74 years old woman with respiratory restriction, fullness and abdominal pain with polycystic disease of the liver. Sua presents large cysts varying between 5 untill 20 cm predominantly in left site including left site atrophy. She presents normal hepatic function and two years ago was submitted a laparoscopic deroofing in other service. What is your best approach?
A) new lap or open deroofing?
B) lap or open left hepatectomy or even left lateral segmentectomy with contralateral derrofing if possible?
C) Transplantation ?
D) lap or open perycystectomy with total resection of lef hepatic cysts and observe right lesions?
E) other option.
Patient already submitted to previous surgery we suggest ultrasound-guided percutaneous alcoholization and under sedation
I prefer laparoscopic left hepatectomy and right side deroofing.
What Sergio proposes is attractive; however, be careful not to leave important/many cysts open free to the peritoneal cavity. We did that some years ago in a younger woman with a lightly more severe polycystic disease and she suffered untreatable ascites which eventually led her to receive a liver transplant. As you don't have this option in this patient, just keep it on mind.
Transplantation is a option too, but the last choice in this case i guess it.
It won´t be an option in Spain as we do not perform LDLT and 74 years is currently out of what it is accepted in the public system.
Intraoperative images after open anatomic left hepatectomy with deroofing of the right and caudate lobes cysts.
I think left hepatectomy was a good otion however remained cyst also may grow and this patient of course needs a good follow up Transplantation is not a good option since these patients almost never present liver failure Could you provide a post operative CT of this patient?
Dear professor, this surgery was very difficult because there were strong adherences and left liver was giant too, leading a very difficult mobilization without rupture. See a giant lesion who presented nodular areas and calcification of its capsule, therefore we would want no violate it because a risk of cystadenoma or worse than it. We did the deroofing of main right lesions thinking about the principle that we should perform less is more for this specific patient. If the 2 smallest right lesions grow, we can unroof or even resect again with more hepatic parenchyma and less risks. Thanks a lot for your commentaries!
I have not still postoperative Ct. But the patient is well, better than before surgical treatment.
It all depends on the location of the dominant cysts. Reoperating on these patients is difficult (that has been my experience hen undertaking liver transplantation-which is a good treatment option for younger, physically robust individuals). Percutaneous drainage of a dominant cyst may assist with symptoms control but it will need to be repeated. Partial liver resection may be feasible if it can be performed with an acceptable risk.
I think that we have performed the best in this case.this patient is at home without previous symptoms.
since the LFT are normal and she is 73 hrd and symptomatic,iT is best to do Laparoscopic deroobfing of all the large cysts.Try not to be too agressieve to preventie decompensation.
She is 74, so would depend on her performance score and expected function of FLR if a liver resection(left hemihepatectomy) is planned.
Treatment of choice would be left hemihepatectomy.
Another deroofing for symptomatic relief is worthwhile if she is not a candidate for left hepatectomy.
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