HPB BTK Episode Recording
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[00:00:00] Hello everyone, and welcome to the Behind the Knife mini-series on Operative Standards for Cancer Surgery manuals developed through the American College of Surgeons Cancer Research Program. The Operative Standards for Cancer Surgery volumes one, two, and three offer concrete evidence-based recommendations on cancer surgery techniques critical to achieving optimal outcomes.

Fifteen disease sites were covered in these three volumes, and standards for additional disease sites are in progress. Select recommendations from the Operative Standards for Cancer Surgery have been incorporated into the twenty twenty Commission on Cancer Accreditation Standards. My name is Morgan Jackson.

I'm a general surgery resident at the Detroit Medical Center and Wayne State University in Detroit, Michigan.

We are also joined today by a few members of the Education Committee for the Cancer Surgery Standards Program, who are also hepatopancreatobiliary surgeons. Myself, Dr. Eliza Beale from Karmanos Cancer Institute and Wayne State University, Dr.

Daniel Nelson from University of [00:01:00] Tennessee Health Science Center, Chattanooga, and Dr. Hop Tran Cao from MD Anderson Cancer Center. The goals of this podcast are to provide education about the standards, generate discussion, and offer technical pearls to both oncologic specialists and general surgeons, to all of whom these standards apply.

All right. Thanks. We are joined today by our guest, a very special friend, Dr. Alice Hui, who is a hepatopancreatobiliary surgeon at Memorial Sloan Kettering and associate professor of surgery at Weill Cornell School of Medicine. Dr. Hui contributed to the development of the operative standards for HPB surgery

Dr.

Wei can you share some of the background on the manuals, maybe specifically as it relates to HCC, and kinda describe the process for defi- deciding which standards were included for, for, uh, the, uh, HPV section of this?

Yeah, so I thank you very much for having me today. Uh, I, I wanna just thank Morgan for introducing some of the sort of [00:02:00] overarching, um, goals of the operative standards.

But really what we're trying to do with this standard is provide people with a technical toolkit that, of surgical techniques which are really based on, uh, evidence-based methods that are s- cancer specific, right? So they address things that, uh, may not be addressed in patients undergoing this liver resections for non-cancer or non-HCC reasons.

And the way, uh, we addressed it for HCC, where the principles are a little di- bit different than colorectal liver metastases, is we assembled a group of surgeons with specific experience in HCC, which included, uh, not just surgical oncologists, but also liver transplant surgeons who take care of patients with HCC, as well as medical oncologists and other people who take care of HCC, like hepatology.

So with that, we, you know, separated the, the questions that were of importance, and then did an environmental scan of the best quality literature and try to [00:03:00] populate the, the information, the content of the, uh, guidelines based on that kind of information. So high-quality information with experts in the field

Great.

Thank you so much. So moving into the guidelines themselves to summarize the recommendations for operative standards in liver resection for hepatocellular carcinoma, um, the first standard is that the surgeon should perform a thorough inspection of the liver and abdomen, either laparoscopically or open, and secondly, should resect all lesions to macroscopically negative margins.

These are both strong recommendations, but they are based on low-quality evidence, including retrospective reports, case series, or case control studies. Dr. Wei, uh, what is your approach for systematically evaluating the liver and a-abdomen for lesions, and how does it d-differ when performing a laparoscopic or a robotic versus an open resection?

Yeah. So I do think it's important as the very s- first step for any cancer [00:04:00] operation to evaluate the liver as well as the surrounding structures to make sure that the indications for surgery are correct. So when we look at, when I put in a camera or at laparos- laparatomy, and I don't think they're fundamentally different what you do, you wanna make sure there's no evidence of extrahepatic disease that would change what you would do.

You wanna make sure that the tumors are con-- uh, that you see correspond to what you expected preoperatively, and if they are different, more different location or larger, that you adjust the plan to be appropriate. And you also need to adjust the non... You need to sort of evaluate the non-tumor liver because that's a situation where the, all the tests that we have so far can be imperfect.

So we wanna look at the size of the future liver remnant, the quality of the future liver remnant. So that means is there fatty liver disease? Is there fibrosis? Is there cirrhosis? And th- does this correspond with your preoperative [00:05:00] evaluation, or is it worse than you might expect? And you, then you wanna also in, uh, make sure that that future liver remnant, which is the part of the liver you're gonna leave in after surgery, has adequate inflow, outflow, and bile duct drainage.

