State of the art liver surgery with robotic technology: Dr. Sucandy (2024)

This transcript is automatically generated.

Betsy Post 0:04
So welcome everyone to this evening’s Doc Talk. We are so excited to have with us, Dr. Sucandy. He’s going to talk to us about state of the art liver surgery with robotic technology. And we’re very, very fortunate to have him. I know that we have, I think, at least a couple of patients or people that have consulted with him in the past. And of course, this is being recorded so we can share it in COLONTOWN University and help many patients in the years to come as well. So just to tell everyone how this is going to work, if you’ve not been on one of the doc talks before, just remember that you’ve all been muted, and we’re going to let Dr. Sucandy do his presentation and talk and educate us. And if you have questions as the presentation goes along, please put those in the chat. So in the chat feature is where you will put your questions. At the end of the presentation, we will go over the questions that are in the chat. So again, I’m going to turn it over to you. Dr sukhandi, thank you so much for being here with us and for doing this presentation. I know this is going to help so many of our patients now and in the future. So I give it to you.

Dr. Sucandy 1:14
Thank you. Thank you. So thank you for the honor and privilege to be part of this program, and I feel when, when I heard about COLONTOWN, I said, Wow, the name is kind of interesting. It’s a COLONTOWN. But you know, immediately I realized that there are a lot of patients who have colon cancer with liver metastasis, and they are kind of sometimes in a difficult situation where the liver tumor are many and they are significant. And you know it is, it is a complex disease to take care of. I am privileged to talk about evolution of surgical treatment for Stage IV colon cancer with liver metastasis. And specifically, I want to raise the issue about robotic liver surgery, which I feel like it is important to know, because many people actually don’t know this. I am the Chief of HPG Surgery at AdventHealth in Tampa. I’ve been in practice for almost 10 years. I trained in Pittsburgh and many places, and we do this on a routine basis. I do liver surgery actually every day, and since 2016 we have performed 1000 liver surgeries, and approximately 600 of them are actually minimally invasive. So you can see how we try to really improve and bring the best surgical option for patients with colon cancer, with the liver metastasis.

Dr. Sucandy 2:51
So the outline is my talk will be five items. One is mechanism and how the colorectal rheumatist is occur. The second is how the treatment changes since 1960 to today, the rise of minimal invasive surgery. What are the trials that compare minimal invasive versus traditional open resection for liver? And where are we going in the future, and what is the new technology there? This is just opening slides. Colon cancer is the third most common cancer United States. 50% of colon cancer result in liver metastases, either synchronous, meaning that they are diagnosed within the same six months of the primary cancer, or metachronous, where they are diagnosed at a different time beyond six months of primary diagnosis. The fortunate thing is, liver is the only site of metastasis in about 40% of patients. It means a 40% of patient they only have liver disease. Now the standard of treatment is to try to remove all the liver tumor with the goal of achieving our zero margins. Now when the patient come to the office, they ask me, doctor, should I get this done or not? The answer is, in this red box, unresectable. Patient has poor outcomes, with five year survival. OS is over survival of zero to 10% resectable patient, however, have significantly better outcome with five years of overall survival of 60% so if the patient come with 12345, liver tumors, and they ask doctor, should I have liver surgery? The answer is, in five years, do you want to live or you don’t want to live? Because if you have this liver clean up in five years, 60% patient will still Arrive alive if you don’t. The statistic says only zero to 10% this kind of big difference. This is why it become a standard of care in United States. So let me. Mechanism of colorectal metastasis. Many papers discuss about this, but basically this is the bottom line. The bottom line is the cell from the colon cancer or rectal cancer, they shed into the small or large bowel venous system, so those tumor cells get carried to the Liver. Liver act like a filter for the cells. So those tumors, they got stuck in the filter, and they grow in the filter. So in some patients, those tumor they stay in the liver for a long time. They don’t grow. But in some patient, immediately they hit liver, they start proliferating, or start making so many tumors, but that’s how the tumor from the colon and rectum get to the liver. Now there have been many papers that discuss about the natural history of hepatic metastasis. Natural History means there’s a patient who come