Introducing Liver Surgery to a Regional Hospital

Dr George Petrou FRACSSpecialist Surgeon Port Macquarie Base Hospital

www.portlapsurgery.com.au

69 Lake Rd, Port Macquarie NSW

Hepatobiliary Surgery, Laparoscopic Surgery, Obesity Surgery, Endosurgery

Port Macquarie Critical Care Conference

• Is there a need?

• Is it safe?

• Local expertise?

• Preliminary results?

Indications for liver surgery

• Colorectal metastases• Hepatocellular carcinoma• Cholangiocarcinoma• Neuroendocrine tumours• Hepatic sarcomas• Some benign lesions• Select metastases- breast, gastric, pancreatic,

melanoma

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 mets at time of diagnoses of primary

• 120 colorectal cancer resections performed in Port Macquarie per year

Survival Function

SURVIVAL

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Cum

Surv

ival

1.0

.8

.6

.4

.2

0.0

Survival Function

Censored

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

Selecting patients for liver surgery

• 30% normal functioning liver remnant

• Patients eligible for surgery – 40-50%

Morbidity

• Morbidity 20-30%

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

Safe Despite Significant Morbidity

• Preoperative assessments of liver function• Preoperative anaesthetic assessment• Modern imaging- CT, MRI, PET• Intraoperative ultrasound• Post operatve anaesthetic and intensive care expertise• Interventional radiology• Surgical devices

– CUSA– Staples– Ligasure– Argon– Electrocautery– Flowseal

Local Expertise

Our service in Port Macquarie

• Established GIT multidisciplinary team (Cancer Care Centre)• Easily accessible high definition CT and MRI • No PET- send to Sydney• 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

Feb 2008-Oct 2009• 21 Major liver resection completed• 4 Minor liver resections completed• 3 Major liver resections on waiting list• CRC 12 (46%)• Benign 10 (38.5%)• Cholangiocarcinoma (8%)• HCC 1 (4%)• SI cancer 1 (4%)

• Median operating time 3 hrs• Blood transfusions- 3 units packed cells (total)• 30 day mortality 1 (4%) Liver failure• Post 30 day mortality 1 (4%) Pulmonary embolism

• Morbidity data and survival data- soon to be published

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