So those are the things I would systematically do, whether or not it's minimally invasive or open. And I don't think it necessarily matters. So that's really the very first step. Uh, I think we also need to do an ultrasound, but at least the very first step is to l- do a visual inspection and cor- and make sure it corresponds with what you anticipated

Awesome.

Thank you so much. And then a little bit more detail, how do you select patients then who are better candidates for a minimally invasive resection versus starting as a, as a laparotomy?

So I think it depends, of course, on your familiarity and your comfort level with doing minimally invasive surgery.

You know, as, uh, many of you know, that there is different levels [00:06:00] of, uh, difficulty for MIS surgery. You wanna make sure that if you're doing a minimally invasive approach, and most of us are now doing robotics versus traditional laparoscopy, though they're both very good, that you wanna be able to make sure that you can respect the re- uh, the principles of the surgery are there.

So usually for hepatocellular carcinoma, we aim to do an anatomically-based approach. So whether or not that's a formal major hepatectomy, so a sectionectomy, but also if you wanna do a segmentectomy or bisectionectomy, right? So these are smaller but anatomical units of approach. If you're able to do that minimally invasively, I think you can do it minimally invasively.

When would I do an open approach? In patients who've had extensive prior surgery, perhaps, though I think you can be successful minimally invasive as well. I would also do an open approach if I felt that the tumor could not be visualized or identified or localized with the MIS. So for example, a patient with a small HCC on the background of a [00:07:00] highly dysplastic liver with a lot of regenerating nov- uh, nodules, that's a patient for, in whom I might choose an open approach rather than minimally invasive approach, mostly because I'm worried about localizing the tumor accurately at the time of surgery.

That makes sense. Thank you so much

So in addition to you know, carefully reviewing high-quality preoperative imaging, these guidelines emphasize that intraoperative ultrasound of the liver is the current standard for intraoperative HCC staging and evaluation. Major structures including the hepatic vein confluence, portal vein divisions, and associated bile ducts should be located assessing distance and relationship to all lesions.

In your training and then practice, how did you gain experience performing and interpreting intraoperative liver ultrasound?

Yeah, so intraoperative ultrasound is extremely powerful for all liver surgery, and I would say it should- goes beyond [00:08:00] HCC staging. It should be used for anybody who's having a liver resection for any reason.

How do you gain proficiency? So you can do it in many ways, and I would say you should do it in multiple ways. First of all, there are some courses that you can take. The AHPBA runs a course. Many other associations run a course on intraoperative ultrasound specifically to learn the principles, um, of intraoperative ultrasound.

The other thing is that you should have it available to you for every case and ultrasound the liver whenever you have the opportunity to, so that you become familiar with the normal anatomy and what to anticipate, right? So in every operation, you can pull an ultrasound and look at the inflow, outflow of the structures, even if you're not using it for specific localization procedures.

The, the other thing is that we actually get access to a lot of ultrasounds that we don't look at. So for example, when patients come to see me in clinic and have an outpatient ultrasound, I actually pull up the images and I look at them because somebody, an ultrasonographer tech, has actually [00:09:00] done sa- you know, like this kind of very standardized sagittal cross-sectional longitudinal imaging and marked all the major structures.

So you can actually use that as another training tool to look at it. But I do think it's extremely powerful. It's very, very nuanced, so I think you have to practice it a lot and you have to use it whenever you can. So that, that's what I would say. My training and practice, I do it all the time and, um, I, I still think I'm getting more sophisticated the more I practice

Thanks.

Do you routinely use an adjunct like ICG or methylene blue during your liver resections?

Yeah, I do. So particularly for MIS, but even growingly for open surgeries, I will as well. ICG, for those of you listening who may or may not be familiar, is, um, a fluorophore that you can use for many purposes, but if you wanna use it for the bile ducts, you need to inject it about [00:10:00] 20 to 40 minutes prior to a use so that it can be processed within the liver and excreted in the bile ducts.

The other way that we can use it for liver surgery is not just for bile duct visualization or biliary visualization, but for vascular visualization. So you can... I, I would sometimes use it not so much for the bile duct anatomy for a major liver resection, but in order to do something called negative staining, whereas when I take the inflow, I then give the ICG, and then the part of the liver without flow will actually be-- will not have ICG, and then I will only-- I'll be able to see the transection or parenchymal margin.

