LAPAROSCOPIC EVALUATION OF MASSES IN END STAGE LIVER DISEASE PATIENTS

Abstract

P592 The Model of End-Stage Liver Disease (MELD) scoring system is the current standard for determining recipient priority for liver transplantation. Under this scoring system, a patient diagnosed with hepatocellular carcinoma (HCC) receives a considerable increase in their priority score. As a result, multiple programs have adopted an aggressive surveillance program, which frequently utilizes surgical exploration, to confirm the presence of and provide treatment for tumors. Methods: All potential liver transplant candidates who were explored for a radiographic mass were identified, and patient demographics, tumor characteristics and patient survivals were examined. All patients with tumors identified by intra-operative ultrasound underwent radiofrequency ablation (RFA). Results: Sixty-four patients were explored for undiagnosed liver masses. Three (7%) patients were managed via an open incision; one laparoscopic patient required conversion to improve access to safely ablate a dome lesion. Fourteen (21%) patients underwent laparoscopy without ablation: absence of diagnostic lesions (n=7), metastatic disease (n=5), or benign tumor biopsy (n=2). Mean hospital stay for the series was 36 hours (range 20 to 50 hrs). Complications included new onset of ascites (n=5), worsening of ascites (n=23), and wound infection (n=4). No treatment related mortality was incurred. Of the 46 patients who received RFA, 16 (34%) were excluded from transplantation: newly diagnosed pulmonary hypertension (n=2), unabated alcohol usage (n=2), poor physiologic age (n=2), lack of social support (n=5), morbid obesity (n=2), metastatic disease (n=1), and death [variceal bleed, recurrent HCC] (n=2). Twenty-seven (42%) explored patients were transplanted, while 9 (14%) patients were excluded from transplantation based on findings identified during the procedure. With the diagnosis of HCC, 24 patients in need of therapeutic transplantation had their MELD scores increased from 14 to 22 points. Six patients are currently awaiting either completion of their evaluations or transplantation. Time from RFA to transplant ranged from 2 weeks to 1 year. Examination of explants identified one (2%) liver in which HCC was missed. Of the 24 patients who underwent RFA, all had evidence of necrosis, which varied from 30 to 99%. While those with RFA-to-transplant intervals greater than 3 months had the highest percentages of necrosis, those with shorter intervals, though demonstrating lower percentages of necrosis, displayed extensive apoptotic tumors. Conclusion: Laparoscopic evaluation and RFA of hepatic tumors in cirrhotic transplant candidates is both safe and efficacious. With continued changes in the MELD scoring system, laparoscopy can provide both accurate staging and interventional therapy for candidates awaiting transplantation. In this series, laparoscopic findings saved 14% of patients from an unnecessary open exploration at the time of organ availability. The findings of this series also indicate there is a linear rate of necrosis found in cirrhotic livers after ablation.