A 35-year-old woman seeks evaluation at a clinic with a complaint of right upper abdominal pain for greater than 1 month. She says that the sensation is more of discomfort than pain. She denies any history of weight loss, changes in bowel habit, or nausea. Her medical history is unremarkable. She takes oral contraceptive pills and multivitamins every day. Her physical examination reveals a palpable liver mass that is 2 cm in diameter just below the right costal margin in the midclavicular line. An abdominal CT scan reveals 2 hypervascular lesions in the right hepatic lobe. The serum α-fetoprotein level is within normal limits. What is the next best step in the management of this patient’s condition?

Discontinue oral contraceptives

A 32-year-old woman comes to the emergency department for a 2-week history of right upper quadrant abdominal pain. She has also been feeling tired and nauseous for the past 5 weeks. She has a history of depression and suicidal ideation. She is a social worker for an international charity foundation. She used intravenous illicit drugs in the past but quit 4 months ago. Her only medication is sertraline. Her temperature is 37.8°C (100.0°F), pulse is 100/min, and blood pressure is 128/76 mm Hg. She is alert and oriented. Scleral icterus is present. Abdominal examination shows tenderness to palpation in the right upper quadrant. The liver edge is palpated 3 cm below the right costal margin. There is no rebound tenderness or guarding. The abdomen is non-distended and the fluid wave test is negative. She is able to extend her arms with wrists in full extension and hold them steady without flapping. Laboratory studies show: Hemoglobin 13.8 g/dL Leukocytes 13,700/mm3 Platelets 165,000/mm3 Prothrombin time 14 seconds Partial thromboplastin time 35 seconds Serum: Total bilirubin 4.8 mg/dL Direct bilirubin 1.3 mg/dL Aspartate aminotransferase 1852 U/L Alanine aminotransferase 2497 U/L Urea nitrogen 21 mg/dL Creatinine 1.2 mg/dL Hepatitis A IgM antibody Negative Hepatitis B surface antigen Negative Hepatitis B surface antibody Negative Hepatitis B core IgM antibody Positive Hepatitis C antibody Positive Hepatitis C RNA Negative Urine beta-hCG Negative Which of the following is the most appropriate next step in management?

Vaccination against Hepatitis B

A patient with HCC and a long history of alcohol dependence and chronic hepatitis C has been using the mTOR inhibitor sirolimus 100 mg for cancer treatment. Her cancer has shown a partial response. She also has a history of hypertension and poorly controlled type 2 diabetes mellitus complicated by diabetic retinopathy. Current medications include enalapril and insulin. She asks her oncologist and hepatologist if she could try everolimus for its purported survival benefit in treating HCC. Based on clinical considerations, which of the following statements is most accurate?

The patient is not a good candidate for everolimus due to her history of diabetes

The patient should start everolimus 50 mg because of the survival benefit relative to sirolimus 100 mg

The patient is not a good candidate for everolimus due to her history of hypertension

The patient should start everolimus 100 mg because of the survival benefit relative to sirolimus 100 mg

The patient should start everolimus 50 mg because of her history of alcohol use disorder and hepatitis C

A 52-year-old man comes to the physician because of progressive abdominal distention and weight gain over the last 2 months. He was diagnosed with alcoholic liver cirrhosis with large ascites 1 year ago. He has congestive heart failure with a depressed ejection fraction related to his alcohol use. For the last 6 months, he has abstained from alcohol and has followed a low-sodium diet. His current medications include propranolol, spironolactone, and furosemide. His temperature is 36.7°C (98°F), pulse is 90/min, and blood pressure is 109/56 mm Hg. Physical examination shows reddening of the palms, telangiectasias on the face and trunk, and prominent blood vessels around the umbilicus. The abdomen is tense and distended; there is no abdominal tenderness. On percussion of the abdomen, there is dullness that shifts when the patient moves from the supine to the right lateral decubitus position. When the patient stretches out his arms with the wrists extended, a jerky, flapping motion of the hands is seen. Mental status examination shows a decreased attention span. Serum studies show: Sodium 136 mEq/L Creatinine 0.9 mg/dL Albumin 3.6 mg/dL Total bilirubin 1.9 mg/dL INR 1.0 Which of the following is the most appropriate next step in treatment?

Perform large-volume paracentesis

Refer for liver transplantation

Refer for peritoneovenous shunt

Change propranolol to carvedilol

Refer for transjugular intrahepatic portosystemic shunt

A 55-year-old man presents to the emergency department with hematemesis that started 1 hour ago but has subsided. His past medical history is significant for cirrhosis with known esophageal varices which have been previously banded. His temperature is 97.5°F (36.4°C), blood pressure is 114/64 mmHg, pulse is 130/min, respirations are 12/min, and oxygen saturation is 98% on room air. During the patient's physical exam, he begins vomiting again and his heart rate increases with a worsening blood pressure. He develops mental status changes and on exam he opens his eyes and flexes his arms only to sternal rub and is muttering incoherent words. Which of the following is the most appropriate next step in management?

