I am a hepatopancreaticobiliary (HPB) consultant surgeon, with an added interest in liver transplantation. These complement each other well because many of the more complex procedures around cancer HPB surgery relate, technically, to the procedures we carry out in liver transplantation. For example, advanced pancreas cancer operations often require removal of major blood vessels (portal vein/ superior mesenteric artery) close to the cancer to enable complete clearance, and I’m very used to dealing with that because of my clinical experience.
We currently perform about 125 liver transplants a year – from both cadaveric donors and also from live, related donors – and we operate on more than 400 patients a year for both benign and malignant liver and pancreas conditions. We are one of the biggest liver and pancreas surgical units in the country.
At what stage would a patient be referred to you? Would they have seen another specialist previously?
There is a range of referral pathways – from local general practitioners, where patients may present jaundice or weight loss/abdominal pain, or from allied healthcare professionals such as gastroenterologists and oncologists, where a diagnosis has already been made. We aim to see all HPB referrals, especially if a cancer diagnosis is suspected, as early as possible through their clinical journey. In that way, through a multi-disciplinary discussion (MDT), the correct investigations can be instigated as quickly as possible, enabling treatment options to be discussed with the patient at the earliest opportunity.
A large number of our patients come from abroad. The medical community treating this type of disease is surprisingly small, so referral pathways become established, hopefully after the referring team are happy with the clinical care that has been provided to their patient in the UK. Patients are also increasingly doing their own research via the internet and choosing to come to London for their treatment.
As I alluded to earlier, every cancer patient we see in the UK goes through a multi-disciplinary meeting where their past medical history, presenting complaint and investigations are discussed amongst a group of allied specialists, so that the opinion you get is not just that of one doctor, but a team. This would be made up of HPB surgeons, hepatologists, radiologists, oncologists, cancer nurse specialists and, if required, palliative care.
As we are a teaching hospital with a world-renowned scientiﬁc proﬁle, some members of that team will have an academic interest and be able to recruit speciﬁc patients into clinical trials, if relevant. Localised adjuvant treatment options, such as SIRT, Nanoknife and thermal ablations, can also be offered with the skill mix available, if surgical resection is not an option.
We work well as a team at the Royal Free – it’s not just about the individual doctor being referred an individual patient. What is important is that any given patient has a seamless pathway through the allied hospital specialists to achieve optimal clinical outcomes rapidly, efficiently and with thorough understanding of the journey. The clinical nurse specialist (CNS) will often provide the emotional support during their time at our hospital, so that the holistic aspects of care are also brought into sharp focus. Having the opinion of a team with a great deal of experience gives a patient not only the peace of mind that the treatment they are receiving is correct, but also that it is as up-to-date as it can possibly be.
If one looks at primary liver cancer (Hepatocellular cancer) as an example, this is most commonly seen in people with concomitant chronic liver disease. The treatment options for this are clearly complex and diverse. These patients need to be managed jointly between surgeons/hepatologist and, potentially, oncologists to assess the severity of liver disease, irrespective of the tumour, so that the ability of their liver to cope with different treatment options can be predicted.
In such cases, the surgical options would be either resection or transplantation, and in our unit these patients need to go through not only standard blood tests, but also ICG (indocyanine green) clearance, and hepatic venous wedge pressure measurement to assess the signiﬁcance of the patient's portal hypertension.
These investigations, together with very detailed examination of their liver imaging, indicate whether a patient could undergo a resection, whether they would be better served with liver transplantation, or whether other local ablative therapies, such RFA or embolisation, should be offered in conjunction with our radiological team.
Various factors determine the nature of the treatment, from the age and ﬁtness of the patient to the extent and severity of their liver disease. There is no ‘one-size-ﬁts-all’ approach to liver cancer. It requires a complex diagnostic algorithm prior to initiating treatment. At the Royal Free, we can offer a full range of investigations and treatment options. We're one of the few centres in the UK to have a joint medical/surgical/oncological “one-stop” HCC clinic, where the patient can see all the relevant specialists, rather than going from place to place for different tests and opinions.
Surgical planning has beneﬁtted considerably through improvements in detailed imaging reconstruction, working jointly with our radiological colleagues. We now have the ability to create 3D reconstructions from CT and MRI scans, allowing us to plan complex operations much more safely. Likewise, volumetric analysis of the liver gives accurate calculations for residual liver following complex resections. Such techniques allow a better prospect of preserving liver volume and function when carrying out liver-sparing surgery.
There is also a growing trend towards minimally invasive surgical techniques, such as laparoscopic (keyhole) and robot-assisted liver surgery, which allow for faster recovery times without compromising on surgical quality or safety to the patient. There are national ongoing trials to determine which patients most beneﬁt from these advances, so that we can provide patients with a realistic and transparent evidence base when offering different surgical techniques.
All patients are entered into our Enhanced Recovery ( ERAS) programme, where dedicated nurses specialising in peri-operative care – including adequate pain relief, but minimising opiod usage, early mobilisation and intensive physiotherapy – all beneﬁt the patient and have been shown to not only shorten hospital stay post-op, but lead to a dramatic reduction in complications such as chest infection and venous thrombosis, which used to be exacerbated by prolonged periods of bed rest.
The days of 'one-size-ﬁts-all' or surgeons operating with little practical beneﬁt are thankfully long gone, and signiﬁcant prognostic beneﬁt can now be achieved in the face of complex HPB cancer by incorporating a dynamic team approach to the diagnosis and treatment of each patient.