This webinar will present different techniques of “advanced” hepatic surgery, including Liver transplantation and Split-liver grafts, and RAPID procedure, with a twist of global surgery as international surgeons/experts can provide their input regarding these procedures.
Good day everyone and welcome to today’s webinar extreme liver surgery around the world hosted by the international relations committee my name is Jesse romance and I am one of the committee administrators for the IRC before we get started I want to inform everyone that today’s webinar will be recorded and will be available
For viewing after the webinar on the ACs YouTube channel additionally if you have any questions during the webinar um please submit them through the Q&A box as there will be a Q&A portion at the end of the webinar with that I’m pleased to introduce you to today’s moderator Dr
George sulfus Dr sulfus is Professor of transplantation surgery and the chief of the Department of transplantation surgery at the Aristotle University of thinoi school of medicine he has received the Edward Eason award for excellent in patient care and education he has published over 180 papers in peer-reviewed journals and PubMed as
Well as 35 book chapters with an H index of 19 Dr suus has edited six books and is a reviewer of 30 International journals and on editorial Boards of several others including the international surgery and the anals of Surgical Oncology he was the past chair of the ACs inter National Relations Committee
And is currently the chair of the Greece chapter at the college additionally he is a member of the executive counil of the helenic surgical society and the vice president of the helenic transplantation Society with that I’ll now turn over to Dr sofal Dr suus thanks J Jesse and thank you
Everybody for joining us today for the ACs international relations committee webinar on Extreme liver surgery around the world today we will hear presentations from Dr Paul dagina and Dr Martin hurdle on the rapid technique and small liver graphs as well as hex Vio hepatectomy respectively after which Dr
Human fun will provide commentary we will end up with the questions and answer portion for the full panel proceeding with our first presentation Dr Paul D it is my pleasure to welcome him today he graduated from the University of foso in 1987 he’s B certified in general surgery vascular surgery and transplant surgery
And a senior consultant surgeon within the fields of abdominal transplantation liver kidney pancreas HPB surgery and vascular surgery since 2004 he has been director at the department of transplantation medicine at Oso University hospital he has a particular clinical and scientific experience and interest within the fields of liver transplantation Advanced
HPB surgery abdominal vascular disease and liver transplantation for malignancy the transplant oncology research group at Oso University Hospital has pioneered the concept of liver transplantation for non-resectable liver metastases from cctl cancer and published numerous papers on this topic he’s a board member of the European Libor transplant Association associate editor of
Transplant International and British general surgery open as well as member of several International societies including transplantation Society the ilts esad ihpba the European surgical Association and the international Surgical Group and we’re very lucky and honored to have him today with us so thank you very much George um I will share my screen
To uh start the first presentation so what I’m going to discuss is uh what we call the rapid technique for liver transportation of small partial grafts I have no particular disclosures uh So during the last uh let’s say 15 years um transplantation for malignancy is an emerging Trend uh and it goes beyond the traditional indications like hosell carcinoma we are seeing this as a more broad development and this um fa makes us face the problem of availability of grafts particularly in
This setting of patients not having liver failure but um having extended or experimental indications of course you can try to alleviate this partly by make sure you use very stringent selection criteria you might use um uh extended criteria donors uh one might also more systematically try to Esta split lcraft
Programs um uh because we know a lot of the splitable livers are not really utilized for logistic reasons and finally living donor liver transplantation might um be an option incentives practicing this but the experimental nature of some of these indications really is a discouragement uh for for doing uh liver uh living donor
Transplantation so uh we began thinking about this about 10 years ago and um uh our basic idea was whether it’s possible to use a very small grafts in the setting of malignant liid tumors uh and it’s standard care to use segment two and three uh for a child and
Then the extended right graft for an adult with very little penalty for for the adult recipient so basically the question was Could you actually use segment 2 and three as a surplus for an adult recipient obviously you have two fundamental problems that has to be
Solved if you put in such a small graph we’re talking about a graph to body weight rtio well below 05 maybe 03 to4 you will for sure have postoperative liver failure so that’s the number one problem the second problem is also well described in the literature and it’s called the small for