with the coronal metastasis and they watch them, how they do if no treatment is given. So if you can see the diagram on the left hand side in the x axis, is years. It means, at the beginning, everybody alive, 100% but in five years, you can see here barely anyone survived without treatment. Now in 19 8340 years ago, the three year survival for solitary it means single liver metastasis, is 21% if they have multiple metastasis in one side of the liver, the survival dropped down to 6% so the number of tumor does have implication from prognosis standpoint, you know, in terms of the survival in the three to five years. Now, this is a slide that I want us to all look at. The dotted line on top is the patient who have resection with clean margin and then no evidence of disease. The bottom line, the red arrow, is the patient who have no resection for whatever reason. So you can see here at five years, I hope you can see the pointer five years the survival is essentially like 1% while here the survival is about 35 to 40% this is in 1983 many things have changed since 1983 and the Survival has increased significantly. This is another paper from Rene Adam from Paris showing a comparison between resected patient versus non resected patient. This is at 10 years. This is beyond five years. Is 10 years, and you can see here patients who are resected aggressively and leave with no tumor in five years, a quarter of patients are actually cured. I know it’s hard to believe, but 25% of patients are actually cured, five in 10 years. So the take home message is, resectable, patients should undergo live resection due to the increased survival the comparison of surgery versus others, a lot of oncologist has difficulty understanding this, especially when I came to Tampa, I found out a lot of oncologists actually don’t know what the surgical treatment should be, and they keep the patient with chemotherapy forever. I’ve offered a patient who have chemotherapy for seven years to appoint the patient’s like, oh, adapter. I’ve, I’ve tried all chemotherapy, and they have circled me with like, three times because they’re running out of chemotherapy. You can imagine, seven years. So surgery plus chemotherapy. Give you the first line on top. They have the best survival you see chemotherapy alone. This is a second line, much inferior survival. The third line is do nothing. It’s called Basic supportive treatment. Barely the patient live a year plus with chemotherapy, only two and a half years with surgery, they live much longer with the five year survival now reaching 70% now I want to talk about how the treatment has evolved. In the last 40 years, the treatment has changed dramatically. Why the surgical treatment for liver and extra hepatic disease, meaning that the tumor outside the liver is now more aggressive. The systemic chemotherapy has improved as well. It’s getting better. Now we have immunotherapy. All the stage four patient get genetic testing, by definition, is automatic in our program, they all get the. Analysis and PDL, one inhibitor testing the outcome of surgical liver recession also improved. How it’s improved in a 1970 to 1980 to split the liver in half and remove half of the liver, it leads to about 20% mortality. It means five patient one died from this today, the mortality of well done operation to split the liver is less than 1% so you can see here the technology has improved, the understanding of the liver surgery has improved. Equipment has improved. The liver surgery now is more casual. It’s no longer something that is scary, something that is like the end of the world. No, this is a big surgery, yes, but it is done widely. It can be done safely with very little mortality. Now, a little history about this in 1976 the surgical treatment started with a minor liver section. At that time, the surgeon were a bit unsure of how to do big liver surgery. So what they do is they do a little bit of surgery just kind of, you know, taking 5% of the liver and call it, and those tumors were on the edges of the liver, not in the central part of the liver. Technically, it is much easier to remove patient tumors that is smaller. It is much easier to remove the tumor that is on the edge of the liver. Now they study the patient as well solitary lesion patient with the single tumor in the liver, some patient actually live more than 10 years. You see here, eight patients live more than 10 years out of 60. Patient now, patient with a multiple lesion, a lot of lesions, they all died before five years. So at that time, the conclusion was, you can operate on the patient as long as it’s minor and it’s as long as a single lesion. But remember, this is 1976 when the chemo was not good, surgery was not good. Now fast forward. Fast Forward in 1980 so this is six years later. Another paper on analysis surgery that says, Well, you can actually do major liver section, and at least 20 to 30% of patient will gain benefit, survival benefit, from this. You can see the picture here. The tumor is big on the right side. In order to remove this, you