The incidence of liver cancer is rising in the United States. To deliver better care for these patients, UCSF Medical Center recently established the Hepatobiliary Service, which provides comprehensive treatment for patients with both primary and metastatic cancers of the liver, gallbladder and bile duct, as well as benign liver disease.
Livers that have tumors
on both sides are treated first
by resection or ablation.
"Rather than isolated silos of care, we have a team approach, which makes a big difference for the overall care of the patients,” said Carlos Corvera, M.D., F.A.C.S., who leads the new service.
Based on the successful model of UCSF's liver and kidney transplant programs, the Hepatobiliary Service combines the expertise of hepatobiliary and transplant surgeons, diagnostic radiologists, interventional radiologists, medical oncologists, hepatologists, gastroenterologists and anesthesiologists.
Second step in treating
the liver: A portal vein
embolization is done.
"When you are looking at a broad spectrum of disease, there are often competing therapies for which a patient might be a good candidate," said John Roberts, M.D., F.A.C.S., chief of the UCSF Transplant Service. “It’s good to have all the people in the room so everyone can give their perspective about which therapy is best for that particular patient, similar to a tumor board model.”
The group has established standard protocols for both outpatient and inpatient care, and patients are housed together on one unit. They receive pre- and post-operative care from a team that specializes in treating hepatobiliary surgical patients. "There is continuity of care, and we have built redundancy into the system, so there is always a continuum of individuals who can do these operations and take care of these complex patients," said Corvera.
After the right liver and
tumors are removed, CT scan
shows growth of the remaining
In addition to Corvera and Roberts, the group includes hepatobiliary surgeons Hobart Harris, M.D., M.P.H., and Eric Nakakura, M.D., Ph.D. Transplant surgeons Nancy L. Ascher, M.D., Ph.D., Chris Freise, M.D., and Ryutaro Hirose, M.D., are also part of the team.
UCSF is one of a few centers nationally that performs a large number of advanced laparoscopic liver procedures. While some large tumors still require open surgery, many liver procedures can be done laparoscopically. In addition to shorter hospitalization and recovery times, minimally invasive approaches reduce the likelihood of wound complications, particularly since the liver is the source of many proteins important for wound healing. This approach also allows many patients with significant comorbidities to receive surgical treatment.
The use of laparoscopic intraoperative ultrasound with the help of our diagnostic radiologist helps to detect liver tumors that are not always visible using only preoperative diagnostic imaging. Identified tumors can then be treated by removal, or if they are deemed unsuitable for resection, are treated by ablative techniques to destroy the tumor in place. Combining minimally invasive surgery with non-operative "liver only" directed therapies for liver cancers has broadened the number of patients eligible for palliative or curative treatments. "In the past, these patients would all die within a period of months," Corvera said. "With these newer treatments, we've converted the liver cancer of some patients into a chronic disease."
Coronal CT scan of patient
with multiple liver tumors
The Hepatobiliary Service offers a full range of treatment options for patients with liver cancers. Some patients with tumors on both sides of the liver may require staged operations to address the full scope of their disease. For example, if the right liver has more tumor volume than the left liver, surgeons plan to remove the entire right lobe. They precondition the "future remnant" liver by resecting or ablating tumors on the left side. They then deliberately block part of the blood supply (portal vein) to the right liver for several weeks, promoting growth of the future remnant prior to resecting the right liver. This approach provides extra time for the left liver to regenerate, and helps reduce risk of liver failure resulting from a major resection that leaves an insufficient amount of remnant liver.
Some patients are appropriate candidates for treatments by radiologists that may allow for treatment prior to surgery, or enable avoiding surgery altogether. Because primary liver tumors thrive on highly oxygenated blood, blocking the artery feeding the tumor may kill the tumor. There are new experimental treatments in which interventional radiologists may inject a slurry of chemotherapy-eluting beads into the small branches of the hepatic artery. These beads, about 50 μ in diameter, have been incubated with an agent such as doxorubicin, which releases into the liver over time. The beads not only clog the branches of the hepatic artery, cutting off the oxygen supply to the tumors, but also deliver targeted chemotherapy.
Recent studies show that only about 5 percent of the chemotherapy circulates in the bloodstream, resulting in fewer side effects than systemic chemotherapy. Similarly, beads containing yttrium-90 that release radiation may be used in a targeted, well-tolerated manner.
Angiogram after right hepatic
The Hepatobiliary Service treats patients with metastatic tumors affecting the liver, including those with breast, colon, renal cell, stomach and esophageal cancer. The service also specializes in the treatment of patients with bile duct cancers, which are rare, often lethal, and only curable through surgery. These include gallbladder cancer and hilar cholangiocarcinoma (also known as Klatskin tumors).
For liver, gallbladder and bile duct cancer cases requiring major resections, UCSF transplant surgeons apply their expertise from living donor liver transplantation to perform complex reconstruction of the hepatic artery, portal vein or bile duct. This allows the Hepatobiliary Service team to resect cancers involving major blood vessels which may be deemed inoperable at other centers.
The Hepatobiliary Service has also established a patient-centered approach for nonsurgical preparation and perioperative care. In the past, all patients were required to make a preoperative visit to draw labs and assess risk of surgery. "We saw a lot of healthy patients who were fit for surgery, who had to come in for unnecessary trips and get repeated labs," said Claus Niemann, M.D., a Hepatobiliary Service anesthesiologist. "It was a huge burden for patients, particularly if they held down a job and lived four hours away." Based on a recent UCSF presentation at the International Health Economics Association in Toronto in 2011, the median distance traveled for these appointments was estimated to be 125 miles for California residents.
Once a surgeon determines that a patient is a surgical candidate, patients can submit their medical health history online. Either Niemann or another anesthesiologist, Helge Eilers, M.D., reviews the medical history and diagnostic tests that were recently performed. Subsequently, they contact the patient to discuss the perioperative plan and obtain additional information, if needed. If required, they obtain test results from outside doctors and medical centers, and can sometimes arrange for additional tests to be performed close to a patient's home.
Because Niemann and Eilers are experienced in the care of liver transplant patients, they know the risk factors that may increase their likelihood of surgical complications, and which tests are necessary to proceed with surgery. "If they have any specific questions or concerns, they can refer a patient to be pre-evaluated by a specialist at UCSF, such as a cardiologist, who is familiar with the physiologic stresses of complex operations," Corvera said. "That’s something that can’t be done at most other hospitals.”
By reviewing medical histories and existing diagnostics and talking with patients, the Hepatobiliary Service has been able to approve about half of patients for surgery without requiring an additional trip to UCSF for the perioperative consultation.
The anesthesiologists also provide their email addresses and pager numbers, and are available to answer questions that arise. "We really try to establish a relationship early during the evaluation process, so the patient feels comfortable calling us," Niemann said. "The feedback has been extremely positive. We want make it as easy as possible for them."
For more information, please contact the Hepatobiliary Service at (415) 353-9286, or visit hb.surgery.ucsf.edu. For emergent referrals, contact the UCSF Transfer Center 24 hours a day at (415) 353-9166.
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