N. PEARCE

Hello. Can you hear me? I can hear you.

Good morning and welcome to the Congress of Palazzini. Welcome to Rome.

Thank you very much, very kind of you.

We have some patient delays at our end, if you can hear us well.

There's problems with the critical care facilities here.

But we're up and running. We have a patient in the anaesthetic room.

probably be about half an hour away from actually starting the case I would say

maybe 20 minutes so apologies slow start we have one of our trainees Carlo who

will come and present the case to you in a few minutes and he'll speak Italian so

that everybody can understand exactly what the case is and I'll then describe

our surgical strategy.

Right, beautiful.

In fact, I have Carlo here. Are you happy to present now?

Yeah, absolutely.

We have Carlo just here.

Good morning everyone.

I'm Carlo Frollo, specializing in

the General Surgery School in

Pilano. Good morning

and welcome. Many compliments.

Thank you.

The case I'm going to present

is that of a 69-year-old patient

that in November 2010 was subjected to the resection of the small intestine for an intestinal carcinoid

PT4N2, a well-differentiated carcinoid and during the follow-up in the imaging of three months ago

metastatic interest in the liver by the carcinoid has been found and it turns out to be a multifocal disease and both lobes are interesting.

and most of the disease is focused on the right liver and in the left liver there are two lesions at the level of segment 2 and segment 4b

and they are highly suspected to be metastases of this carcinoid.

Adesso lascerò presentare la strategia chirurgica al mio consultant, Mr. Pierce, consultant in pancreatic liver, consultant in pancreatic liver and in pancreatic liver surgery, and advanced laparoscopic surgery.

Grazie mille Carlo.

Thank you, thank you very much.

So surgical strategy, do you want me to just talk about that now?

Yeah.

With this patient having neuroendocrine tumor

and it being low proliferation index disease,

we're looking at the scans and the pattern that we see

on the scans is one that has the potential

to give us a complete surgical cure.

However, we know from experience that very often

there is more disease and it's being reported

by our colleagues in the radiology department.

So the laparoscopic approach gives us

the perfect opportunity to restate the disease so that we can see whether there is more disease

than apparent on CT and MR. So we'll be using intraoperative ultrasound to assess the pattern

of disease. If things aren't exactly as we anticipate from the scans, then we'll be looking

at multifocal wedges from the left liver, the central right-sided disease, and a relatively

small volume left liver according to our volume metrics on the scans and so it

would be sensible to do a right portal vein ligation during the procedure to

stimulate hypertrophy of the left liver so that we come back and treat this as a

two-stage resection we're happy with that as a strategy if we see that the

patient has much more extensive disease then I think there is still a role for

for surgical cytoreduction here.

This patient has liver only disease.

There is no disease elsewhere on octreascan or on CT,

chest, abdomen, or pelvis.

So our thoughts are that we would,

even if this patient has multifocal small volume disease

on the left, that is not going to all be

surgically resectable, we would still achieve

probably a 95% cytoreduction of his disease volume

by taking the major deposits from the left and doing a right

hepatectomy subsequently so I think even if we see more disease I'm likely

to follow the same surgical strategy but with different intent whether it's

curative intent or whether it's just surgical cytoreduction as he's got a

very significant syndrome low proliferation disease that needs to fit

I think he will get the best long-term outcome by having surgical intervention

in either scenario. Yes, all is clear. Thank you. Has the patient symptoms of endocrine

disease? He has carcinoid syndrome, so he has systemic syndrome symptoms. When he presented

originally, he presented with a long history, 10 years of irritable bowel type symptoms,

symptoms, diarrhoea and cramping abdominal pains. He's already had his primary resected

by colleagues in a different hospital about six months ago and his diarrhoea and cramping

abdominal pains have gone. So he currently has no acute abdominal symptoms, his symptoms

are purely syndromal.

Okay, thank you. We are waiting for looking for you.

Sorry?

You are waiting for looking at the surgical procedure.

Yeah, we're still waiting. I'm afraid. I hope you don't have the same problems in Italy.

But sometimes things are a little slow here in England.

In Italy, we have a long time to...

Well, here in England, it might say that I am the boss, but I know the reality is different.

It might be sensible for you to link to another center for a little and we will

let you know when we have the patient ready to go and I will then give you

external imaging to show you our port placement and then we'll demonstrate the

disease inside and where we're going okay okay thank you no idea for you good

good morning can you hear me hello okay this is Rome thank you for participating

to this meeting and my name is Michele Golia and we are looking we have your

images laparoscopic images can you explain to us the case and the procedure

that you have planned please you've heard already some of the stories of

patient with near endocrine tumor below 1% proliferation index has according to

his imaging got isolated liver metastases involving segment 4b of the

liver also involving segment 2, 3 but much more extensive disease in the right

side of his liver. However when we laparoscope him we see that he has peritoneal

abnormality and I think sometimes this would just be peritoneal reaction but if

If you look at the nature of his metastases on his liver,

they're a similar color,

and I'm suspicious that this is all peritoneal disease,

which would be a shame.

His primary was in his midgut.

The peritoneum lower is clear,

except for one spot that we were a little concerned over.

Can we have the laparoscopic images, please?

Yes.

Okay, now it's okay.

Okay, we're gonna say that all over again.

Okay, so what we've got so far is we've got four ports in, we've got a 5mm port here, we have a 10mm epigastric port, I'm through a 10mm port here, we have another 5mm port there.

The patient has disease that we've been looking at on the interruptive ultrasound, a dominant

deposit here in segment four, multifocal disease throughout the right liver, many deposits

of one to three centimeters on the interruptive ultrasound.

However, he also has this peritoneal reaction, and we've sent this for frozen section to

We're sent the frozen section to see if that's actually

your endocrine disease or not.

