Tests you may have prior to liver and pancreas surgery

Please refer to the QScan website http://www.qscan.com.au/ for more detailed information about these scans.

CT scan

A CT scan is probably the most common test ordered for liver and bile duct problems. It is a test that involves lying on a hard table and passing in and out of a donut shaped tunnel. The room is open and airy. There is no feeling of claustrophobia. For liver tumours, the scan is largely useless unless you are given an intravenous injection of dye or contrast. This makes you feel very warm and like you want to pass urine. The contrast is important to find tumour in the liver and other organs. It is very important that you have normal kidney function and take precautions about certain diabetic medications before having this contrast. Some people are highly allergic to x-ray contrast. You may also be asked to drink x-ray contrast prior to the scan. You may have a loose bowel movement after taking this contrast. The x-ray centre will ask you about these things and you may need to have a blood test before the scan.

MRI Scan

An MRI is a test where you lie on a table and slide into a narrow tunnel. A magnetic field with the help of a computer creates a three-D image of your abdomen. Like a CT scan, contrast is typically used and the type of contrast is very important to look for certain things within the liver. MRI is very useful to get an accurate picture of the bile ducts. If the right contrast is used, it can be very good in telling the difference between various liver lesions.

Reading a liver MRI scan is a highly skilled task and it is preferable that the test be performed by experienced radiologist after consultation with us.

Some patients find MRI very claustrophobic. The X-ray Department take great care to make this experience as pleasant as possible. It is also a very noisy test and you will be provided with earplugs. You may not be able to have an MRI if you have certain types of metal implants in your body. Please check with the X-ray facility prior to having the scan.

Heart and lung tests

Several tests may be required to assess your fitness for major surgery. This will depend on your age and other health problems. These tests may include an ultrasound of the heart (Echocardiogram), lung function tests and exercise tests.

Key hole surgery or diagnostic laparoscopy

This is done under general anaesthesia (fully asleep) in the operating theatre. A small cut is made in the belly button and the tummy cavity is blown up with gas. A camera is inserted. There may be 1 or more additional cuts made so we can move things around with long instruments. This test is done to look for small lumps of cancer that may have spread around the abdominal cavity. This is relatively common in advanced bile duct cancer and if present, is not curable. This type of advanced cancer is not seen well on scans. This test can often be done as day surgery and there is minimal discomfort. Sometimes there is shoulder pain for 24 hours after the procedure.

PTC (Percutaneous Transhepatic Cholangiogram)

The principle of PTC is to unblock the side of the liver that will be saved during the final operation so it can grow. The blocked side will shrivel away. This provides the best hope that there will be enough liver left at the end of the surgery for you to survive. You can expect to have a PTC tube in your liver for 4-6 weeks after the liver is unblocked to give the liver time to grow. You may be sent home during this time.

If you are jaundiced, this test will be done shortly after you are admitted to the hospital. It is performed in the X-ray Department by specialist radiologists. This can be a very tricky procedure and it is vital that there be good communication between the radiologists and the surgeons. It is very important that the radiologist be very experienced in this type of procedure.

Under local or general anaesthetic, a soft tube is inserted through the skin and into the liver. The surgeon will decide in advance which side of the liver will need to be drained. This tube is passed through the liver and into the blocked bile duct. Instantly, bile will come out of the drain under pressure. The bile may be golden yellow, dark green, bloody or clear like water if the liver has been blocked for a long time. This tube relieves the pressure in the blocked bile duct and allows that section of liver to recover. Taking the pressure out of that section of the liver allows that part to grow and the undrained part to whither. We will be watching carefully for the level of jaundice in the blood to drop. If it does, then this is a good sign that this section of liver will be enough for you to live on after the surgery.

At the end of the procedure, you will have a soft tube coming out of your abdomen emptying into a drainage bag. The nursing staff will monitor how much bile comes out each day. It may drain up to a litre of bile per day. At some point, this tube may be capped off and there will no longer be any drainage. A PTC often involves a number of trips to X-ray for different procedures over a number of days. It can take a week to get right.