So there's lots of ways to use it, but I routinely use adjuncts whenever I can. Before we used ICG in the, quote-unquote, "old days," which is really old, we used to use methylene blue sometimes with direct portal injection. That's a very Asian method. And, um, so there's many ways to do that, but I think you should be using these things if, particularly for [00:11:00] HCC, where you want an anatomic resection whenever you can

Dr. Wei, real quick, with regards, you know, there are places where people will pre-inject ICG, like, three days before for colorectal liver mets and for C- HCC to try to localize the tumors or get the ICG to concentrate in the tumor. Is that something that you do, or do you find that helpful?

It's not something that we do in North America.

I do think it's something very standard that's done in Asia because they're using ICG to also assess liver function prior to surgery. I, I really do think it can be help- helpful. It's not something I have direct experience with now. I really think we're in the infancy of seeing fluorophores help us localize anatomy and tumors, so in the future we'll probably be doing this more often.

Right now we just don't do it because of logistical [00:12:00] constraint, which is that it's hard to give ICG in the clinical... In the clinic, in the outpatient setting

Okay. Thanks so much for that. Let's, uh, jump into a little bit of the technical elements, if you don't mind. Uh, as a somebody who does a lot of robotic surgery, I know. Can you walk us through the steps of performing a robotic-assisted right hepatectomy that meets the operative standards?

Yeah. So, uh, I think thank you for asking me to do an anatomic resection.

It's much easier because, of course, that's really part of the principles of HCC surgery, which is really different from other diseases like metastectomies for colorectal liver metastases, which many of the listeners will have experience with. So for HCC in a patient who requires an anatomic resection for right hepatectomy, the, the most important things I think for all MIS surgery, and I think everyone who does MIS surgery knows this, is positioning.

So for robotic right hepatectomy, I'm very careful to position them in a dec- uh, sorry, [00:13:00] sloppy decubitus position. I bump their arm up with a Gallagher bar a- and I make sure that they have a steep reverse Trendelenburg. We put in the ports. The first thing I do with laparoscopy, right, is I... once I, I, is I do a visual inspection, and I make sure it's dictated in note because I think it's really the key for lapara- uh, for oncologic surgery, is to make sure that what I'm seeing, there's no extrahepatic disease, there's no evidence of peritoneal disease, there's no additional metastases that I see, and there's no evidence of worse portal hypertension or cirrhosis than I anticipate.

Next thing I do is I localize the tumor. So I put an ultrasound on the liver, and I visualize the anatomy, make sure the tumor's where I expect it to be, make sure it's the size I expect it to be, and then lastly, I look at the anatomic configuration of the liver to make sure the anatomy of the liver, the inflow and outflow, is as I expect.

Are there, is there any variance in the, in hepatic [00:14:00] inflow, the portal inflow, or the hepatic outflow? So I can plan my procedure. And then just one pro tip I would give the, uh, the audience is that if you see variation in the anatomy You should have your spidey senses up that there could be more variation than you anticipate.

So hepatic artery anatomy is quite variant and, and can be variant without biliary or portal vein anatomy. Biliary anatomy is the second most variant. Portal venous anatomy is the less variant. So if you have portal vein abnormalities, you should have your spidey senses up that, that there could be concomitant biliary tract anatomy.

So that's the kind of ways that we start. Once we have done exploratory laparoscopy, make sure that the anat- make sure there's no extrahepatic disease and confirm the operation that we're doing. Then I get inflow control early, right? So there's a couple ways to get inflow control. I tend to use an intraglyssonian approach, a very classical approach.[00:15:00]

I open the glyssonian capsule, take the hepatic artery to the right, take the portal vein to the right, and I divide them. I then give ICG, very low dose, so you can see the difference between the green stuff, which still has arterial blood flow, which is the future liver remnant, and the stuff which should not have ICG, which should tell me the transection line for right hepatectomy, it would be Cantlie's line.

I, I don't take the outflow yet. I take the outflow intrahepatically, and then I do a parenchymal transection. I use the ultrasound all the time to mark the anatomy throughout the case to make sure I'm in the right place, to make sure I'm not getting confused about where I am, and to make sure there's an adequate margin on the tumor, and then I transect and take the right hepatic vein intrahepatically, making sure not to injure the tumor, make a hole in the tumor, these are soft fleshy tumor, and ensuring there's an adequate margin.