Size syndrome it’s basically um a portal vein hyper profusion syndrome with destruction of the of sinusoids which leads to to hyper and the synthetic failure and fail regeneration so the early developed the patients will usually die after a couple of weeks um so basically the concept was published in 2015 called the rapid
Concept and this is an ACM for resection and partial liver segment 2 three transplantation with delay total ectomy um and um the principles used is um that you have the patient with um uh the uh liver with tumus and you start by doing a resection uh preferably um either to one
To three or uh left and the aim of the resection is has nothing to do with the Surgical Oncology is basically to provide space for um a partial graft and to ensure that we have an adequate Venus outflow then um you have to make sure
That you have a liver ENT to address the first problem um meaning that you can avoid post-operative liver failure even if the GR should fail then you transplant in the small graft uh and the aim is to have uh a rapid uh regeneration so you redirect uh
The portal flow to the graft to stimulate fast Li regeneration but at the same time we want to avoid small forze syndrome so the redirection of the portal flow to the ra should be done under close hemodynamic uh monitoring so finally you close up the patient you do a graph volume uh
Measurements weekly by CT or Mr and the patient is ready for the second stage hepatectomy when the grafted body weight ratio is about 08 or approaches 35 to 40% of standard liver volume now the him Dynamic assessment is very important uh we know other orentation methods like the Alps uh
Technique where they have never paid attention to this so basically when you have done the transplant you have a steady state situation you put in a pressure catheter in the portal circulation and you insert flow props to the portal vein and a to The graft and
Then you can do your trial clamping to make sure that that the portal pressure of the clamping is not too high um and uh the the limits uh should be well below 20 mm of mercury if clamping results in in high pressure you can do a splenic AR relegation you could
Do banding on the portal vein or you can even do shunting because if you don’t do this you might have bad outcomes with small for size and you might also have arterial constrictions to the hetic artery which might increase the likelihood of hetic artery thrombosis um so this protocol has been
Adapted uh by seven European centers that you can see outlined here uh and the first technical results was published uh around a year ago um with 22 transplants performed here on the right hand side you can see an Insider picture with the two graphs
To the to your right is the is the graft and the remnant is on the left hand side Remnant right liver and you see the corresponding CT with deportalized liver and a well perused small graft um in animal experiments we have been able to show that um dur
The repeat technique gives a superior U uh kinetic growth rate and volume increase as compared to hepatectomy and we have also been able to show that this also translates into higher il6 production and iOS induction in the clinical setting all the patients have a tremendous volume increase in the course
Of uh two weeks uh and uh in fact the median time to the second stage was 14 days um and uh when this was compared uh to portal ve nalization or Alps you can see that uh the rapat technique far outperforms these augmentations techniques in terms of uh absolute or uh relative volume
Growth looking at T safety uh we had one death in this population translating to 90-day mortality over 4.3% all patients um succeeded in having the second stage so the one patient dying had hepatic AR thosis um 3 to four weeks after completing the second stage uh there was
No donor Morality In The Living donors so um this has also now been published uh more anecdotally or as case reports also in patients with child aerosis in HCC that haven’t succeeded to get diseased onor Li Transportation all these transplants have been performed in turkey and in the setting of sorosis I
Have not personally performed it in sorosis but in the setting of curosis it’s even more important to pay attention to the hemodynamics because the these patients have portal hypertension so all these patients have had shuns to manage this that subsequently are closed by the second stage hepatectomy so quite recently
There was an consensus meeting in um on the rapid procedure for a day uh during the international Society of liver surgeons meeting in zuur Switzerland and uh this was a consensus meeting according to the Danish model and uh the the meeting success successfully provided a set of recommendations uh concerning standardization of
Nure appropriate selection U of the recipient and the type of grafts and optimized surgical techniques and uh the type of interventions needed uh and uh a dedicated registry is uh is about to be formed to to support this activity so just to go back to the start
Of the concept published in 2015 this is the very first patient in the world he was at the time 50 years old male with a rectal carcinoma diagnosed in 2013 he had a T4 primary um KS BF wild type he had all segment disease was on third line chemo
