Robotic liver surgery – Quo Vadis?

Here is my highlight form the most recent edition of the journal HPB

Surgery is often driven by technology and liver surgery is no exception. Following the evolution of laparoscopic liver surgery it was only a matter of time before robotic liver surgical technical experience developed. One of the issues with technology is that it tends to be driven by enthusiasts and this often means that technical progress frequently outstrips scientifi c evaluation.

It is in this context that Nota and colleagues have undertaken the most comprehensive systematic review to date of robotic liver surgery, to attempt to address its place in modern liver surgery. The study used the PRISMA guidelines and includes all studies reporting 5 or more patients focusing on liver resection. Studies were assessed for quality and data were extracted to allow comparison of outcomes between easy or diffi cult access minor resections and also major resections.

The study includes 363 patients and showed good safety and feasibility in all 3 categories of resection studied. Operation times were long but conversion rates were low and length of hospital stay of patients was reasonable. Margin positivity was similar to percentages published for non-robotic techniques. The authors comment that the major advantage of robotic liver surgery may be for small relatively inaccessible resections where conventional laparoscopic resection is not feasible. They call for prospective randomized controlled trials to properly evaluate robotic surgery and while this is a laudable aspiration it may be a significant challenge to recruit patients or surgeons to such studies.

Metal House – Smoking Kaiju Robot (スモーキング怪獸ロボット) – Front

Metal House – Smoking Kaiju Robot (スモーキング怪獸ロボット) – Front

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Cholangiocarcinoma awareness month


The 17th February was the first World Cholangiocarcinoma day. The charity dedicated to bile duct cancer in the UK, the Alan Morement Memorial Fund or AMMF have been running a cholangiocarcinoma awareness month through february. Each day they have posted a story from a patient or their family about their battles with this difficult disease. These stories are very powerful and show that the cancer not only affects the individual but also their family and friends. I would encourage you to look up the AMMF and read some of these patient stories to better understand this challenging cancer and why we need to do something about it.

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Cholangiocarcinoma day

The 17th of February is an important day in our house as it is the birthday of one of our kids. This year it has an added significance as it is the very first cholangiocarcinoma day. Bile duct cancer or cholangiocarcinoma is a devastating disease that can affect all age groups. It is often difficult to diagnose and typically presents in an advanced stage. Surgery is the best opportunity for cure but less than 20% of patients are amenable to surgical resection. Chemotherapy and other treatments are largely palliative and there is a desperate need for new treatments for this disease. 

It is classified as a rare cancer although in the Western World the annual incidence has significantly increased over the past decade. Bile duct cancer has now overtaken hepatocellular cancer as the biggest cause of death from primary liver cancer. There is a low public awareness of bile duct cancer (partly because of its Latin name cholangiocarcinoma which is a bit of a mouthful). 

Many research groups, including ours, are making real progress in understanding and developing new treatments for bile duct cancer. Please spread the word and help raise awareness of bile duct cancer on Cholangiocarcinoma day.  

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Surgery outperforms radiofrequency ablation as a treatment for small hepatocellular carcinomas

Here is my highlight form the October edition of  the journal HPB which suggests that there needs to be some use over the use of radio frequency ablation as an alternative to surgical resection for hepatocellular carcinoma.

Radiofrequency ablation (RFA) has emerged as a useful option for treating some patients with hepatocellular carcinoma (HCC) but exactly where it fits in the management options is less clear. The best results from RFA are predicted in patients with small tumours ❤ cm in diameter.

Miura and colleagues from the Medical College of Wisconsin have undertaken an analysis of outcomes from almost 3000 patients who either underwent surgical resection (SR) or RFA for HCC 3 cm or smaller in diameter. As might be expected from a non-randomised retrospective study there were some differences between the groups in terms of proportion with cirrhosis and alphafetoprotein levels (both higher in RFA group). In the overall analysis the resection group had a better unadjusted survival at 5 years of 67% compared with 55% for RFA. The group then applied propensity scoring to attempt to overcome the selection bias between the two groups and after matching the survival benefit of surgical resection was maintained at 54% overall 5 year survival compared with 37% for the RFA group. Other factors associated with adverse outcome for RFA included older patients and those with cirrhosis. A further analysis excluded patients who underwent ablation using non thermal techniques but again the disadvantage in survival from RFA remained evident.

The authors conclude that RFA is inferior to surgical resection and that treatment strategies should emphasize a surgical resection first approach reserving RFA for patients with HCC in whom surgery is either unsafe or not desired by the patient.