I will do a selective lymphadenectomy. [00:16:00] So for HCC, because the lymph node staging does not change the long-term, uh, r- role for adjuvant therapy, at least at this time, our operative standards do not require lymphadenectomy for staging on all patients, so I do it selectively if the lesions-- if the lymph nodes are enlarged and if they're concerning.

But I do not do it standardly for everybody with HCC

Okay. Thanks a lot. And so do you... I, I, I assume you march along the middle hepatic vein as your... as kind of like your, your landmark for a right hepatectomy. For a left hepatectomy, tell me a little bit about where your ports might differ and how your positioning might differ.

Right. Um, yeah.

Yeah, so a left hepatectomy, I would say, is a more straightforward operation. These patients are split like supine, so I use the French position so the physician assistant or your assistant can stand in between that, but you're, you're absolutely right. What, uh, uh, Dr. [00:17:00] Tran-Kow said is absolutely right, is that we would typically yeah, m- mark the middle vein so that our transaction margin will be selected either to be medial or lateral to the ve- hepatic...

middle hepatic vein as appropriate. That's really the secret to, uh, a major liver resection. For a left hepatectomy, uh, it's a little bit easier because the inflow is a little... There's... It's a bit longer and a little bit farther away from the main portal vein and the common hepatic artery. So the left hepatic, the artery, is usually easy to take.

The left hepatic... Sorry, the left portal vein is long and extrahepatic. I usually take it at the b- base of the falciform. And then I... The same thing, I'll mark with uh, ICG after the inflow's taken in order to... And then I'll go along Cantlie's line. For a classical left, I will go to the patient's left of the middle vein.

Uh, the one thing I will mention is that I always set up for a Pringle maneuver. Whether or not you need it or not depends on the case, but I think as a safety move, you always wanna have it available [00:18:00] to you so you have- Right ... adequate inflow control if you need it

And then maybe, um, last set of questions from a technical standpoint.

When you're dealing with a patient who has cirrhosis and/or portal hypertension what particular considerations you take, um, i- in addressing them surgically?

Yeah, so for these patients you have to be much more careful about parenchymal-sparing approaches. I would do everything possible to, uh, do a s- the smallest anatomic unit that would be appropriate to get their tumor out.

I, I think the other thing that you'd be careful with people with cirrhosis and portal hypertension is I think these patients benefit much more from a MIS approach because you don't disrupt any collaterals they may have that are going through the anterior abdominal wall, for example. I'm also super careful about making sure that the, uh

anything that could open up, uh, like for example ligamentum teres is ex- is sealed very, very carefully and that because it could, uh, open up after. And, uh, just [00:19:00] making, just, you know, be very co- uh, cognizant of all the collaterals they may have. So for those patients you know, although there haven't been a lot of randomized trials, but we do know from multiple case series that patients with cirrhosis may benefit more from an MIS approach than an open approach, and I think these patients are very, uh, good candidates for that.

Thank you very much. That's a great point.

Great. So, uh, moving on to the second guideline, uh, which is to obtain macroscopically negative margins. The operative standards do specify that a Glissonian pedicle-based or anatomic resection is preferred over a non-anatomic resection due to the risk of intraportal metastases.

If you are performing a non-anatomic resection, the gross margins should be at least one to two centimeters. Dr. Wei, what do you find are the benefits of performing an anatomic versus a non-anatomic resection, and how do you weigh the importance of pedicle-based resection with maximizing functional liver remnant?[00:20:00]

Yeah, so I do think we-- I tried to address that a little bit earlier. I, I think for HCC, uh, really doing an anatomic-based resection is something we should try to aim for. The importance of it is that you can be extremely refined if you do a pedicle approach, saving actually the most liver, right?

Because you, uh, s- for these patients, so for example, if they have a segment seven lesion, by taking just segment seven or just segment eight, in many ways, uh, you might save more functional liver than doing a large, wide local excision with at least two centimeters all the way around. I think it's something we're not as familiar with in U-- the United States 'cause so much of the liver disease we do is for colorectal liver metastases.

But I do think with the MIS approaches and even with the open approaches, that that's something we're becoming more familiar with

Right. And then do you ever have to [00:21:00] change your approach in the operating room based on the identified tumor location and the intraoperative ultrasound? Does that ever change your approach between anatomic or non-anatomic resection?