He actually also had a couple of small L uh lung lesions that we decided to accept he was operated in June 2014 he had a weight of 92 kilo and received just 330 gr of liver this is the same guy in from a newspaper article he he
Volunteered to half a year ago and he’s actually now the summer 10 years out uh completely cured from his by just 30 330 G of liver so um these are his City images uh from the time after to transplant you can see a nice and regenerated liver and you see the
Lung nodules the same pictures in 2023 the summer the nodules in the his lung are virtually uh the same never any change his liver looks magnificent and his CA levels have been consistently low and normal ever since so I think it’s a very good example of of showing that you
Can actually U cure patients with transportation for cor Li metastasis and the other thing you can actually do it uh by novel techniques like this so um to conclude this is a technique that might be a possible strategy to engra to increase the ility of grafts uh but it should be reserved for
Patient with a low M score and preserved liver function and you have to consider portal hon Dynamics uh to avoid small forze syndrome life donation and minimal invasive surgery are possible refinements and this is still a work in progress and we need to have prospective trials and international Ries to to
Develop this further but it essentially provides the combination of reduced living D risk and no weight list harm which is a very attractive goal so this is um uh all I had to to say about the repeat technique and I happy to take any questions thank you very much you’re mute
George thank you very much Dr Lena for a very impressive presentation we’ll um U have all the questions and answer uh at the end um and um we’re gonna move on with the next presentation we like to welcome Dr Martin hurdle Dr hurdle is the chief of abdominal transplant and
Capilary surgery at TS Medical Center in Boston Massachusetts his clinical Focus areas include kidney liver and pancreas transplantation as well as complex hepatobilary surgery has been the recipient of several Awards including the annual iur Achievement Award in 2016 17 Dr herle is a member of the international liver transplantation
Society American Association of the study of liver disease the New England surgical Society the transplantation Society the American side of trans surgeons in the American College of Surgeons Dr hurdle thank you for Carol thank you George thank you to the ACs for allowing me to uh present and U the
Title was initially different but we thought that uh this presentation would be more helpful for the the general liver surgeon out there uh a procedure that can be used more often than it is used used currently and I’m happy to present about this um now I’m trying to scroll here we
Go so the liver Anatomy obviously is not not known forever there’s Andreas valius on the left 1543 glissen we know the glisten Tri it already a development here how much more we knew about it and really CL Kuno uh was the one who described first the liver segmental anatomy and uh he was
Really important in bringing us to the next level he did casts of livers here is picture shown of thetic veins as you can see right middle left atic vein and uh that in the end allowed us to develop a segmental Anatomy understanding and uh here you see the Neta Atlas how it is
More and more developed and uh here I show you C Le line uh because that is interesting uh the division between right and left liver an atomical division line is not visible on the liver obviously and this is what he wrote in 1897 that basically in a
Patient who didn’t have a portal vein on the right side the the left side would or the contralateral side would hypertrophy which is also important for my presentation because indicating that if you don’t have a portal vein The Liver Health is impaired and uh what we then did with my
Friend Dr Eric sh he probably was at the meeting in Zurich as well that Dr Lena described uh we did an animal model because we didn’t know really what what happens uh when you do a portal vein liation in in in in uh planning for an extended liver resection and the
Situation is this that we did an animal model and did in one group a portal vein liation or it was in the pig um uh and just left the right lateral segment so the pig is different in the anatomy it’s the right lateral segment you will see
In the next slide and the other group was poal vein liation and hepatic vein liation so double vein embolization and you see that the recovery after only s days poan liation has maybe a 20 uh 2 5% increase and the uh double vein embolization leads to an increase in in
Liver volume on the non-treated side to about 90 80 90 Almost 100% And here you see we after this is in the pig we took tripon methyl and blue and Infused it through the portl ve and you see that only the right lateral segment which is in humans the left
Lateral segment this small piece is is perused and there’s no crossover into the uh treated or into the cancer site you you might say and you see what we found is that the development of collaterals between portal vein liation alone and portal vein and hipic M uh occlusion is different and here number
