Introducing liver surgery to the mid north coast nsw
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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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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

Indications for liver surgery

  • Colorectal metastases

  • Hepatocellular carcinoma

  • Cholangiocarcinoma

  • Neuroendocrine tumours

  • Hepatic sarcomas

  • Some benign lesions

  • Select metastases- breast, gastric, pancreatic, melanoma


Colorectal cancer

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


Selecting patients for liver surgery

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%


Patient work up to determine operability

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.


New chemotherapy

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


Neoadjuvant chemotherapy

Neoadjuvant Chemotherapy

Preoperative chemotherapy before liver surgery.

Improves survival & increases operability.


Introducing liver surgery to the mid north coast nsw

Inoperable


Introducing liver surgery to the mid north coast nsw

After Neoadjuvant chemotherapy this is now operable


Introducing liver surgery to the mid north coast nsw

RESECTION


Margins

Margins

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


Survival marginal status

Survival: marginal status

  • Transection with CUSA (destroys 1cm)

  • Inspect margin macroscopically

  • R0 microscopically clear (>1mm)

  • R1microscopically involved (<1mm)

  • R2macroscopically involved (edge ablation)


Survival marginal status1

Survival: marginal status


Extrahepatic disease

Extrahepatic Disease

Rule: excise when minimal


Pre operative pet scan

Pre-operative PET scan


Survival extrahepatic disease

Survival: Extrahepatic Disease


Synchronous resection with bowel

Synchronous Resection with bowel

Rule: safe if minor liver resection is planned (2 or less liver segments to be removed)


Survival synchronous vs metachronous

Survival: Synchronous vs Metachronous


Number of lesions

Number of lesions

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


Survival no of lesions

Survival: No. of lesions


Portal vein embolisation

Portal Vein Embolisation

Increases operability and safety with extended resection.


Introducing liver surgery to the mid north coast nsw

Inoperable as not enough remnant liver left to make surgery safe

Small L Lateral


Introducing liver surgery to the mid north coast nsw

Right portal vein is radiologicallyembolised as a day procedure


Introducing liver surgery to the mid north coast nsw

The remnant liver grows after 4-6 weeks


Introducing liver surgery to the mid north coast nsw

The tumour is now operable as surgery is now safe

RESECTION


Is it safe

Is it safe?


Literature morbidity

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%


Morbidity and mortality australia

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


Introducing liver surgery to the mid north coast nsw

Local Expertise


Mid north coast nsw

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


5 year results port macquarie nsw surgeon george petrou fracs

5 year resultsPort Macquarie NSWSurgeon- George Petrou FRACS


Feb 2008 jan 2013

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%)


Morbidity

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%)


Introducing liver surgery to the mid north coast nsw

The liver tumour is easily seen at operation with US

Laparoscopic US

George Petrou FRACS


Summary introducing liver surgery to a regional hospital

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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