I, I, you know, sometimes I think you have to be flexible, right? Like, you wanna be safe for the patients, and you certainly want to try to do it. I, I do think some patients, for example, like for they, if they have a tumor that sits in between the Glissonian capsules, whi- which is actually quite unusual for HCC, but let's say it bridges two and you have to do a bisectionectomy, in that situation you might move to a non-anatomic approach and just do a wide local excision for the patients.

Uh, so I, I think you wanna be flexible for the patients if you need to, and to save as much future liver remnant as you can. I, I don't typically do frozen sections, but I really will try to use, um, the ultrasound to guide an anatomic approach. And I think this goes back to what we said earlier. I do think ultrasound is exceedingly powerful, and I think that we should all aim to [00:22:00] try to, um, to get familiar with it and use it you know, even for colorectal liver mets so that you can really be very selective on where you're cutting.

Thank you so much.

Dr. Wei, you, you mentioned, uh, the lymphadenectomy earlier. I was hoping you could kind of expand on that a little bit. Is your management of portal lymph nodes different based on histology? Like, does it differ between a hepatocellular carcinoma and, say, a f- a fibromallar type?

Yeah, so I think lymph node, uh, sampling or, or staging is actually really important for all cancers where it's important.

That sounds ridiculous, but basically I think that you want to adjust the operative standards for the disease that you're treating. And just to be very simple, if you're doing an adenoma, you don't have to do a lymphadenectomy. So lymphadenectomies are really in the domain of cancer surgery, right? So for cancer [00:23:00] surgery, I think you need to know why you're doing a lymphadenectomy.

Is it therapeutic or is it staging or is it both or neither? If it's neither, you probably shouldn't do it. If it's both, you should do it all the time. But I think it's just important to know those principles, and I actually think that's what's some of the terrific things that is important for the operative standards, is to clarify and make explicit to the community like us why we're doing it and if we should do it.

Because of course, lymphadenectomy sounds easy, but there's always the possibility of injury, and there's also the possibility of doing it not well, right? Like, you know, lymph node sampling, you know, w- you know, do you just take the cystic duct lymph node? Well, that probably is not enough. Do you do a... Do you strip it all the way down?

Do you do a portal lymphadenectomy? Do you do all the way to the celiac? Do you... You know, so you kind of have to know what you're doing for it. So I, I would say it, it matters. For HCC, it doesn't seem to affect either [00:24:00] staging or adjuvant therapy at this time. But if adjuvant therapy becomes something that we are routinely recommending for HCC, then I would do it if lymph node status affected adjuvant therapy.

So I think it's just important to know the principles

And just kind of going back to, to, uh, making sure that our listeners are aware of the guidelines, wanted to clarify that, um, in the operative standards guideline, only patients with histologically positive or radiographically enlarged portal lymph nodes should undergo lymphadenectomy at the time of hepatic resection, and that lymph node sampling is not recommended in routine cases without preoperative suspicion of lymph node involvement.

Right. Yeah. And, and I think if you have patients in the operating room with frankly positive nodal disease, then I think you wanna just take a pause and try to understand whether or not the liver resection that you're aiming to perform is gonna benefit [00:25:00] the patients or not, and that's where something, you know, where there's a lot of nuance to that.

For example, if you have a patient with a 15-centimeter tumor that's at risk of rupture or has ruptured, in that specific situation, liver resection with or without lymphadenectomy may be appropriate, whereas if you see someone with a small... You know what I mean? I think-- So I think lymph nodes are relatively sophisticated, but they're not routinely recommended at this time.

They could change with evidence, and I think the operative standards would change with them if adjuvant therapy showed that lymph node status was something that affected whether or not patients should have adjuvant therapy or not

All right. Thank you so much. Um, so that is all that we have today for the HCC portion. As a trainee, the operative standards outline critical steps for operative techniques and essential elements to address in oral [00:26:00] board scenarios. Additionally, residents are often tasked with initial documentation, and these synoptic operative elements need to be included within the operative report.

If you're interested in learning more about the cancer surgery standards, please visit the Operative Standards Toolkit on the ACS website, which is linked in the show notes. Additionally, excerpts from the Operative Standards for Cancer Surgery, Volumes one through three are included in each of the Commission on Cancer Surgery Operative Standards.

Thank you again, everyone, for joining us. And, uh, please catch upcoming episodes in the coming months regarding more operative techniques for cancer surgery