have to split the liver and remove the right side. And even with this operation, at least 20 to 30% of patients were able to gain survival benefit. And remember, this is 1980 This is when I was one year old. Fast forward, 2000 in 2000 people started to offer patient with multiple bilobal hepatic metastasis. They have tumor here, here, here, here, both sides of the liver. When I came to Tampa first time, 2016 a lot of oncologist said, Well, if the tumor is both sides, it’s game over. The answer is not. This is actually understanding from 19, 1980 so even in 2000 resection of bio both sides of the liver, brain results similar to a survival for a simple metastasis, single metastasis, at that time, the survival five years is 37% so you can see on the previous slide it was 25 it’s slowly rising up to 37 now, at that time, extended resection was avoided, and also concomitant resection of the colon orectal primary was also avoided, because the technology was not very good, and it brought a higher mortality rate. So at that time, it was avoided. Now it’s no longer avoided. It’s actually recommended, as long as I said. So the bottom line at that time was resection of multiple tumor both sides resulted in true survival. Fast forward, five years later, 2005 What if the patient have liver metastasis resected today? How about in three years, if the patient have another tumor? What should What should we do about it? Should we let the patient go? Should we do nothing, put them on chemotherapy forever, radiate them. What do we do? So the answer is, the patient needs a repeat liver section, as long as the patient is able to undergo live resection. Why? Because it further improves survival with lower and lower operative risk, even with three to. Section, it is harder to do. It is higher potential complication a little bit. But in the right hand, it can be done safely with low, low operative risk, and this will bring lots of survival for the patient. This has been published extensively. Now, how about if the patient have liver metastasis and then lung metastasis, this is something that also is an issue in the medical oncology literature. You know they they will say, well, liver metastas is bad enough. How about the lung metastasis? But also, this is an old school look at this paper here, the patient with Synchro metastasis of lung and liver when they get resected, the sort of Apple is much better than the patient are not resected. You see the two curve here, curves here, so the upper RAS section, Lars and non resection. This is for synchronous metastasis. It means the diagnosed together. If they are not diagnosed together. It means they come, you know, a year later, for example, that lesion in the lung should be resected. Also, why? Because look at this curve, also, different patients got resected. They live a lot longer, improve survival. Another paper from America that basically also have the same conclusion, surgical resection of both liver, hepatic or and Pulmonary metastasis is associated with prolonged survival in selected patients. Obviously, you cannot offer them to everyone, but there are a lot of patients who can benefit from this. The most common location of colorectal metastasis is the liver. The second most common location is long. So those are number one and number two, and you can see here overall survival after the section of the other metastasis, even in 10 years, 10 years a long time, about 19% of patients still alive, and there is no way to achieve this without reception. No way. Now we can see the evolution of treatment. The surgeon become more aggressive. The patient can live longer. Chemo is getting better. Everything work for the patient. So now what? Now the question is, where is the limit? Is there any limit? Yes, there’s a limit. So what is the limit? One is the general health and performance status of the patient. The patient has to be acceptable risk for surgery. How is the liver working? And if had the liver disease, any cirrhosis, how much chemo the patient has gotten? As we know, the chemo also give a negative impact for the liver function. So sometimes the patient got so much chemo to a point where the liver is so damaged, it is difficult to offer the patient a micro surgery because the quality of the liver is poor. We also need to know, did the patient have a liver section in the past, because that can affect the planning for the future. Did the patient get y 90? Did they get particularly pumped? Did they get ca mobilization? They all have to be known take into consideration, because overall this kind of treatment affect the liver function to some extent. Now the question is, how much liver to live with the patient to avoid not having enough liver. It’s called post operative liver insufficiency, or also called liver failure. How much is live is enough to leave behind? Now in our program and also in all the centers that perform serious liver surgery, this needs to be studied before surgery, the surgeon cannot just, oh, I just eyeball it, and I know, no, it’s not. It’s not, it’s