Of collateral tfts those are uh uh collaterals in the polar vein system that form and you see it that any more of those collaterals develop per visual field in the uh portal vein liated liver compared to the portal vein hepatic vein lated liver so you in the in the range of five per
Liver visible towards four times more portal vein alone and those are those tfts so what we did we did basically what Kuno had done we put acrylic into the organs this is the portal vein is red um and you see those uh tfts here basically collaterals from the uh left lateral
Right lateral segment in the pig uh to the healthy to to the portal vein liated side so this side has no portal vein and this side has a portal vein inflow and you see that this is not visible at time at day one we did obviously control group those don’t
Exist but within a few days and this is day seven those we call them tfts vascular nests develop and that basically then diverts the flow from the non- liated side to the ligated side and and abolishes a bit the effect of portal vein liation however if you and I think
I have one more picture here similar you see how dense those vessels are and and and how the connection here is and basically if you um uh do a double vein embolization then you push the blood flow from the cancerous side to the non-cancerous side simply because the
Only flow that is left is the arterial flow into a tumor like this you see an arterial flow but everything else is stopped there’s no portal venous flow into the area that is to be ected so the contralateral side will get all this flow and there is no collateral
Formation as much simply because there is no outflow the blood cannot go if it were to go from healthy to to disease it would not be able to leave the liver so it has to go from the liver side from the cancer side to the noncancer side so
A patient like this it’s a hepatitis B patient a large 15 cm um HCC uh it went to the Border I will show you to the right hepatic vein uh it you could say you could just do a non-anatomic reection here um but again as I said the the right hepatic vein was
Very close and all this liver down here would not have good drainage a bit to the middle hepatic vein but it is much easier and much safer if you are able to remove the right side without uh having to fear of a penalty here you see it here and you see the the
Hepatic veins here going in and basically what we did we did a port ve this picture is terrible but what you see here is a uh plug that was put in the right hepatic vein and this plug you will see later and then there is the embolization of the portal vein so the
Hepatic vein occluded with this mlat device it’s called and this is uded with um uh coils and and chemo glue and here’s the reection side you see the uh hilum the artery the B duct um this is the rection so the tumor is gone a small piece of liver is left
Behind but here you see the tumor and you see the the um coils and you see also this Amplatz device you see the two bellies and it’s hidden in the uh the end pieces are hidden in the right hepatic vein here but you see how close the tumor went to
This uh middle hetic vein so I think it was the right thing oncologically to reect it and the liver regenerates extremely well within one week so we do this one week before the expected uh resection which is different from portal vein embolization alone where you usually wait six weeks and uh
The the um prze is comparable at least if not better to a six we portal ve liation alone or embolization alone so you see the left L is very big there’s still some this is a stomach but there was some aides on the cut Surf and you
See how segment four is abused here uh despite the pine was patent but uh you you can just get away then with having segment one two and three uh here’s an a coronal image and here’s another patient who uh is a 72-year-old patient had uh chemotherapy
For over a year with cisplatin and uh and um um I forgot what the other drug was combination therapy and had also had received y90 in the right L this is a bod dark cancer uh the uh problem was and we did know at the time that he was fibrotic
Stage three fibrosis and we did a double embolization on him here’s another picture and left lateral was really the only part that was could be left behind but in a 73y old he was felt before I saw him that he was unresectable and uh this is a specimen
In the end that we removed and uh you see the big int aaic B duct cancer and here is now you see this umplut device you see one end the other end is still lodged into the uh right hepatic vein and uh afterwards he also developed the
Size because of the fibrosis that he had in his liver um but he has recovered he’s now two years out and is still tumor free at this point and it’s having a a good life goes to Vegas for for entertainment um and uh the reason why I present this is
People might say oh this is all reable without any any fancy stuff the left lateral segment might you might get away with it but doing this pre-treatment allows you similar to what Dr Lena showed that he invokes regeneration of the left lateral segment and and doubling in size before he removes the
Ride lob of the liver the the tumor containing uh Native liver and this is a similar approach that we grow the liver before we do the surgery and we can grow it very quickly and it is much more stable the growth and more um reliable and it’s and it’s much shorter as you