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Enhanced recovery after liver surgery: safety and efficacy

Here is my highlight from the August edition of the journal HPB (impact factor 2.675)
Enhanced recovery after surgery (ERAS) programmes have taken the surgical world by storm. Liver surgery is no
exception and a number of studies have examined the role of ERAS in this branch of surgery.
In this edition of HPB, Dasari and colleagues from Birmingham, UK, looked at outcomes of patients undergoing
liver resection for a 6 month period before and after implementing a structured ERAS programme. What they found
was that there was a reduction in post-operative complications but not in post-operative length of stay. Many ERAS
intervention studies have reported a reduction in length of stay or time to functional recovery and in this study the
authors attributed the lack of difference to age and comorbidity, but it may be they had already adopted practices
associated with enhanced recovery as part of their standard management but before implementation of a formal ERAS
programme. The reduction in complications is interesting because this pertained to a number of different complica-
tions with no obvious common thread. This finding probably supports the notion that it is the complete package of
ERAS elements that contributes to improved outcome rather than one or two particular elements.
This study excluded certain groups of patients including those undergoing ALPPS, concomitant biliary or vascular resec-
tion and those undergoing living donation procedures. The first two groups are understandable but a strong case can be
made for early mobilization and enhanced recovery of patients undergoing living liver donation, particularly if as in this
study, it is associated with lower complication rates.
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Cardiopulmonary exercise testing and fitness for liver resection

Here is my highlight for the July edition of HPB which has a new impact factor for 2014 of 2.675 !!!

Cardiopulmonary exercise (CPEX) testing has gained considerable popularity in pre-operative assessment of patients undergoing major surgery in a variety of specialties. The test at its most simple level involves placing a patient on a bicycle and asking them to cycle against resistance up to their maximum limit of exertion while undergoing monitoring. This allows assessment of cardiac ischemia by ECG, anaerobic threshold based on gas exchange and oxygen saturation and other parameters such as maximum power output.

In this issue of HPB, Kasivisvanathan et al. from London, evaluated the usefulness of CPEX testing in patients scheduled to undergo major liver resection. The study included 104 patients considered ‘high risk’ out of 218 scheduled to undergo liver surgery during the study period. 70% of patients studied experienced postoperative complications. Using multivariate analysis, the only variable which was associated with increased postoperative morbidity was VO2 level at an anaerobic threshold of <10.2. This AT figure is similar to some other studies in different specialties and should be viewed with some confidence. This may prove to be a useful value to help counsel patients about their risk of surgery and this in itself is an important point. CPEX does not really tell us whether patients should have surgery or not but what it can do is to help quantify the risk of surgery and help the patient reach a fully informed decision about whether to proceed or not. In terms of complications, it would be interesting to see a more complex analysis of whether CPEX can predict resilience to unpredictable complications such as biliary sepsis or unexpected perioperative haemorrhage. liver4 copy

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The jury is still out on oral contraceptive withdrawal in focal nodular hyperplasia

Here is my highlight from the June edition of the journal HPB, official journal of the International HPBA, Americas HPBA and European and African HPBA.

Focal nodular hyperplasia is a benign liver tumour typically affecting young women of reproductive age. The lesions are usually easy to diagnose with modern contrast enhanced cross-sectional imaging, however, the management of these lesions remains controversial. Focal nodular hyperplasia rarely causes symptoms and many lesions are detected purely by coincidence. As a consequence of the lack of symptoms and the absence of risk of malignant transformation, surgery is not considered a mainstream treatment (unless there is diagnostic uncertainty). Attention has focused on the association between female sex hormones and focal nodular hyperplasia.

In this edition of HPB, Chandrasegaram and colleagues from Adelaide, Australia, have undertaken an analysis of estrogen receptor expression in tissue from patients who underwent either resection or biopsy of focal nodular hyperplasia and from surrounding non-lesional liver. What they found was a very high rate of expression of estrogen receptor in both focal nodular hyperplasia and non-lesional liver. By contrast progesterone receptor expression was low. This conflicts with a number of previous studies that reported low or variable estrogen expression in focal nodular hyperplasia.

The issue over whether women with focal nodular hyperplasia should be advised to stop taking the oral contraceptive pill (OCP) is still contentious. While the findings of this study support other data showing an association between estrogen and focal nodular hyperplasia, the sample size is quite small and the association is circumstantial rather than mechanistically proven. The OCP is a highly effective contraceptive and also has benefits in terms of regularizing women’s hormonal cycles and these known benefits have to be balanced on an individual basis with a potential benefit of withdrawal in patients with focal nodular hyperplasia.

noncancerous-lesions-profile-3Image belongs to

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Making sense of the liver volume/function relationship in health and disease will lead to safer liver surgery

Here is my highlight for the february edition of the journal HPB

CT scan based liver volume analysis has become a standard technique for complex or extended liver resections as a means of estimating likelihood of liver failure and improving patient safety. Volume analysis of the predicted future liver remnant is known to work well for patients with normal or near normal liver function with predicted minimum liver volumes of around 25%, reliably avoiding post-operative liver failure.

