A nineteen year old female underwent 85 to 90 per cent partial hepatectomy to treat a minimal deviation hepatoma. Observations afterwards suggested that the limit of resection compatible with survival had been reached. She recovered perfect health after many months, although liver regeneration was not complete. Severe but eventually reversible alopecia and ascites developed postoperatively, undoubtedly as a complication of the massive hepatic resection. © 1975

Corman, JL

Groth, CG

Putnam, CW

Starzl, TE

Taubman, J

English

PubMed

D-Scholarship@Pitt

Alopecia, Ascites, and Incomplete Regeneration after 85 to 90 Per cent Liver Resection T. E. Starzl, MD, PhD, Denver, Colorado C. W. Putnam, MD, Denver, Colorado C. G. Groth, MD, Denver, Colorado J. L. Corman, MD, Denver, Colorado J. Taubman, MD, Denver, Colorado The purpose of this report is to describe some un-usual manifestations that followed a very exten-sive hepatectomy (85 to 90 per cent) and to com-ment about the less than complete degree of re-generation that occurred postoperatively. Case Report A nineteen year old girl had undergone exploration one week prior to admission because of a huge mass that occupied all of the upper abdomen and which, as indi-cated by liver scan (Figure 1, left), replaced much of the liver. Tissue diagnosis of a well differentiated hepatoma was made from the previous exploration. Measurement of alpha fetoprotein was negative. For some months she had had severe abdominal pain that was eventually demonstrated to be due to hemorrhage into the tumor. A selective celiac arteriogram demonstrated a single he-patic artery. (Figure 1, right.) Although the entire arte-rial blood supply appeared to be involved in tumor, an attempt at resection was decided on. The procedure was carried out May 10, 1972, through a bilateral subcostal incision. The right hepatic artery, portal vein, and hepatic duct were ligated and divided. Branches of the left main hilar structures passing to the medial segment of the left lobe were cut, leaving only From the Departments of Surgery and Radiology, University of Colorado School of Medicine and the Denver Veterans Administration Hospital . Denver. Colorado. This work was supported by the Veterans Administra-tion Hospital. Denver. Colorado; by grants AI-AM-08898 and AM-01772 from the National Institutes of Health; and by grants RR-000S1 and RR-00069 from the General Clinical Research Centers Program of the Divi-sion of Research Resources. National Institutes of eea~hK Requests for reprints should be addressed to Thomas E. Starzl , MD. Department of Surgery. University of Colorado Medical Center. 4200 East Ninlh Avenue. Denver. Colorado 80220. Vofume 129, May 1975 the lateral segment connected. The right and middle he-patic veins and all the small hepatic veins entering the inferior vena cava from the caudate lobe were sacrificed so that only the left hepatic vein remained. The lateral segment of the left lobe was smaller than usual, consti-tuting approximately 15 per cent of the normal liver mass. Part of this segment had to be excised to remove the tumor, which extended to the left of the falciform ligament. The remaining hepatic fragment was thought to represent between 10 and 15 per cent of a normal liver. The excised specimen weighed 2,100 gm and had areas of hemorrhage within the tumor. It was examined histologically in five university departments of patholo-gy noted for their special interest in liver disease. All consultants described the well-differentiated features of the neoplasm. Two diagnoses of hepatocellular adenoma were made, but three of the consultants classified the le-sion as a hepatoma (hepatocarcinoma) . After resection was completed, the residual fragment felt tense, a condition that was aggravated by efforts to cover the raw liver edge with the falciform ligament or omentum. Consequently, the raw surface was left open. The large right subphrenic cavity was extensively drained. The operation required nine hours and 5,500 ml of blood. Postoperative ventilatory support was pro-vided for the first five hours. The patient was complete-ly disoriented for three days but then suddenly became lucid. Serious abnormalities in liver function, including jaundice, did not clear. until the third week. (Figure 2.) Albumin, totaling 250 gm, was administered during the first five days, which maintained the serum albumin concentration at greater than 3.0 gm/lOO m!. The pa-tient had a continuous leak of ascitic fluid from the drain sites. Measurements of abdominal girth also indi-587 Starzl et al SGOT (IU) <. .