Know when you take uh long to resect and you have two months or so between embolization and and surgery some patients might drop out so this will reduce that danger uh but of course it’s a a team effort oncologist Interventional Radiologists radiation oncologists potentially radiologist and
The surgeon we all have to work to work together and uh but I think the more we use it the less postoperative liver failure we will see and I’m happy to take questions and thank you again thank you very much Martin just very impressive uh work and um we’ll have the
Questions at the end but uh first we’re gonna uh hear from uh Dr human Hong who’s going to be our commentator and uh help us understand the significance of what we’ve seen uh Dr yuman Fong is Chairman of surgery at the City of Hope Medical Center he’s known for his work
That helped prove that Livery section can lead to long-term survival and cures for patients who had estatic cancer to the lier for clinical accomplishments he was awarded the late and PR master clinician award from the side of surgery for the elementary track he has helped design many novel surgical tools
Including surgical robots and his laboratory design cancer killing viruses and immune cells he’s worked in medical engineering has led his election to the American Institute of Medical and biologic engineering he has C fored over a thousand articles and 22 textbooks which have been cited over 990,000 times since the science ien ific literature
For his contributions he has been awarded the Shipley award from the southern surgical Association the fence Carl aard from the American surgical Association and has been elected to the American Society of clinical investigation and the National Academy of Medicine Dr far your the floor is all
Yours thank you very very much and for that kind introduction I just want to point out even though we are here gathered to talk about extreme liver reection what we’re really talking about today is how to make it safer for patients and uh there was a long long time when we were doing
Extreme liver restrictions to the tune of 10% mortality that was back in the 80s and the early 90s when we were doing resections and transplantation when it did not make biologic sense when patients were dying of their cancer well we’re talking about today our techniques allow us to do extended indication
Receptions and transplantations that allow patients to live longer the most important parameter and to survive their surgery and to recover faster that’s what we’re talking about here today so I have two questions for Dr Lenny and uh first again I with the uh left lateral sector being the a target for reection and
Transplantation does it even have to go up into the left up into the right of quadrant and I why why take out the first part at all when I read your paper in 2015 I knew it was going to be a landmark paper that that was going to
Transform uh transplantation as we knew it but I didn’t quite understand why you were putting it back up in the in the right numberer quadrant to start with with and obviously everybody succeeded so it’s fine but is there any advantage to doing that should it be somewhere
Else the other that I’m wondering about really is the biology of transplantation and are you measuring circulating tumor DNA levels in the patients before you do xplant because that would actually give you the r a parameter to look at to see who will recur in the in the new liver okay does
It correlate to circulated tumor DNA and then are you doing anything extra on the explanted liver are you doing a y90 ablation of all the tumors to decrease the level of circulating tumor DNA and possible tumor seeding to new piece of liver you’re on mute thank you very much for this
Excellent question so so I I would try to take the second first um so we uh this story uh about transplanting Coral is is uh beginning to get old so we started back in 2005 and obviously at that time liquid biopsy and and circulating DNA was not really available
In to that extent so what we have been doing is make sure that we have banked um enough tissue so we’re currently doing it on on the population because I think basically you have to have numbers before we do that analysis really to tell so basically what can you use
Circulating DNA for uh well I can Envision two things that um you could uh uh I don’t think it will be any specific Mark itself because we have been looking at DNA in corals for years uh but we could you could um uh argue that high tits of of cir in DNA
Might be a very bad prognostic sign and with uh there is Cleveland has done done a little study that was published some months ago uh where they they showed that after transplant they had a proportion of patients were completely cleared some were um without recurrence but they had recurrence of DNA so that
Will be exciting to follow but I think think in the repeat setting I mean uh you um uh you have sort of started uh the procedure and if you you you don’t know if it’s going to be cleared before you have taken out uh The Remnant right so I’m I’m um not
Confident whether it’s going to change very much I think uh we should think of transplants for corals as addressing the aill Seal of liver reection because to my mind the aill of liver re section is under staging of the disease meaning that we think that patients has this and