Where volume analysis falls down is in patients with abnormal liver function and particularly cirrhosis. The problem is essentially that the liver function can be highly variable at the dysfunctional end of the scale and the volume function relationship becomes unpredictable.

Kim and colleagues from South Korea have presented an analysis combining conventional hepatic volumetry w ith retention of indocyanine green (ICG) at 15 minutes. In this study, they have confirmed that in healthy liver, volume measurement alone can reliably identify patients at risk of developing post operative liver failure. In patients with underlying liver disease or cirrhosis, expressing the future liver remnant volume in relation to the ICG15 retention time also provided a clear cut off value that identified a safe level at which resection could proceed. This ratio of future liver remnant volume to ICG15 was >1.9. This therefore provides a useful and practical approach to estimate patient safety in patients undergoing major resection. Patients with healthy liver probably only need to undergo volume analysis and if the future liver remnant is greater than 25%, resection can proceed. Those with cirrhosis or marked fibrosis should undergo both volume analysis and measurement of ICG retention at 15 minutes. If the ratio of these measurements (FLR : ICG15) is >1.9, resection can proceed safely but if less than this then a modified approach should be used or there will be significant risk of liver failure.

livervol copy
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Age is no barrier to tolerability or efficacy of radioembolization for colorectal liver metastases

Here is my highlight from the december issue of HPB

Radioembolization is still searching for its precise niche in the armoury of treatments for colorectal liver metastases. The majority of protocols advise its use in patients who have non-resectable and chemotherapy-resistant liver metastases with some requiring failure of first line chemotherapy and some second line chemotherapy. Guidance on its use in patients with extrahepatic sites of disease is also somewhat variable. Economic considerations influence patient selection in a number of healthcare models in addition to outcome data.

In this edition of HPBTohme and colleagues from the University of Pittsburgh explore outcomes of older patients treated with radioembolization. They have reported outcomes of more than 100 patients older or younger than 70 years treated with one or more episodes of radioembolization for non-resectable liver metastases which have proved resistant to one or two chemotherapy regimens. Fatigue is a frequently reported complicating symptom of radioembolization. It might be considered that elderly patients have less physical reserve. However, the Pittsburgh group found no difference in either frequency or severity of fatigue in treated patients based on age. Other side effect profiles were also similar suggesting that this treatment modality is well tolerated by the elderly. In terms of patient survival, again there was no difference in outcome based on patient age. The major determinant of poor outcome appeared to be the presence of extrahepatic disease but this was the same irrespective of age.

This article provides evidence that radioembolization is effective and reasonably well tolerated in patients with colorectal liver metastases and should be considered in motivated patients regardless of age.

Survival and tolerability of liver radioembolization: a comparison of elderly and younger patients with metastatic colorectal cancer

  1. Samer Tohme1,
  2. Daniel Sukato1,
  3. Gary W Nace1,
  4. Albert Zajko2,
  5. Nikhil Amesur2,
  6. Philip Orons2,
  7. Didier Chalhoub3,
  8. James W Marsh1,
  9. David A Geller1 and
  10. Allan Tsung


Volume 16Issue 12pages 1110–1116December 2014

SIRT copyPicture from Macmillan cancer organisation

Further patient information at

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Fools rush in where angels fear to tread: damage control surgery for severe pancreatic trauma

Here is my highlight from the Journal HPB for November which relates to an analysis of damage control surgery for major pancreas trauma. This is a must read paper on the very difficult problem of major pancreas trauma from South Africa.

The pancreas is usually considered to be well protected however, it’s anatomical relationships mean that when the head of the gland is injured there are frequently severe associated injuries to vasculature or important structures such as the bile duct and duodenum. Major trauma to the pancreatic head therefore, represents a life-threatening situation for the patient and a complex management issue for the surgeon.

In this issue of HPB, Krige and colleagues from Cape Town, South Africa present a wealth of experience of pancreatic trauma. The article refers to a cohort of more than 400 pancreatic trauma cases with focus on 19 with the most severe grade 5 injuries. The mechanism of injury included penetrating trauma from gunshot and stab wounds as well as blunt trauma from road traffic accidents. Approaches to management were tailored to the individual patient needs. A number of these cases were associated with major haemorrhage from vena cava or portal vein injuries which required control prior to dealing with pancreatic injury itself.

The concept of damage control surgery originated in South Africa and this series includes a number of patients who had two or more stage procedures after initial damage control of the pancreatic injury. This measured approach seems entirely sensible given the potential difficulties of reconstruction after pancreaticoduodenectomy in an unstable patient. This approach is a good learning point and must have contributed to the excellent survival rate of 84% in these patients at the extreme end of the pancreatic trauma scale.


Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum (pages 1043–1049)

Jake E. Krige, Andrew J. Nicol and Pradeep H. Navsaria

Article first published online: 19 MAY 2014 | DOI: 10.1111/hpb.12244

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