-200 160 120 80 40 PRE -OPERATI VE H(PAT I e RESE CT "ON ,/ 19 y/o 9 Figure 1. Preoperative radiographic studies. Left, 99m technetium liver scan (anteroposterior projection) showing the very large filling delec t. RighI, selective common hepallc arteriogram. The broad arrows IndI-cate the extent of the tumor as out-lined by the abnormal conflgurallon of vessels. The thin arrow points to the dorsolateral branch 01 the left hepatiC artery. This vessel, supply-Ing the lateral segment 01 the left lobe, was the only hepatic arterial branch preserved. l +---+---------------------~ r_----------------Bi ll RUB IN (mg %) TOTA L -CONJUGATED 12 10 - ' ........ ...... l~~---~~~~~c======== PROTHROMBIN TIME (%) 100 80 60 40 20 o -------r-"--,..----.---r-....L-Ti i , , I , , I I , Figure 2. Postoperative course. The hyperbilirubinemia and the de-pressed prothrombin time returned to normal In about a month. Pre -01) 0 10 20 30 40 50 60 3 4 5 6 7 B 9 10 II 12 TIME IN DAYS cated retained ascitic material. Within a few days, the patient's hair began to fall out, and she soon became nearly bald. Chemotherapy, never administered to the patient, was not an explanation for the alopecia. The pa-tient had daily fevers, usually low grade, that lasted two months with or without antibiotics. The 99m technetium liver scans taken postoperatively are shown in Figure 3. At first, obvious splenomegaly in-dicated that the tiny liver fragment permitted only a borderline state of portal venous drainage. At one and six months postoperatively , substantial but incomplete regeneration had occurred. (Figure 3.) Further regenera-tion was not evident at thirteen months postoperatively. The ascites was treated with hydrochlorothiazide (HydroDiuril®) and spironolactone (Aldactone®) for eight months and did not recur. Nine months were re-quired for regrowth of hair. After a follow-up period of twenty months, the patient had quite normal liver func-588 T I ME IN MONTHS tion and no evidence of recurrent tumor. Her weight was 125 pounds, 12 pounds greater than her preoperative weight. Her menstrual periods, which had stopped for a long time after operation, returned. Comments Among hepatic neoplasms, the type of tumor found in this patient is recognized for its occasion-al huge size, slow natural history, and tendency not to metastasize. These characteristics have led some authorities [1,2] to call it benign hepatoma or adenoma. Hemorrhage into the tumor as oc-curred in this patient has been reported [3-5]. Appreciation of these favorable prognostic fea-tures prompted our aggressive attitude toward re-section. The extent of hepatic resection in this pa-The American Journal 01 Surgery Figure 3. Serial postoperative 99m technetium liver scans. Two days, only a tiny fragment of the Jiver is visualized; the spleen (S) has en-larged in comparison with the pre-operative study. One month, regen-eration has begun. Six months, fur-ther regeneration has occurred. Thirteen months, the hepatic mass has increased slightly in the inter-vening seven months, but regenera-tion remains incomplete. 2 days , 6 months tient apparently reached nearly the absolute limit compatible with survival. The diminutive residual liver fragment could barely transmit the portal flow, resulting in splenomegaly and probably con-tributing to the ascites that persisted for months afterward. The degree of regeneration that fol-lowed was not complete more than a year later and probably never will be. To our knowledge, only a few patients with such extensive hepatic resection have survived. The surviving patients are usually reported as having undergone "extended right hepatic lobectomy," a term introduced by Pack et al [6]. As summarized by Lin [7], most reported series of partial hepatec-tomies have included very few or no such proce-dures; Lin reported none in his personal series of 107 hepatic resections. The reported amount of tissue remaining after extended right hepatic lobectomy is not easily Volume 129, May 1975 Liver Resection I month • s s 13 months s s quantifiable and is almost exclusively dependent upon the estimate of the surgeon, which could vary from