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 (Blue, Green & Red teams).
The Blue team staff surgeons are Dr. Gallinger and Dr. Moulton. The Blue team surgeons cross-cover each other on a weekly basis. The Fellow assigned to Dr. Gallinger and Dr. Moulton rounds daily with the Blue team resident staff, and has limited transplant activity during that 3 month block. The Blue team has 2 Physician Assistants.
The Red team staff surgeons are Dr. Greig, Dr. McGilvray and Dr. Sapisochin who often cross-cover each other.
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.
Transplant & HPB Fellows, 2010 David Cavalucci, Trevor Reichman, Sylvester Black, Adrian Fox, George Zogopolous, Peter Kim
The yearly volumes are:
|Meso + large non-anatomic||23||20||55|
|Segmental + “wedge”||35||53||25|
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.
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:
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.
HPB & Transplant Fellows, 2013
Pablo Serrano, Rory Smoot, Siong Liau, Maja Segedi, John Seal, John Conneely
|Adult deceased donors||130|
|Adult live donors||48|
|Pediatric deceased donors||20|
|Pediatric live donors||22|
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.