IV fluids and fresh frozen plasma

A 52-year-old man presents to his physician after his routine screening revealed that he has elevated liver enzymes. He complains of occasional headaches during the past year, but otherwise feels well. The patient reports that he was involved in a serious car accident in the 1980s. He does not smoke or drink alcohol. He has no history of illicit intravenous drug use. He does not currently take any medications and has no known allergies. His father had a history of alcoholism and died of liver cancer. The patient appears thin. His temperature is 37.8°C (100°F), pulse is 100/min, and blood pressure is 110/70 mm Hg. The physical examination reveals no abnormalities. The laboratory test results show the following: Complete blood count Hemoglobin 14 g/dL Leukocyte count 10,000/mm3 Platelet count 146,000/mm3 Comprehensive metabolic profile Glucose 150 mg/dL Albumin 3.2 g/dL Total bilirubin 1.5 mg/dL Alkaline phosphatase 75 IU/L AST 95 IU/L ALT 73 IU/L Other lab tests HIV negative Hepatitis B surface antigen negative Hepatitis C antibody positive HCV RNA positive HCV genotype 1 A liver biopsy is performed and shows mononuclear infiltrates localized to portal tracts that reveal periportal hepatocyte necrosis. Which of the following is the most appropriate next step in management?

Sofosbuvir and ledipasvir therapy

Interferon and ribavirin therapy

Tenofovir and entecavir therapy

Tenofovir and velpatasvir therapy

Liver resection principles for USMLE Step 3: High-Yield Surgery Lessons

🗺️ Key Structures - Liver Landmarks

Couinaud segments of the liver with vascular supply

Couinaud Segments: Liver functionally divided into 8 segments (I-VIII), each with its own portal triad inflow and hepatic venous outflow.
- Right Lobe: Segments V, VI, VII, VIII
- Left Lobe: Segments II, III, IV (IVa/IVb)
Portal Triad: Contained within the hepatoduodenal ligament.
- Proper Hepatic Artery
- Portal Vein
- Common Bile Duct
- 📌 Mnemonic: Duct, Artery, Vein (DAVe)
Surgical Lines:
- Cantlie's Line: True functional division (IVC fossa to gallbladder fossa).
- Falciform Ligament: Anatomical division.

⭐ Segment I (Caudate Lobe) is unique; it receives dual blood supply and drains directly into the IVC, often sparing it in Budd-Chiari syndrome.

🔪 Core Principles - The Resection Rationale

Indications:
- Malignant: HCC, colorectal metastases (most common), neuroendocrine tumors.
- Benign (symptomatic/malignant potential): Adenoma, giant hemangioma.
Contraindications:
- Unresectable extrahepatic disease.
- Inability to achieve negative margins (R0).
- Advanced cirrhosis (Child-Pugh B/C).
- Insufficient Future Liver Remnant (FLR).
Future Liver Remnant (FLR):
- Volume of liver remaining post-resection; critical to prevent liver failure.
- Required FLR: >20-25% (normal liver), >40% (cirrhotic/chemo-treated).

⭐ Colorectal cancer is the most common source of liver metastases considered for resection.

FLR Augmentation:
- Portal Vein Embolization (PVE): Induces contralateral lobe hypertrophy.
- ALPPS: Two-stage hepatectomy for rapid hypertrophy.

CT volumetry of liver remnant before and after PVE

🔪 Management - The Surgical Playbook

Pre-op Assessment: Determines resectability and predicts outcomes.
- Liver Function: Child-Pugh score (A/B acceptable; C is contraindication) & MELD score.
- Future Liver Remnant (FLR): CT volumetry is crucial. Requires >20-25% in a normal liver, >40% in a cirrhotic/chemo-damaged liver. Portal vein embolization (PVE) can induce FLR hypertrophy.
Intra-op Techniques:
- Pringle Maneuver: Clamps portal triad for inflow control. Use intermittently to limit ischemia-reperfusion injury.
- Parenchymal Transection: Methods include clamp crushing, CUSA, or harmonic scalpel.
Post-op Care:
- Monitor for PHLF: Post-hepatectomy liver failure. Watch for ↑INR, ↑bilirubin, encephalopathy.
- Nutrition: Early enteral feeding is vital.
- Drains: Monitor for bile leak (drain bilirubin > serum).

⭐ The "50-50" criteria for PHLF on post-op day 5: Prothrombin Time <50% AND Serum Bilirubin >50 µmol/L (>2.9 mg/dL). Associated with high mortality.

⚠️ Complications - Post-Op Perils

Post-Hepatectomy Liver Failure (PHLF): Most feared complication. Defined by impaired liver function post-resection.
- Mgmt: Aggressive supportive care (FFP, albumin), consider MARS (liver dialysis) or transplant for severe cases.
Bile Leak: Persistent high bilirubin concentration in surgical drain output.
- Mgmt: Maintain drainage. For high-output leaks, perform ERCP with sphincterotomy and/or biliary stenting.
Hemorrhage: Can be early (technical error) or late (e.g., pseudoaneurysm erosion).
- Mgmt: Resuscitate, angiography with embolization, or surgical re-exploration (re-laparotomy).
Infection/Abscess: Presents with fever, leukocytosis, and localized fluid collection on imaging.
- Mgmt: Percutaneous drainage and broad-spectrum antibiotics.

⭐ The "50-50 criteria" (INR > 1.7 & Bilirubin > 2.9 mg/dL on POD5) is a simple, powerful predictor of post-hepatectomy mortality.

⚡ Biggest Takeaways

Couinaud segments guide anatomic resections, respecting vascular supply.

The Cantlie line divides the liver into true right and left lobes.

Key indications: colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC).

Future Liver Remnant (FLR) is crucial: >20% for healthy liver, >40% for cirrhotic liver.

Portal vein embolization (PVE) pre-operatively induces hypertrophy of the FLR.

The Pringle maneuver (clamping portal triad) controls inflow bleeding.

Most feared complication: Post-Hepatectomy Liver Failure (PHLF) (↑INR, hyperbilirubinemia).

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