surgeon to surgeon. In most patients, the re-sidual tissue in a full lateral segment would be ap-proximately 20 per cent. However, there seems lit-tle doubt that the remnants left in the cases of McDermott et al [8], Stahl [9], and Smith [10] were smaller than this. Whatever the size of the fragment, almost all authorities claim that full res-titution of liver mass occurs by regeneration. Only Stahl [9] has described the kind of incomplete re-covery observed in our patient. Despite the hazardous metabolic state of our pa-tient during the first postoperative days and weeks, recovery was not marred by any serious ex-trahepatic complications. The cyclic changes in basic liver function were similar to t.hose described by others after major hepatic resection [8,9,11-14]. Prompt resumption of a healthful diet was proba-589 Starzl et al bly the most important factor in our patient's re-covery. A unique postoperative finding in this case was the development of baldness beginning a few days after hepatic resection. This has not previously been described in the literature, but by personal communication we have learned that Fitts [15] at the University of South Carolina observed a simi-lar condition after hepatectomy of comparable magnitude. The explanation is not known, but the baldness clearly was not the result of chemothera-py since the patient was not so treated. The low grade postoperative fever was probably not re-sponsible. Presumably the alopecia represented a protein-sparing metabolic economy at a time of in-tense stress. At the same time there was no evi-dence of defective wound healing. Summary A nineteen year old female underwent 85 to 90 per cent partial hepatectomy to treat a minimal deviation hepatoma. Observations afterwards sug-gested that the limit of resection compatible with survival had been reached. She recovered perfect health after many months, although liver regener-ation was not complete. Severe but eventually re-versible alopecia and ascites developed postopera-tively, undoubtedly as a complication of the mas-sive hepatic resection. References 1. Motsay GJ, Gamble WG: Clinical experience with hepatic ad-enomas. SurgGynecolObstet 134: 415,1972. 2. Edmonston HA: Tumors of the liver and intrahepatic bile ducts. Atlas of Tumor Pathology, section VII . fascicle 25 . Washington, DC, Armed Forces Institute of Pathology, 1958. 3. Scorer CG: Spontaneous rupture of hepatic adenoma. Br J Surg 56: 633, 1969. 4. Davis JB, Schenken JR, Zimmerman 0 : Massive hemoperi-toneum from rupture of benign hepatocellular adenoma. Surgery 73: 181, 1973. 5. Hermann RE, David TE: Spontaneous rupture of the liver caused by hepatomas. Surgery 74: 715 , 1973. 6. Pack GT, Islami AH, Hubbard JC, Brasfield RD: Regeneration of human liver after major hepatectomy. Surgery 52: 617, 1962. 7. Lin T-Y: Results in 107 hepatic lobectomies with a prelimi-nary report on the use of a clamp to reduce blood loss. Ann Surg 177: 413 , 1973. 8. McDermott WV Jr, Greenberger NJ, Isselbacher KJ, Weber AL: Major hepatic resection: diagnostiC techniques and metabolic problems. Surgery 54: 56, 1963. 9. Stahl WM: Radical right hepatic lobectomy for hepatoblasto-ma in infancy. Five year survival. NY State J Med 72: 2083, 1972. 10. Smith R: Liverresection . J R Call Surg Edinb 17: 154, 1972. 11 . Pack GT, Molander DW: Metabolism before and after hepat-ic lobectomy for cancer. Arch Surg 80: 685, 1960. 12. Pinkerton JA, Sawyers JL, Foster JH: A study of the postop-erative course after hepatic lobectomy. Ann Surg 173: 800,1971. 13. Almersjo 0, Bengmark S, Hafstrom LO, Olsson R: Enzyme and function changes after extensive liver resection in man. Ann Surg 169: 111 , 1969. 14. Aronsen KF, Ericsson B, Pihl B: Metabolic changes following major hepatic resection . Ann Surg 169: 102, 1969. 15. Fitts WT Jr: Personal communication, November 3, 1972. Reprinted from th e May issue of The American Journal of Surgery. A Yorke M edical Journal. Publish ed by Dun . Donnelley PubliSh ing Corporation. 666 Fifth Aven ue. New York . N.Y. 100 19 . Copyright 1975. Printed in the U.S.A. 

Alopecia, ascites, and incomplete regeneration after 85 to 90 per cent liver resection

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Alopecia, ascites, and incomplete regeneration after 85 to 90 per cent liver resection

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