This number of lesions that and we can clean uh do the two stage and clean but it pro it is clearly shown that um there is a systematic understaging and it this uh tendency toage is actually a function of the number of lesions so the the group in roachester showed that in a
Systematic investigation of expense from trans patients with col Li metastases about 70% of those having complete radiological response had living tumor cells and 50% of the patients had non diagnosed lesions so this is a big problem uh in Toronto they have a trial where they do live donor for for color
Rectal uh and they are very stringent in terms of making sure that they are not technically reable they have looked at those that were uh deemed to that were reected instead of transplanted they are similar in every way as the transplanted but in the reected population the recurrence frequency at one year is
86% so I think we we have to uh we have to um regard transplantation as as addressing the problem of Mis staging so really what we should start talking about is uh it’s not where the technical resectability yes or no we should talk about biological resectability and then choose whe it
Should be a partial resection or 100% resection the first question could you repeat it why does it have to be in the right quadrant no it doesn’t have to so so you could you could do a a posterior SEC uh posterior right uh section you can
Remove that and put the left Lal there doesn’t matter at all uh and in fact often when I do pediatric transplant if it’s a bit too big I would flip it over and put it on the other side so so you are I mean it’s just your uh our um
Imagination that sets the borders so that hurdle superb contribution if I may Dr Dr Fong if I might just one add to this because we have done you asking where’s the location of the graph so we have done at the University of Essen in the late 90s we did two transplants in acute
Liver failure patients with this split graph into the right lower quadrant yes both I helped with some of those in the 90s yeah see both uh uh well let’s see how your your experience was but we had both failed because we think that the Venus congestion is more you’re further
Away from the diaphragm this is actually the same reason why we now do pancreas transplant always very close underneath the liver we used to do bladder drainage and pancreas transplant and so forth but we had Venus congestion and Venus clots sometimes and so those livers did not
Work in the long run because when the patient was getting up the the column of blood pushing was was high and and I see that Dr Lena is agreeing so so that’s my contribution to to the location so I think it should be we actually have done
It in a patient with hyp oxyura we just put a left lateral segment in and left the right low but we resected left lateral and and then diverted the portal flow two3 left lateral and and it worked fine as well so I can only congratulate
You this is fantastic and and uh I have learned a lot this morning so I appreciate so Dr herdle superb contribution in terms of the two vein imization my I have three questions for you should we do it as a primary event we were trying to grow liver or should
We do it only when the portal vein imization doeses not work okay because uh when the portal ve enolization does not work should we repeat it or should we do a portal ve enolization and the hepatic vein and lastly I’m reading more and more and doing more and more y90 lamies for
Primary cancers of the liver and so that hepatoma you showed I probably would have approached that either with a primary reection if the plate leg ground was high or a y90 embolization in fomy if the plate count was low okay and uh so how do you compare the two vein to the White
9 yeah so so the first question I would just always do double vein embolization if you think the The Remnant liver the the future Remnant is not big enough uh you I don’t think you lose anything um you know the the IR folks they we used
To in the 90s we used to go in first surgery we liate the right P even divided or not divided and that was it and obviously if you don’t go into to the periphery of the pan distribution there is a lot of crossover from the not
Ligated part of the liver and now the Radiologists use coils and glue and go as far in the periphery and and they know if they don’t do that there will be a lot of crossover however my proposal but I don’t have the data yet when you do the hepatic vein embolization or
Occlusion at the same time you will not have a good to bad flow or from from the from the from the to be preserved side to the cancerous side you should not have flow because technically it should be impossible for blood to go from the from the future liver Remnant to the
Cancerous side because there’s no outflow and in fact there is hepatic artery flow that still pumps blood into the cancerous side um we have not seen in the patients we have done it’s a number now uh the liver enzymes do not increase uh the liver function stays
Stable um uh the patient doesn’t even feel it obviously it’s a it’s an outpatient procedure um that is off there’s in the chat a question how does it compare to Alps um obviously and and it Compares very favorable because you don’t have the morbidity associated with with Alps and the liver regeneration I