Complications Associated with PTC

PTC is an invasive test but is usually performed with very few problems. This is a list of potential concerns.

  1. Infection (cholangitis): by its very nature, a PTC will introduce bacteria into a stagnant, blocked system. Infection occurs in 50% of patients. It is expected and you will be given intravenous antibiotics prior to the procedure. Infection presents as a high fever, pain, shivers and shakes. Your blood pressure may be low. Rarely, this type of infection requires treatment in intensive care with special medications to support the blood pressure. You will feel absolutely terrible after an attack of infection of this nature.
  2. Kidney failure: being jaundiced is very hard work for the kidneys. You will be given extra intravenous fluids, but kidney failure can occur at any time especially during an infection. This kidney failure may be temporary, may require dialysis and occasionally, it is fatal. Another problem for the kidneys is the large loss of fluid out of the PTC. It can be difficult to drink enough water to keep up with this loss. For this reason patients usually have to stay in hospital for the entire time a draining PTC is in place.
  3. Bleeding: serious bleeding is uncommon. There may be bleeding into the abdomen requiring urgent surgery or there may be bleeding into the bowel or PTC tube that will require further x-ray procedures. You may require a blood transfusion. It is perfectly normal for a small amount of blood to come out of the tube from time to time.
  4. Leak of bile: bile may leak around the tube and into the abdomen. This can cause pain and infection. It may need another x-ray procedure or uncommonly an operation.

PET Scan

This test relies on the idea that some tumours use glucose faster than the surrounding tissues. Radioactive glucose is injected into the blood and you will lie under a special camera. The glucose may concentrate in areas of cancer spread. It does not work for all cancers but is useful for bowel cancer and melanoma. It can detect cancer throughout the entire body.

ICG –Indocyanine Green Test

This test will be done if you have cirrhosis of the liver. It helps us decide whether your liver will have enough reserve to cope after a piece has been removed. Indocyanine is a green dye that will be injected into the blood via a small needle in the arm. A normal liver will rapidly break down this dye and it will be passed in the urine. A liver with cirrhosis is less efficient at breaking down the dye. A special device, similar to a soft peg will be placed over your finger. After 15 minutes the machine shines a light through the fingernail and can read how much of the dye is left in the bloodstream. If there is more than 15% of the dye still in the blood stream after 15 minutes, there is a high chance that you may develop liver failure if you undergo liver resection.

Portal Vein Embolisation

This procedure is done when the tumours are in such a position that there may not be enough liver left at the end of the operation to remove them. It is also useful if you have cancer in both sides of the liver. It is done in x-ray and involves a needle being passed through the skin and into the portal vein, the large blood vessel from the liver. On the side of the liver that will eventually be removed, the portal vein is blocked off with small metal coils. When this is done an incredible thing happens – the other side of the liver will begin to grow. After six weeks, the size of the liver is reassessed and if the growth has been significant, then a date for surgery is planned.

Blood Tests

Full blood count, Kidney and Liver function tests.

Tumour markers: Ca19.9, CEA: it is important to remember, blood tests for cancer are not helpful in some people. They are used only as a guide and not for diagnosis. These tests can be elevated in anyone with jaundice even if they don't have cancer.

Endoscopic Ultrasound – EUS

This is a test done to assess problems with the pancreas and lower bile ducts. It is done under a light anaesthetic by a skilled gastroenterologist. A flexible telescope with an ultrasound mounted in the head is inserted via the mouth into the stomach. Because the pancreas is behind the stomach an excellent view of the pancreas can be obtained. A fine needle can be inserted into the area of concern and a biopsy can be taken. This is the most common way to get a biopsy of the pancreas. If the diagnosis is obvious from the CT scan however, this test may not be performed.

ERCP – Endoscopic Retrograde Cholangiopancreatography

ERCP gives an X-ray picture of the bile duct. It is also used to place a plastic tube in the bile duct to relieve jaundice. This is done under a light anaesthetic by a skilled gastroenterologist. A flexible telescope is inserted via the mouth into the stomach. It is not performed in every patient and has some serious risks including pancreatitis, perforation of the bowel and bleeding.