Patient

1 January 2017

Liver cirrhosis may be caused by alcohol abuse, autoimmune diseases of the liver, hepatitis B or C virus infection, chronic inflammation of the liver or iron overload within the body. The incidence of HCC is especially high all over Asia pacific region than Western countries is because of the prevalence of hepatitis B in Asia. It is estimated that 1 out of 10 population in Hong Kong is a hepatitis B carrier, and 25 % of them will eventually progress into liver cirrhosis and further into HCC. HCC affects men more than women.

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Amongst the male inhabitants, it has an incidence of 33 per 100000 cases whilst woman has 10 per 100000 cases each year (Hopital Authority, 2006). Although a lot of surveillance works have been carried out in current health care services all over the world, the rate the tumour is being detected at a late stage of HCC is still very high. This can account for a high death rate over all other types of cancer and becomes the third most common cause of cancer deaths in Hong Kong (Hong Kong Cancer Registry, 2011). Treatment modalities of HCC depend on the size, number and location of tumours.

Liver resection and liver transplantation still remain the best curative modalities for HCC. Other treatments are available such as transarterial chemo-ebolization (TACE), radiofrequency ablation (RFA), High intensity focused ultrasound (HIFU) ablation or systemic chemotherapy. Case Study Mr. Leung is a 37 years old male clinically admitted to Princess Margret Hospital Surgical ward on 7/3/2012 for laparoscopic hepatectomy. He has past history of vacicocele with operation done during childhood in mainland China. He also has history of dyspepsia, and hepatitis B carrier put on entecavir regularly.

A computer tomography (CT) scan was performed in last year which revealed two lesions on segment 5 and 6. Followed by another MRI scan in February this year, the report showed an increase in the lesions which suggested HCC. Mr. Leung works as a home interior decoration worker for years. He was married with two children, one was seven years old with Down’s syndrome while another is only seven months old taking care merely by his wife. He migrated from mainland China twelve years ago with three sisters and one brother, all living in Hong Kong now.

His parents were living in Hong Kong too and they have no history of any liver diseases but mother having DM and HT only. He was a smoker and drinker before but quitted them all several years ago. His education level only reached to primary six in mainland. His general condition on arrival was conscious and alert with blood pressure 125/60, pulse rate was 80 beats per minute, temperature was 36. 4 degree Celsius, respiratory rate was 18 breaths per minute. He came with his wife and his brother’s wife on admission. On health assessment, palpation was performed a slightly enlarged liver was observed.

The abdomen was soft and non-tender. No signs of jaundice was noted, but patient verbalized subjective weight loss during the past 2 months, dropping from 60kg to 55kg till now. His case doctor has assessed him after admission and offered him laparoscopic hepatectomy plus or minus open approach pre-operatively. Consent was obtained immediately after explanation on operation and its risks and complications delivered by his case doctor with his relatives. Pre-operatively blood was checked with white blood count 4. 5 (normal range: 3. 7-9. 2), hemoglobin 14. 9 (normal range: 13. -17. 1), platelet count 124 (normal range: 145-370), INR 1. 0, potassium 4. 0 (normal range: 3. 3-4. 6), sodium 140 (normal range: 136-144), ALP 65 (normal range: 35-128), ALT 45 (normal range: <46). Anesthetist assessed him in the afternoon and explained to him about anesthetic procedure peri-operatively and its risks and complications, including the chance of blood transfusion during surgery and its risks as well. Consent was then taken by anesthetist with plan of general anesthesia prescribed and plan of patient-controlled analgesia (PCA) post-operatively.

The pre-operative pamphlet on the operation, anesthesia, and pre-operative preparations were provided to patients. Pre-operative video was also displayed to him for orientation purpose, which introduced the operation theatre, pre-operative preparations and post-operative pain control regimes within the hospital. He was reminded to keep fast after mid-night after dinner. A dulcloax suppository was given to patient per rectal for bowel preparation before surgery. Pre-operative bathing with Hibiscrub was also instructed by the cubicle nurse for skin preparation.

He was put as the first case on the surgery list and transferred to the operation theatre on 8/3 morning around eight am. Eventually, only laparoscopic hepatectomy was performed which revealed a 5 cm and 3 cm tumour on segment 5 and 6. They were resected and sent to laboratory for pathology. The operation lasted about five hours and he was then transferred to intensive care unit for post-operative observation. On day 2, he was transferred back to general surgical ward after one night observation in intensive care unit.

On transfer in from intensive care unit, his blood pressure was 130/ 85, pulse rate was 90 beats per minute, afebrile, respiratory rate was 20 breaths per minute, SpO2 was 96% on 2L oxygen via nasal cannula. Ryle tube was in position with small amount bile-stained fluid collected while foley catheter with satisfactory urine output. Patient-controlled analgesia (PCA) was provided to patient for pain control. Pain score was 6/10 on resting while 8/10 on turning on bed. He was kept on nil by mouth and vital signs and SpO2 were closely monitored. Problems

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