Surgery for liver cancer at Hammersmith Hospital

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1 Surgery for liver cancer at Hammersmith Hospital Information for patients, relatives and carers This booklet has been provided to help answer some of the questions you may have about surgery for liver cancer. What is surgery for liver cancer? The liver is the largest organ in the body and is situated on the right hand side under the ribcage. It is responsible for: Producing energy for the body Making bile, which helps with digestion Storing and filtering blood Breaking down toxins (poisons) Removal of waste products Producing substances that the blood requires in order to clot p1

2 You have been told that you have developed a tumour (a growth of cancerous tissue) or tumours in your liver. The majority of liver tumours are malignant (harmful) and can be divided into two main groups: 1. Those starting in the liver known as primary liver cancer 2. Those spreading to the liver from elsewhere in the body (including from other organs) either by the blood or lymphatic system known as secondary or metastatic liver cancer. Primary liver cancer Primary liver cancer is also known as hepatocellular carcinoma and is sometimes, but not always, caused by long-term damage to the liver from either viral infections (such as hepatitis B and hepatitis C) or prolonged over-consumption of alcohol. In western countries, hepatocellular carcinoma is less common than secondary liver cancer. Secondary liver cancer Secondary liver cancer is mostly caused by cancer spreading from the large bowel (colorectal cancer). This form of liver cancer is the most common of all liver cancers in Western countries, but spread can also originate from other organs. The frequency of liver metastases (cancer spreading to the liver) from colorectal cancer is as high as 50 per cent. There is a rising incidence in colorectal cancer, and therefore the incidence of secondary liver cancer is also increasing. Patients with untreated liver metastases from colorectal cancer have an extremely poor life expectancy of possibly only six to 18 months. What treatment is available and what are the risks and benefits of each treatment? Currently, the best available treatment to cure cancer within the liver is to have it surgically removed. However, this may not be possible for reasons such as involvement of major blood vessels in the liver, poor liver function or if you have several tumours in your liver. As it may not be possible to remove liver tumours in their entirety, a combination of treatment including surgery and chemotherapy may be offered. These different types of treatment may be offered in any order, depending on your individual needs. Even if you have liver surgery, the chance of a tumour returning is as high as 50 per cent, so it is important to use other types of treatment to try to reduce the chance of the tumour returning. p2

3 Your consultant can draw on the picture below to show you what will be done during surgery. You may be offered one of the following two options. The first is offered as a potential cure, whilst the second is usually a palliative treatment. This means that we hope it will relieve symptoms such as pain and possibly prolong life expectancy. 1. Liver resection This is the surgical removal of the part of the liver affected by the cancer. Although there are other types of treatment for primary and secondary liver cancer, such as chemotherapy and radiotherapy, these are largely ineffective. Without surgery, the cancer would continue to grow and, in most cases, death would normally occur within six to 18 months. However, with liver resection for cancer that has spread from the large bowel (colorectal cancer), up to 50 per cent of patients will survive for five years. Liver surgery is complex and dangerous. The reported death rate from liver resection is as high as five per cent, and 50 per cent of patients will develop serious complications during the recovery period. These include: A two per cent risk of bleeding, with the need for further surgery A two per cent risk of a bile leak 90 per cent of these cases are managed by inserting a tube to drain the bile p3

4 A two per cent risk of an abscess forming, requiring drainage (as above) A ten per cent risk of a chest infection, requiring antibiotics A less than one per cent risk of liver, kidney or heart failure, requiring admission to an intensive care unit A less than one per cent risk of thrombosis (blood clots) A five to ten per cent risk of problems with the wound healing 2. Thermal ablative therapy At Hammersmith Hospital, we also offer an alternative procedure to help patients with liver cancer whose tumours cannot be completely resected (removed). This treatment is known as thermal ablation or thermal ablative therapy, where heat is used to destroy cancer cells to prevent them from spreading. It is not a cure but is offered in the hope that it will relieve symptoms and enable other forms of treatment to delay the progress of your disease. As with any procedure, there are risks associated with thermal ablation. These include: A less than one per cent risk of haemorrhage (bleeding) A five per cent risk of infection, which may need a further procedure to treat A less than one per cent risk of disturbed wound healing A less than one per cent risk of the need for further surgery In some cases, when using thermal ablation, we are able to operate laparoscopically (using keyhole surgery). This results in a much smaller wound, a shorter hospital stay and a quicker recovery from surgery. In other cases thermal ablation can be performed percutaneously, where under a general anaesthetic thermal ablation needles are inserted through skin into the liver tumours. However, this type of surgery is as major as having an open operation and the complications which may arise can be equally serious. These include: Damage to viscera (other organs). One per cent of cases will need further surgery to repair the damage A two to five per cent risk of bleeding, which may require an operation to repair A two per cent risk of bile leak 90 per cent of these cases are managed by inserting a tube to drain the bile A two per cent risk of an abscess forming, requiring drainage (as above) A ten per cent risk of a chest infection, requiring antibiotics p4

