Clinical Programs

The HPB Oncology Program

The HPB Oncology Program functions within the GI Site group at the University Health Network (Toronto General Hospital & Princess Margaret Cancer Centre). The six HPB surgeons are members of the Department of Surgical Oncology at UHN and the Division of General Surgery, Department of Surgery, University of Toronto. The Head of the GI Site Group is Dr. Jennifer Knox.The Lead of HPB Surgical Oncology is Dr. Ian McGilvray. The staff are:

  • Surgical Oncology: Dr. Steve Gallinger, Dr. Ian McGilvary, Dr. Carol-anne Moulton, Dr. Trevor Reichman & Dr. Gonzalo Sapisochin.
  • Medical Oncology: Dr. Eric Chen, Dr. Neesha Dhani, Dr. David Hedley, Dr. Raymond Jang, Dr. Jennifer Knox, Dr. Monika Krzyzanowska
  • Radiation Oncology: Dr. Anthony Brade, Dr. James Brierley, Dr. Laura Dawson, Dr. Robert Dinniwell, Dr. John Kim, Dr. Jolie Ringash, Dr. Rebecca Wong

The HPB Surgery Program includes:

  • 4-6 Surgical Fellows: 2 HPB Fellows, 2 Transplant Fellows (the two 1st year Fellows) and the non-Matched Fellow(s)
  • 1 Physician Assistant
  • Senior & Junior Residents in General Surgery (Blue & Red teams)
  • Medical Students in General Surgery

HPB Surgical Volumes

TGH is the largest (of 4) HPB centres in the greater Toronto area (GTA). The Operating Room at TGH accommodates 2 – 4 HPB rooms per day. The annual institutional volumes for major HPB cases and liver transplants at TGH has been:

  2016 2017 2018
Liver resections  165 177 171
Pancreas resections 171 173 137
Liver transplants  202 195 175

 

 

The HPB Service

Fellows 2011

Transplant & HPB Fellows, 2011

Front Row: Pablo Serrano, Ehab Rafael, Peter Kim, Markus Boehnert
Back Row: Paul Greig, Davic Cavallucci, Sylvester Black

The in-patient service of Division of General Surgery at the Toronto General Hospital is housed on 9-Eaton South and has 3 clinical teams of residents & students (HPB, Surgical Oncology & ACS teams).

The Team HPB staff surgeons are Drs. Gallinger, McGilvray, Moulton, Reichman and Sapisochin. They cross-cover each other on a weekly basis. The Fellow assigned to HPB rounds daily with the staff surgeon, HPB designated PA, and resident, and has limited transplant activity during that 3 month block.

Faculty rotating on the Surgical Oncology team are Drs. Cattral, Ghanekar, Sayed and Selzner.

The in-patient ward includes a 6-bed acute care unit for early post-op HPB cases. Patients requiring ventilation and/or pressors are managed in the Medical-Surgical Intensive Care Unit.

Hepatic Surgical Oncology & the Liver Program

Fellows 2010

Transplant & HPB Fellows, 2010 David Cavalucci, Trevor Reichman, Sylvester Black, Adrian Fox, George Zogopolous, Peter Kim

The yearly volumes are:

  2016 2017 2018
Right hepatectomy+ 35 36 47
Left hepatectomy+ 23 29 27
2/3 resection 11 22 14
Meso + large non-anatomic 44 49 53
Segmental + “wedge” 52 41 30
TOTAL 165 177 171

Hepatic Oncology includes the surgical management of primary hepatic neoplasms (including hepatocellular carcinoma and peripheral cholangiocarcinoma) and secondary lesions (e.g. including colorectal and neuroendocrine metastases). Liver resections range from limited “wedge” resections to formal anatomic resections. For colorectal metastases, resections can be synchronous with the primary resection or metachronously. Staged resections are used for bi-lobar disease. Volumetric assessment of the future liver remnant (FLR) is performed by the HPB & Transplant Fellows using the dedicated Myrian (R) software. Pre-operative portal vein embolization is used to facilitate hypertrophy of the FLR. Intra-operative ultrasound is facilitated by the diagnostic radiologists in the OR. Most thermal ablation of hepatic neoplasms (RFA or microwave) is performed transcutaneously by the Interventional Radiologists.  Approximtely 30% of liver resections are performed laparoscopically, including formal right and left hepatectomies.

Liver transplantation for hepatocellular carcinoma constitutes approximately 30% of all transplant activity. Deceased donor liver transplant is facilitated by MELD exception points for tumors that fulfill the Ontario criteria (i.e. the UCSF criteria or Total Tumor Volume+ AFP criteria). For patients whose tumors exceed the Ontario criteria, living donor liver transplant is an option if the tumor(s) fulfill the Extended Toronto Criteria.

Pancreatic Surgical Oncology & the Pancreas Program

New patients with pancreatic malignancies are triaged centrally. With programmatic support provided by the McCain Clinic, newly referred patients are managed by a multidisciplinary team of Surgical, Medical and Radiation Oncologists which are coordinated through a weekly MCC.

