This document discusses introducing liver surgery to a regional hospital. It finds that there is a need for liver surgery due to conditions like colorectal cancer metastases. While liver surgery poses risks, the regional hospital has developed the necessary expertise, support services, and preliminary results show the surgery can be performed safely. The introduction of liver surgery was challenging but results so far have been encouraging.

1. Introducing Liver Surgery to a Regional Hospital Port Macquarie Critical Care Conference Dr George Petrou FRACS Specialist Surgeon Port Macquarie Base Hospital 69 Lake Rd, Port Macquarie NSW Hepatobiliary Surgery, Laparoscopic Surgery, Obesity Surgery, Endosurgery

2. Is there a need? Is it safe? Local expertise? Preliminary results?

3. Is there a need?

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

5. 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

7. Selecting patients Traditional Morbid operation with high risk of bleeding Resectable lesion < 5cm <3 lesions No bilobar disease No extrahepatic disease No synchronous disease Margin > 1cm CEA< 200 10% patients with CRC liver mets candidates for surgery

8. 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

11. Selecting patients for liver surgery 30% normal functioning liver remnant Patients eligible for surgery – 40-50%

12. Is it safe?

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

14. 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

16. Local Expertise

17. 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 percutaneousdrain 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

18. Preliminary resultsPort Macquarie Base Hospital

19. Feb 2008-Sep 2009 19 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

20. 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