If it is, we can make a case still for doing some surgery

in terms of control of syndrome,

but I think we'll be less aggressive

because this is not the cure

if that's positive peritoneal disease.

So in the meantime, whilst we're waiting for that

to come back, I think we can take this bulky deposit

that he has in here.

It has a three and a half centimeter central deposit inside segment 4B.

And whilst we're waiting for the frozen section, my plan is just to take this out as a wedge.

And we'll take things from there.

Does that make sense?

Yeah, sure.

So the original disease was a carcinoid, right?

Yeah, carcinoid.

And he's got a very potent carcinoid syndrome.

dromedes on high-dose sandostatin LAR, the long-acting somatostatin analog, and his disease

was, his primary disease was in the small intestine. He's had that resected, and there's

no suspicion of recurrence in that region. What we're really dealing with is isolated

or liver-only metastases. However, laparoscopically, the pattern is worse than you would anticipate.

This is not ideal, so we'll make a case for surgical cytoreduction to help with his syndrome.

Okay.

We'll assess the proliferation index of his metastases in his liver,

since if he has high proliferation clone in the liver,

then that will also make systemic therapy more useful.

When was he resected?

When will I resect?

No, when was the small bowel resected?

how long how long ago six months ago six months ago okay six months ago and he was done in another

hospital they identified his liver metastases and uh he was only referred to us six weeks ago

okay how old is he

Hello, can you hear me?

yeah we can hear you do you have the results of histology it is just coming through on the phone

we are watching you and we can hear you there is peritoneal disease confirmed that's neuroendocrine

tumor in the peritoneal reactive tissue that we've removed so uh that changes our surgical strategy

here. I think I'm not going to put this guy through a very major resection with

extensive peritoneal disease. I don't think we can justify that at the moment.

I think the sensible thing for us to do is probably to take the wedge from

segment 4B which will be the dominant nodule from the left side and we can come

back and do this purely to tell us what the proliferation index is in his

his remaining disease. We do see some patients with neuroendocrine disease who have a separate

clone of high proliferation index disease, which is the clone responsible for the metastatic

picture. So we often see a difference between the primary and the secondary disease. So

I think there's some value in doing this, and it's a dominant nodule. So I'm happy to

do that, but I don't think there's any value to him putting him through the major right

side of resection even though we can achieve a large site of reduction I

think there are ways that can be done embolically so I'm being fine to leave

that are you audience happy with that so if they understood you are finished with

this procedure or are you going to take the main lesion I'm going to take the

main lesion here. So the next thing that I'm going to do is put in a

How large is the lesion?

It's approximately 35 millimeters.

Okay.

So we'll just put the scan on the ultrasound.

And how deep is it?

How deep is it?

It's central within this.

Can you bring the machine here?

What we're doing at the moment.

If I was doing this for colorectal metastases,

and I'd be looking for a 10-millimeter margin,

I would be taking a much bigger wedge.

This, just looking at this on the ultrasound,

The tumor, the metastasis is central within here, it's edged from there to there, and

you can't see it other than on the ultrasound, which is not helpful for you.

I use the CUSA once about three centimeters into the liver, or let's get a bit less.

I tend to switch to a two-handed approach, and I alternate from one hand to the other.

It just helps me, you know, I don't want to go into the middle of them,

the middle of the panic vein rather than trying to take things out.

No, I haven't put it on yet.

Nylon.

Nylon.

Hemolock.

WEC.

I think the vessels this size, I'm happy to leave one on a vane or a duct.

I'm trying to get a roughly two millimetre cup of tissue.

I think they're very secure.

I have used them on...

If I'd been doing portal vane ligation, which we won't do today,

I would do the right portal vane ligation,

leave it with a single hemlock flip, a larger size than that,

and leave it in continuity.

So, we won't be doing that today, we can justify it.

Put the camera back in the abdomen again.

All we've done is we've just off the Pringle for a minute.

We're just cleaning the camera.

Okay, okay.

In about two minutes, I'd say, three minutes.

Okay.

You've probably been at a different site, but what we have at the moment...

Okay, now we can see.

yes we can see

I'm trying to keep our resection lines vertical as much as possible to try and reduce the coding in.

So I try and make this a dominant resection line.

I make this a dominant resection line.

And then you have two straight lines in.

I try and keep them as the principal lines of transection for a 4B.

Because if you start coming in the top, you undermine into 4A.

If you come in too much from below, you just go up into the lesion.

Going in straight from that side to that side keeps you honest with this.

It's good to maintain your margin.

And also repeatedly doing the ultrasound, which we'll do again now.

I think it's disappointing there's not more to do today.

I'm sorry.

We'll finish this off on the next Pringles link.

We're nicely cleared.

that's very very central that lesion and there's no problem for margins on that

I'm very happy with that

I'm using a combination of the trickle technique and a bit of spray, I've got some Fibrillar

drain, or I certainly leave the drain, up our leak rate, it's about the same laparoscopic

and open. How long will you leave the drain? If the drain's clear tomorrow, for a smaller

section, take the drain out tomorrow and you can go home tomorrow. This patient is exactly

as if this was a complicated or difficult laparoscopic cystectomy, so we try and keep

it as simple as possible so I mean really we try with our post-operative

management to try and make this as simple and straightforward as possible

we try and avoid any of the analgesia so they have oral analgesia they have a

wound catheter insert there's a six centimeter incision five centimeter

incision that's come out the right of it also and a lance of gridiron incision

and thank thank you very much for with this very nice demonstration and for

for participating to this live surgery meeting.

We hope to have you with us next year too.

And congratulations, congratulations.

Thank you.

Thank you.

Thank you very much.

Goodbye.

Thank you, goodbye.

It's been an honor to be part of it.

Thank you very much.