5 Treatment at Hammersmith Hospital Whilst being treated at Hammersmith Hospital, you will be given the name of one member of staff who knows about you and your treatment, and who should be your main point of contact with the hospital. This person could be any health professional working in the hospital and is known as your key worker. You should be given his/her contact details soon after your cancer diagnosis. If you do not know who your key worker is, please ask your doctor or nurse. When you have a discussion with your doctors, you are welcome to include friends or relatives. They may be able to remember details of a consultation that you have forgotten and they can ask questions on your behalf, if you wish. You may also like to make a note of any queries or concerns to discuss with the doctor. We can send you a summary of your outpatient consultations on request. If you would like us to do this, please tell your doctor during your appointment. What happens before my operation? We will admit you to the ward on the day of your operation. Two weeks before your admission date, we will arrange for you to attend our pre-assessment clinic. You will be seen by one of our surgical doctors and a member of our nursing team. Your temperature, blood pressure, respiration rate, height, weight and urine will be measured to give the nurse a baseline (normal reading) from which to work. You will have an ECG (tracing of your heart rhythm) and a chest X-ray. A blood sample will be taken to see how well your liver and kidneys are working. We will advise you at what time you will need to stop eating and drinking before surgery. We will ask you to have a shower or bath before coming into the hospital. All make-up, nail varnish, jewellery (except wedding rings, which can be taped into place), body piercings and dentures must be removed. One of the nurses will then come and prepare you for the operating theatre. It is essential that you come to this appointment, as it will give you an opportunity to ask the doctor any questions you may have. It may help to write them down before you come. What happens on the day of my operation? Your surgeon will review you, explain the procedure to you in detail and ask you to sign a consent form. This is to make sure that you understand the risks and benefits of having the operation. The anaesthetist will visit you to discuss the anaesthetic before you go to the operating theatre. The operation usually lasts between two and ten hours, depending on the type and complexity of the procedure. Our average operating time is about five hours, and less than five per cent of our patients require a blood transfusion during the operation. p5

6 What happens after the operation? You will wake up in the recovery room before you are taken back to the ward. Your wound will be covered with a dressing. You will have a variety of tubes attached to you, including: A nasogastric tube that enters your nose to drain the contents of your stomach until your gut starts working again A catheter (tube) in your bladder to drain urine away and allow you to rest Drains (tubes) in your wound. This is so that any blood or fluid that collects in the area can drain away safely and will help to prevent swelling. The tubes will be removed when they are no longer draining any fluid Intravenous drips (in the neck or in the arm) to provide you with fluids and prevent dehydration until you are able to have something to eat and drink Please tell us if you are in pain or feel sick after the operation. We have tablets and injections that we can give you when needed, so that you remain comfortable and pain-free. We will either give you an epidural injection in the spine or you may have a device that you use to control your pain yourself. This is known as PCA (patient-controlled analgesia) and you will be shown how to use it. You will also be prescribed a course of antibiotics as a routine precaution against infection. When you are well enough, we will encourage you to get out of bed and move around as much as possible to prevent post-operative complications such as chest infections and thrombosis ( DVT or blood clots). We will remove your sutures (stitches) about ten days after your operation. If you have already been discharged home by this time, the ward nurses will arrange for your local practice or district nurse to remove the sutures for you. When can I go home? You will be in hospital for about five to seven days, depending on the type of operation you have had, your individual recovery, how you feel physically and emotionally and the support available at home. This will be discussed with you before you have your operation and again while you are recovering. Is there anything I need to watch out for at home? You may feel different sensations in your wound such as tingling, itching or numbness. This is normal and is part of the healing process. However, if you experience a high temperature or fever, swelling, pain, discharge or excessive redness around the wound site, please contact your GP, hospital nurse specialist or the ward where you had your operation, as you may have an infection. p6

