This document discusses introducing liver surgery to a regional hospital in Port Macquarie, Australia. It addresses whether there is a need for liver surgery, if it can be done safely with the local expertise available, and provides some preliminary results. Specifically, it notes that between 2008-2009 they completed 21 major and 4 minor liver resections with encouraging preliminary results and low mortality and morbidity rates. It concludes that it has been a challenging but exciting time to introduce liver surgery to the regional hospital with enthusiastic colleagues, and their preliminary results 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. Indications for liver surgery Colorectal metastases Hepatocellular carcinoma Cholangiocarcinoma Neuroendocrine tumours Hepatic sarcomas Some benign lesions Select metastases- breast, gastric, pancreatic, melanoma

4. 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

6. 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

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

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

10. 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

12. Local Expertise

13. 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 percutaneous drain 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

14. Feb 2008-Oct 2009 21Major 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

15. 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