Fifty-eight years old male patient, known to be cirrhotic with compensated liver under medical treatment, presented with increasing painless jaundice noticed by his relatives in the past 2 weeks. He is diabetic on oral hypoglycemic and not known to be hypertensive. Examination revealed yellowish discoloration of sclera and skin, abdominal examination showed scratch marks, splenomegaly (4 fingers below the costal margin in left midclavicular line), shrunken liver and no other remarkable findings. Lab findings were as follows; HB 11.4 gm%, total bilirubin 12.7mg%, direct 9.8%, urea 44mg%, creatinine 1.2mg%, AST123u, ALT 112u, albumin 3.6mg %, INR 1.2 and HBA1c 8.1. Triphasic CT abdomen revealed a small hypoechoic lesion in the region of the head of pancreas 3.2×2.4 cm with clear peripancreatic vessels, dilated CBD 12mm, cirrhotic liver with undulating surface with focal hepatic lesion at segment VIII 2×2.5 cm showing arterial enhancement with venous washout and splenomegaly 19 cm with hilar splenic varices. How do you manage?
It is a big conflict.
But let us think together, we have a patient with a border line liver with marked cirrhosis ( shrunken liver with undulating surface), and findings of portal hypertension (splenomegally and hilar varices )
According to CT there is double pathology, both needs major surgery for each ( Whipple’s operation & central hepatic resection ; seg VIII)
And also there is emergency condition (rapidly developing jaundice >12 over 2 weeks ) it will harm the already compromised liver by time.
So do you think decompression of jaundice will give the liver a chance to breath, and you to think in ablative procedure for the HCC
Or embark to ablate it intraoperative? I think he will not tolerate resection of both. He even may not tolerate Whipple’s