Patients with resectable pancreatic ductal adenocarcinoma (PDA) are managed by the surgeon. Those with locally advanced lesions are considered for downstaging with neo-adjuvant chemotherapy to facilitate resection, or with combined chemo-radiation to facilitate resection with arterial reconstruction (ARCAP protocol). Post-operative adjuvant chemotherapy is facilitated through the McCain Clinic

Patients with neuroendocrine lesions are managed by a team that includes Neuro-Endocrinologist and the monthly neuroendocrine MCC.  The surgical approach to primary and metastatic lesions is augmented by ablation and embolization strategies through collaboration with Interventional Radiology.

 

fellows 2013

HPB & Transplant Fellows, 2013

Front Row: Amelie Tremblay-St. Germain, Siong Liau, John Seal, Jerome Laurence, Maja Segedi
Back Row: Pablo Serrano, John Conneely, Rory Smoot

The yearly volume of pancreatic procedures is:

  2016 2017 2018
Whipple 115 107 93
Distal 53 52 38
Total pancreatectomy 3 14 6

Biliary Oncology & the Biliary Program

Fellows 2008

HPB & Transplant Fellows, 2008

Dr. Hamad al-Bahili, Dr. Rodrigo Iñiguez-Ducci, Dr. Charbel Sandroussi, Dr. Sulaimen Nanji, Dr. Markus Guba

Through strong collaboration with local interventional endoscopists (ERCP and EUS), patients with mid-and upper 1/3 obstructing biliary lesions are managed by the 6 surgeons. Weekly MCC are held to facilitated the multdiciplinary management.

Carcinoma of the gall bladder may present as an incidental finding in the laproscipic cholecystectomy specimen, or as a mass lesion, often obstructing the mid-third of the bile duct. A resection, appropriate for the stage, is usually indicated.

The management of hiilar cholangiocarcinoma (Klatskin tumor) based on stage and local extent. For tumors that are unresectable on the basis of involvement of the contralateral hepatic artery, consideration is given to neo-adjuvant chemo-radiation and transplantation (The “Mayo protocol”) or arterial resection & reconstruction.

Non-oncologic biliary surgery includes procedures for benign biliary conditions including repair of duct injuries that occur at the time of laparoscopic surgery, and surgical management of recurrent pyogenic cholangitis (RPC) and choledochal cysts. The yearly volume of procedures for benign conditions ranges from 43 – 48 per year.

 

The Liver Transplant Program

The Liver Transplant Program functions within the Multi-Organ Transplant (MOT) Program of the University Health Network (UHN) and the Toronto General Hospital (TGH) and the Pediatric Academic Multi-Organ Transplant Program (PAMOT) of the Hospital for Sick Children (HSC).
The staff are:

  • 6 Surgeons: Drs. Cattral, Grant, Greig, Ghanekar, McGilvary & Selzner
  • 5 Hepatologists: Drs. Avitzur, Lilly, Levy, Renner & Selzner
  • 6 Surgical Fellows: 4 Transplant Fellows (2 first year and 2 second year) and the first year HPB Fellow and the non-Matched Fellow
  • 3 – 4 Hepatology Transplant Fellows
  • 3 Nurse Practitioners: Ms. Healey, Sawicka & Tarani
  • Junior Resident in General Surgery
  • Medical Student in Transplant

The adult program serves approximately 75% of the province of Ontario (13.5M), and most patients from the province of Manitoba, and the pediatric program serves all of Ontario, Manitoba, and approximately half of the Maritimes. The program volumes for 2014 were:

fellows 2013

HPB & Transplant Fellows, 2013

Pablo Serrano, Rory Smoot, Siong Liau, Maja Segedi, John Seal, John Conneely

Adult deceased donors 133
Adult live donors 42
Pediatric deceased donors 25
Pediatric live donors 30
Total 217

The Toronto Living Donor Liver Transplant program is the largest in North America with approximately 50 adult and 20 pediatric LDLTs per year, and over 600 LDLTs to-date.

The majority of the adults receive right lobe grafts, and children receive left lobe grafts. Over 200 potential donors are assessed each year and the Fellows perform all the volumetric analyses using the Myriam Software on dedicated computers. The living donor hepatectomy and transplantation are an important part of our teaching curriculum and the Fellows actively participate in the donor and recipient transplant procedures.

Clinics in Surgical, Medical & Radiation Oncology

Clinics are an essential component in the education and training in HPB Oncology. Each first year Fellow is expected to attend an out-patient clinic for a minimum of one day per week. Through 3 monthly assignments with 2-3 staff surgeons, continuity of patient care is maintained for the Fellow from the clinic to the OR and to the post-operative management. In the HPB Fellow’s second year, Surgical Oncology Clinics are augmented with 3 month rotations in GI Medical Oncology Clinics and GI Radiation Oncology Clinics.