Think is at least as good as with alvs because you don’t have this trauma of surgery that hampers regeneration to a certain degree uh because it’s such a minimal invasive procedure so if you do portal vein embolization which is probably the harder part of the embolization procedure but I think one
Could just put in the future an Amplatz device in the right portal vein for example if you were to treat a tumor on the right in the right hepatic vein and that’s it you don’t need this this several feet of coils and and this this hard work for the radiologist however
They are not there yet the radiologist they still want to do the portal ve embolization the way they they do it um and I forgot your second question I’m sorry the y90 yeah y90 I think should work very well you could the the only concern there I have is that you could
Get a little y90 into the healthy part of the liver that could be a concern no no we we are actually putting it into the good part of liver so that we would end up having a complete atrophy of right liver as well as the tumor for
Primary tumors but let me turn this over to George uh for the audience uh in questions thank thank you very much you so um one of the questions which um um Martin answer was a comparison of the double vein legation to deliver Remnant growth and complications
Um I guess one question I have along these lines is um um Alps kind of becoming old news and less and less um favorable yeah if if the question is for me that’s what I think I would not know any case anymore where I would do an
Alps procedure um and we have done those a number of times when it was coming up but the mortality obviously has to be much higher and is higher and the Regeneration is not better uh the rapid regeneration that we see within a week we are planning the surgery and usually
We do surgery uh 10 to 14 days after the embolization procedure um so we don’t uh we don’t miss Alps um moving on to another question for um Dr Lena um do you see us moving into other types of metastatic disease apart from coloral cancer the way that the surgical
Technique is progressing and the understanding of the biology you very um correctly mentioned um are you any thoughts about looking into other types of met well uh I I think uh many centers haven’t really taken up neuro endocrines uh but we have uh we adopted the Milan uh principles with a slight modification
Meaning that we we are not that concerned about age where where numerical age meaning so we are looking at biological age um and then um we also have accepted patients where uh the primary cannot be located uh and we have now done 26 cases uh for
Since 2013 we have a 10 years survival of 100% And we have just two recurrences in those in that population so I think um new endocrine metastasis is an excellent indication really really and probably underutilized because we know that in these patients in particular understaging of the disease is really
Limiting the usefulness of resection so so there transplant can really play a big role um for other cancers um time will show I think there there might be uh maybe a little roll in G or something like that but but I’m um u i we haven’t gone into other metastatic
Cancers really great thank you thank you um I ask a question George yeah for Dr Len um yeah you you you sometimes employ split liver graphs in the United States it would be extremely difficult to get a split because the organs uh which is in contr to when I was still working in
Germany where an organ would be allocated to the transplant center and not to a specific patient here in the United States it’s allocated to a specific patient and it is hard to sell the patient with a melt of 35 that you’re going to get almost a full liver
But we need left left lateral you’re going to Save a Life sir or lady or Madam and and they don’t that would be fraud with with legal implication and so how is the current Euro trans I don’t know whether whether you’re in Euro transpant in your country um uh so so
That would be interesting for me to understand yeah yeah uh so so the the situation for we we are outside the confidence in will so to say so in in Norway we have a population of 5.5 million and one Center uh and we are not part of eurotransplant we are part of what’s
Called Scandia transplants which is Sweden Denmark Norway Iceland Finland and recently also Estonia so basically we have a in the transplant uh Community we have 28 million people and the reason for having this organiz change organization is basically with just two things it’s for perfect matching of kidneys the other is
To have an urgent listing system that functions for Urgent listing and pediatric transplants but in all the centers we have Center based allocation meaning that here in Oslo we decide who get the specific liver and that uh allows us to do have a much more Dynamic uh waiting list system the other thing
Is that we don’t use M allocation at all we publish back in I think in 15 16 we published a um a Nordic liver transplant experience and M has no implic no impact meaning because our median waiting time has is is around uh has varied from 30
