this might be operable, and I know UC San Diego has an excellent reputation and does large numbers of liver tumor surgeries and you might be able to operate for this.
Doctor: Yes, we have a major program in hepatobiliary surgery, which is surgery of the liver. We do a large number of surgeries of this kind every year.
Patient: What’s going to determine whether you can take the tumor out?
Doctor: I’ll be taking your history and examining you, and we will go over your test results. Then I will be able to decide whether we can do this surgery in your case, and you and I will discuss what is involved in the surgery.
Patient: All right.
Doctor: First, I will take your history.
The doctor takes a detailed history from the patient, asking him to describe all of his prior illnesses, injuries, and surgeries, his family history, and the details of his diagnosis and treatment for the tumor of the bowel. He learns that the patient is an actively working executive who has no heart problems, does not smoke or drink alcohol, does not use drugs, and has a supportive family.
Then the doctor performs a physical examination, finding that the patient is otherwise healthy. The patient’s chest and heart are normal, and there is a scar on the anterior abdomen from the previous operation for colon cancer.
Doctor: Now let’s review the films from your ultrasound and CT scan.
Doctor: You see the tumor on the x-rays in the right lobe of the liver. Just looking at the tumor, I believe it might be possible to remove it safely because it is confined to the right lobe, and the rest of your liver looks healthy.
Patient: Do you think this tumor is from the colon cancer?
Doctor: It is likely that the liver tumor is a secondary tumor, also called a metastasis, from the bowel tumor you had in the past. It is very likely that tumor cells from your bowel tumor, have grown in the liver.
Patient: That is what I thought. How much of the liver would you remove?
Doctor: We would remove the entire right lobe.
Patient: Is this something you can do in my case?
Doctor: Yes. When we are considering an operation like this, an obvious concern is whether a patient can tolerate the operation. I think you are a good candidate for this operation. You are fit and healthy with a healthy heart, and the rest of your liver looks healthy.
Patient: But if you remove the entire right lobe, what kind of liver function will I have?
Doctor: This part of the liver that we leave behind is going to grow and take over the functions that the entire liver has been performing. This takes anywhere from one to six months.
Patient: When will you know whether this is a tumor that spread from the colon cancer or a new primary tumor?
Doctor: We will know after the surgery, when we have removed the tumor and we have the pathology results.
Patient: Am I going to have to have other treatment in addition to the surgery?
Doctor: The surgery is the first step, so we will do that first and then we’ll send you to see an oncologist so that he can determine whether you should have any other kind of treatment.
Patient: So we just can’t tell at this point.
Doctor: Not until we are able to examine the tissue we remove from your liver.
Patient: All right. What about the procedure itself. What is the scar going to be like?
Doctor: You will have an incision on the abdomen. The liver is a large organ, so we make a big incision to be able to do this safely.
Patient: This operation is done under general anesthesia, isn’t it?
Doctor: Yes. General anesthesia, so you will be instructed to not eat or drink after midnight before the day of the operation. You will come in to the hospital in the morning, and we will do the surgery later that day.
Patient: How can you tell whether you are removing all of the tumor?
Doctor: While you are asleep, we will do an ultrasound scan of the liver to make sure there are no other tumors in the rest of the liver. Once we are doubly sure that this tumor is present only in the right lobe of the liver, we will remove it.
Patient: How long does the operation take?
Doctor: It takes about three to four hours.
Patient: Does the operation involve blood transfusions?
Doctor: The operation could involve some blood transfusions because the liver is an organ that has a lot of blood inside and we are going inside of it, so it could bleed. We take adequate precautions and make sure that we have blood available.
Patient: Can I request to have blood from my relatives?
Doctor: Sure. If you like, because your operation is scheduled in advance, we can do some paperwork to be sure your relatives can donate blood for you.
Patient: What else do I have to do to prepare for the surgery?
Doctor: Our coordinator will schedule the surgery for you and go over the instructions with you. You will come in after a shower, early in the morning, with some clean clothes with you. Do not take any aspirin or Motrin or similar medicines for two weeks before the surgery as they cause bleeding. You will come to our surgical area, and if you have any family members that would like to be present, be sure to bring them along so we can talk to them before the operation.
Patient: Is this a high-risk operation?
Doctor: It’s a high-risk operation because, first of all, it is an operation on the liver, and second, the liver is a very vascular organ. Problems can include bleeding. Very rarely we have seen patients go into liver failure, but in your case that is unlikely because we know your liver is well. Other complications that could result from any operation include clots in the leg that can go into the heart or lungs, and pneumonia from staying on the breathing tube for a little while, or infections. Sometimes there is post operative bleeding or leaks, and that might require us taking you back to the operation room.
Patient: And that would happen in the first two weeks?
Doctor: Usually in the first week or so.
Patient: Will I have to be in the ICU when I come out of surgery?
Doctor: Depending on how the operation goes, you may or may not have to go to the ICU. The ICU stay is typically for only a day or two if you are there at all.
Patient: How long will I be in the hospital?
Doctor: For about a week.
Patient: And if it all goes well, when will I be able to go back to work?
Doctor: You should be able to be able to go back to work in about three months or so.
Patient: Depending on what the oncologist says.
Doctor: Yes. Once we remove your tumor, the pathologist will examine it under the microscope, and if we have been able to take the entire tumor out, with a good normal-looking liver margin around it, we are convinced that we have taken out most or all of the tumor. After this, the oncologist will evaluate you to determine whether you need any chemotherapy or not. It depends on the size and nature of the tumor.
Patient: Do I have to be on any special medications after the surgery?
Doctor: You will be given pain medications.
Patient: Is it a painful surgery?
Doctor: When you wake up after surgery, we will give you enough pain medications so that you are not hurting. When we discharge you home, we will send you with some pain medications to keep you comfortable while you are recovering.
Patient: Will there be any restrictions on my diet?
Doctor: There are some restrictions during the first week after the surgery because you are recovering from a big operation. After that, you will be able to eat whatever you want.
Patient: After the surgery, are there any medications I should not take?
Doctor: There are no specific medications that we would instruct you not to take, but we advise you not to take too many medications and always check with us whether it’s okay to take any given medication. After the operation, the liver starts growing very quickly, in about one month to six months it comes back to its normal size.
Patient: Is there anything I can do to help make sure that my liver grows back healthy?
Doctor: There is nothing you have to do; it is the body’s normal response for the liver to grow back. The only thing we would say is you should not drink alcohol.
Patient: How long after the operation do I need to keep coming back to see you?
Doctor: After the operation, you will come back to our clinic the week after you are discharged, and we will see you every two weeks. If you are doing well, then we will not need to bring you back that often. And, as I said, we will send you to the oncologist for an evaluation to determine whether you will need chemotherapy. Then you would come back to see me in six months to a year’s time. You would also have to go back to your primary care doctor, and continue your yearly colonoscopies, and every year we will do blood tests and an ultrasound scan of your abdomen and your liver, to make sure you don’t have new or recurrent tumors.
Patient: I would like to proceed with this surgery.
Doctor: My coordinator will contact you to set it up. If you have any further questions at all, please do not hesitate to call me.
Patient: Thank you.