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Introducing Liver Surgery to the MID NORTH COAST NSW

Introducing Liver Surgery to the MID NORTH COAST NSW. Dr George Petrou FRACS 69Lake Rd, Port Macquarie NSW www.portlapsurgery.com.au Hepatobiliary Surgery, Laparoscopic Surgery, Obesity Surgery, Hernia surgery, Endosurgery. Indications for liver surgery. Colorectal metastases

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Introducing Liver Surgery to the MID NORTH COAST NSW

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  1. Introducing Liver Surgery to the MID NORTH COAST NSW Dr George Petrou FRACS 69Lake Rd, Port Macquarie NSW www.portlapsurgery.com.au Hepatobiliary Surgery, Laparoscopic Surgery, Obesity Surgery, Hernia surgery, Endosurgery

  2. Indications for liver surgery • Colorectal metastases • Hepatocellular carcinoma • Cholangiocarcinoma • Neuroendocrine tumours • Hepatic sarcomas • Some benign lesions • Select metastases- breast, gastric, pancreatic, melanoma

  3. Colorectal Cancer • 2nd most common cancer in Australia • 2nd cancer killer • 50% patients with colorectal cancer have or will develop liver metastases • 15% patients have liver metastases at time of diagnoses of primary • 120 colorectal cancer resections performed in Port Macquarie per year

  4. Selecting patients for liver surgery • Fit for major abdominal surgery. • 30% normal functioning liver remnant. • Size and number of tumours in the liver does not determine operability. • Site of the tumour is more relevant. • Patients eligible for surgery – 40-50%

  5. Patient work up to determine operability • Routine blood tests. • Triple phase CT abdomen and CT chest. • Liver directed MRI. • CT PET used in selective cases (suspected extrahepatic disease or recurrent colorectal cancer). • Multidisciplinary team discussion. • Anaesthetic work up.

  6. New Chemotherapy • FOLFOX- median survival 24 months • New agents are pushing this 2 year hurdle successfully • FOLFIRI, FOLFOXFIRI • +/- VEG inhibitors • Now chemo alone med survival > 2 years • 5 year hurdle is only a matter of time

  7. Neoadjuvant Chemotherapy Preoperative chemotherapy before liver surgery. Improves survival & increases operability.

  8. Inoperable

  9. After Neoadjuvant chemotherapy this is now operable

  10. RESECTION

  11. Margins A clear margin is necessary to prevent local recurrence in the liver

  12. Survival: marginal status • Transection with CUSA (destroys 1cm) • Inspect margin macroscopically • R0 microscopically clear (>1mm) • R1 microscopically involved (<1mm) • R2 macroscopically involved (edge ablation)

  13. Survival: marginal status

  14. Extrahepatic Disease Rule: excise when minimal

  15. Pre-operative PET scan

  16. Survival: Extrahepatic Disease

  17. Synchronous Resection with bowel Rule: safe if minor liver resection is planned (2 or less liver segments to be removed)

  18. Survival: Synchronous vs Metachronous

  19. Number of lesions Rule: Doesn’t matter provided a clear margin and adequate remnant liver volume can be achieved.

  20. Survival: No. of lesions

  21. Portal Vein Embolisation Increases operability and safety with extended resection.

  22. Inoperable as not enough remnant liver left to make surgery safe Small L Lateral

  23. Right portal vein is radiologicallyembolised as a day procedure

  24. The remnant liver grows after 4-6 weeks

  25. The tumour is now operable as surgery is now safe RESECTION

  26. Is it safe?

  27. Literature Morbidity • Morbidity 20-30% • Bleeding 1-3% • Bile leaks 10-30% • Infection 10-30% • Liver failure < 5% • Wound problems 20% • PE DVT 1-3%

  28. Morbidity and Mortality Australia • 30 day mortality 1-5% (3%) • AUSTRALIA • Only 3 centres have reported data • 90% St George Hospital • 10% Adelaide and Melbourne • ANZHPBA consensus- centre should be doing 10 major resections per year

  29. Local Expertise

  30. Mid North Coast NSW • Established GIT MDT (Cancer Care Centre) • Easily accessible high definition CT and MRI • PET- important for recurrent colon cancer • Established interventional radiology with experience in percutaneous drain placement • Theatre team with experience in major vascular and GIT surgery • Anaesthetic and ICU experience in major vascular and GIT surgery • Established GIT medical oncology

  31. 5 year resultsPort Macquarie NSWSurgeon- George Petrou FRACS

  32. Feb 2008-Jan 2013 • Total- 55 liver resections • Benign 12 (21.8%) Malignant 43 (78.2%) • 22 (40%) Major liver resection completed (more than 2 segments removed) • 33 (60%) Minor liver resections completed (2 or less liver segments removed) • Major liver resection and bile duct resection 2 • Combined liver resection with bowel resection 4 • Redo liver resection for colorectal cancer recurrence 3 • Colorectal cancer metastases 27 • Cholangiocarcinoma 4 • HCC 4 • Gallbladder cancer 1 • SI cancer 1 • Neuroendocrine tumour 1 • 30 day mortality 2 (3.6%)

  33. morbidity • Suppurative infection 5 (9.1%) • Wound dehiscence 2 (3.6%) • Incomplete tumour excision (0%) • Pulmonary infection 2 (3.6%) • Pulmonary embolus 2 (3.6%) • Bile leak 4 (7.3%) • Anastomotic leak 1 (1.8%) • Liver failure 1 (1.8%) • Overwhelming sepsis 1 (1.8%) • Reoperation 2 (3.6%)

  34. The liver tumour is easily seen at operation with US Laparoscopic US George Petrou FRACS

  35. Summary Introducing Liver Surgery to a Regional Hospital • Challenging but exciting time • Enthusiastic and supportive colleagues • Preliminary results encouraging • Volume increasing Prometheus stole the secret of fire and gave it to man

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