To 50 days so obviously if you predict 90-day mortality it’s not going to be very meaningful uh and the weightless mortality in the Scandia system is about 2 2.5 to 3% way way lower so so we are we are in a very fortunate situation I
Think that why we have been able to to look at these oncological indications yeah I see thank you another question from the audience how long does it take tumor recurrence after the rapid procedure there are two ways to answer this uh so uh the most honest one is to
Say I don’t know uh because we don’t have a lot of data on that specifically because the indications uh for doing the rapid have have mostly been slightly extended but uh but um it’s it’s a valid remark could could you actually have increased recurrence because you have this regeneration in the beginning and
My answer to that is uh in um the in Alps in portal vein imization in double vein imization we see this all the time you you should worry about the mechanism of having tumor cells going to the to the Future Remnant uh but it it’s not really an
Issue uh in short intervals because the tumor cells doesn’t jump and I think the way to avoid this is actually how you select your patients you should never transpant the patients where you think you have circulating cells or or an instable situation so so I think it’s a matter of patient
Selection um we haven’t we have looked at the right liver in the patients we have done raped and we have not been able to radiologically show that there is an increased growth in the uh interval period so so I think it’s I think it’s a problem that is of a great theoretical
Interest but um uh I think uh I don’t think the uh I think it can be addressed by selection thank you uh we have another question for um Martin when you do the double liation how often do you repeat the Imaging and uh the flr volumetry and
When uh do you do the first study after embolization and also whether you’ve had any experience in children listic Oops you’re on mute pardon now I’m unmuted is that can you hear me now so I can only uh think that the uh regeneration is more rapid in in younger patients but we have I have not done this procedure in a pediatric patient um and the so we do once we have
Identified a patient that this double bin enolization is is beneficial potentially we do the double v mization it’s on the same day you could do it in two steps but we have not felt that that’s indicated or needed because the liver is not suffering because of the double
Embolization uh as you see saw one of my patient was a was a fibrosis patient uh and then a week later we do imaging and then we measure obviously Time Zero liver volume and uh then the volume one week later and in those two patients that I showed you one had an 80%
Increase in volume and the other only a 60% increase the fibrotic patient um however it was felt that overall the lob was large enough to sustain him uh simply at this point we still didn’t know that he had this fibrosis there was never a biopsy of the healthy side which
Um could be entertained and and might be a good idea to know what quality of liver you’re dealing with I have done it in cerotic Frank cerotic and the liver did not regenerate um at all or or very poorly um and then if that happens you cannot do the
Procedure um but but basically within a week we know what’s going on um but the generation then goes regeneration goes on if you then do another image uh three weeks out uh which we do usually four weeks after the surgery that the time zero image for for tumor follow up then
We see that it is enlarged much further usually another 100% at that point from start compared to the initial pre- double embolization time Point great thank you we have a lot of questions unfortunately where we don’t have time and the very last one which is more of statement regarding the
Discussion before with the splits it’s um from Dr Martin from Germany saying that u in Germany we have not often but regularly livered grass which go to the send her transplanting child during the split and then the right L to the next one tumor transplant and your transplant only within
Studies and I think that shows the um differences between the different donor type an organization between the different systems not just between Europe and the us but also within Europe um at this point I would like to um thank um our speakers and U our commentator um Dr Paula Dr Martin hurle Dr
Human and for very interesting uh very interesting presentations and discussions and I will now turn it over to Jesse for final announcements thank you thank you all for joining us on today’s webinar as mentioned at the beginning of the webinar these presentations have been recorded and will be posted on the
ACs YouTube page Additionally you may also view past webinars on the ACs YouTube page under the global uh surgery playlist I would also um sorry I would also like to highlight that this year our residents um can be become members of the American College of Surgeons uh for free um on here is
Just some information on that and then lastly um if you have any questions or feedback on this presentation please contact myself or any of the IRC staff and our information is on the screen thank you all again so much for joining us for today’s webinar and we
Hope that you have a great day thank you bye-bye okay thank you bye byee byebye byebye good to see you