7 You can also contact one of the doctors in our unit by telephoning and asking for bleep 5481 or Will I need to visit the hospital again after my operation? Yes. We will give you an outpatient appointment to see a member of the surgical team within four weeks of your discharge home. Following this, you will be monitored in the outpatient clinic for as long as necessary after your operation. When can I get back to normal? Recovery from this surgery varies from person to person, but tends to take between three and six months. Diet There are no foods that you need to avoid after your operation. Unless you have been advised otherwise by a dietitian, we recommend that you eat a well-balanced diet, including five portions of fruit and vegetables a day. Driving Do not drive until your strength and speed of movement are back to normal, as you must be able to perform an emergency stop. You should also make sure that you are not drowsy from any painkillers and that your concentration is good. Discuss this with your doctor if you are not sure. It is important that you inform your insurance company that you have had an operation to ensure that you are covered in the event of an accident. Work, exercise and general activities At home, it is important that you rest, but you should keep as active as possible, gradually building up what you do each day. Most people are able to get back to normal (including participating in sport or exercise) about three months after they are discharged home. Simple household chores such as vacuuming can involve a lot of bending and stretching, which you may find uncomfortable. Try to get some help with these tasks for the first few weeks after surgery. You should not lift anything heavier than six to eight pounds (the same weight as a full three-pint kettle) for two to three months after your operation. If you have children, try to let them climb onto your lap when you are already sitting down, rather than lifting them up. You should be able to return to work three months after your discharge home. However, this will depend on the type of work you do and you should discuss this further with your doctor. Sexual activity In most cases, sexual intercourse can be resumed once you have recovered from your operation and your wound is fully healed. It is normal to be a little anxious at first, but try to be patient. If difficulties persist, please do discuss them with your doctor, who will be able to help and advise. p7

8 How do I get a second opinion? We will answer all of your questions honestly and to the best of our ability. However, we readily appreciate that after discussing the options with us, you may wish to obtain a second opinion. You are welcome to do this. If you do not know whom to contact, we will be pleased to suggest appropriate specialists for you to consider and will make copies of your notes, X-rays and scans available to them. This will mean that you do not need to have the same tests done again elsewhere. If you wish, we will also make the referral for you. Contacting the hospital After a big operation, you may feel vulnerable and alone, especially once you have left the hospital. The services listed below are available for you, your family and friends. Clinical nurse specialist/key worker for hepatobiliary cancers Out of hours, contact Ward Macmillan counsellor If you need to contact your consultant, please do so by dialling the switchboard at Hammersmith Hospital on and asking to speak to their secretary. Useful contact numbers Macmillan Cancer Support Helpline This is a free line for people affected by cancer who have questions about cancer, need support or just someone to talk to. It is open from Monday to Friday, :00 (interpretation service available). Information Prescription Service This service contains reliable and accurate cancer information to help patients manage their health more effectively. Pancreatic Cancer UK This charity provides easy access to the most up-to-date information on pancreatic cancer. It also provides individual support via and telephone and run discussion forums for pancreatic cancer patients, their carers and families to enable them to share experiences, advice and inspiration. Benefits Enquiry Line The service provides advice and information on the range of benefits available. p8

9 How do I make a comment about my treatment? We aim to provide the best possible service and staff will be happy to answer any questions you may have. However, if your experience of our services does not meet your expectations and you would like to speak to someone other than staff caring for you, please contact the patient advice and liaison service (PALS) on or (Charing Cross and Hammersmith hospitals), or (St Mary s Hospital). You can also PALS at pals@imperial.nhs.uk. The PALS team are able to listen to your concerns, suggestions or queries and are often able to help sort out problems on behalf of patients. Alternatively, you may wish to express your concerns in writing to: The chief executive Imperial College Healthcare NHS Trust Trust Headquarters The Bays, South Wharf Road London W2 1NY Alternative formats This information can be provided on request in large print, as a sound recording, in Braille, or in alternative languages. Please contact the communications team on Cancer services Published: August 2007; May 2009; December 2011 Review date: December 2014 Reference number: T0518/VER3 (previously known as SCA/053/009/VER2) Imperial College Healthcare NHS Trust p9