actually not true. You actually have to spend some times to study the liver to see if I do this, I remove how much percent of the liver and how many percent I leave behind. So it is from the CAT scan and MRI. It is entered into a software they can actually reconstruct the liver in a 3d fashion, and this can give us a measurement, milliliter by milliliter of each segment of the liver to know how much to take out and how much to leave behind. This, also called functional test, is a test to see how much the overall liver function is. The patient who drink a lot cirrhosis, for example, patient who have a lot of chemotherapy, they may have a big liver, but it may not have the same function as the small liver, but healthy. So you can, if you can imagine, like a big, obese patient, right? They are 200 pounds, but they are not necessarily stronger when we compare the patient who is 70 pounds or not 71 like 100 pounds, but it’s all. Muscle, you see. So there’s a difference between liver to liver, and this is something that oftentime we study in order to get true measurement of the liver function before we put them through a major different surgeon. So this is something that we do, for example, I want to show you. This is a routine procedure in our center, actually. So you can see here we reconstructed the liver. And you can see, let’s, let’s use this, for example. So the red, the red structure, is the tumor is deep inside the liver. And we say, okay, if I’m going to split the liver, I’m going to remove this much, and I’m going to keep this much all, all the, all the lines on the left, left hand side. Here it give us. It give me how much, how big is the liver on this side? How big is liver on this side? So I know if I cut here, I remove, for example, 40% and I leave 60% and similar to others. Other diagram here, you can see different type of resections. The software also help us with the tumor localization. The green is the Balder, because we need to, we need to plan this better. In order for the liver to be successful, to be safe, they’re able to grow back. You have to keep the pipe in, pipe out in the balden. It is very common for the patient to ask me, oh, Doctor, the liver grow back? The answer is yes, but there is, there are factors that you need to meet in order the patient liver to grow back. The liver has to have enough fuel in exhaust pipe, out and about, even if the liver is big, but it is missing one of the component, the growing back is not going to happen. And in fact, the liver can quit and and kill the patient. So, yes, it can regenerate, but it has to be done well. So is extended. He protected me, meaning that can a big resection, justified for liver cancer. This is a very important slides in the patient with normal liver, normal liver, it is safe to leave only 20% of the liver.

Dr. Sucandy 22:15
So we can remove 80% patients who have chemotherapy. You have to leave 30%. You can only take out up to 70%. A patient with liver cirrhosis, you have to leave at least 40% it means you can see here, as the liver gets sicker, the less part of the liver can be removed, because otherwise the patient can get into liver failure. And liver failure is a big reason for mortality, death after surgery. So if the patient come with liver remnant that is too small, should we say to the patient, I’m sorry, you have no option, or it is something that we can try to improve dances. There are few things that we can do to improve the small remnant liver to a big one. How to do it? One, this is a very common way. It’s called portal vein embolization, meaning that we block of the blood supply to one side of the liver, and this will induce a growth of the other side of the liver. Uh, number two is we combine the portal embolization with hepatic vein embolization. It means we close the blood inflow to one side and also the outflow on that side, so it is more aggressive closure of the blood vessel on the on the resected side, on the part that is going to be resected in order to induce more hypertrophy of the remnant liver. The other way to do it is to do two-stage. It means, if the patient have 10 tumors, five on the left, five on the right, to do 10 altogether, sometimes it’s too major. So what you do? Do five first, one side, have the patient recover. Two months later, go and do the other side and clean everything. And then the last way of doing this is called ALPS procedure. It is something that not very common in the US. However, in our center, we obviously offer this even robotic ALPS procedure. We have done many of this just because we have a lot of patients with difficult tumors and small liver remnant, and they have been seen by many surgeons in the past. So it is something that can be an option. It has to be done carefully. The calculation has to be done carefully, and the surgeon have to be experienced with major different surgery like this. So this is just the example. The picture of this you can see here, if the patient have a four. Tumor, for example, if we close this portal vein here, the blood will be shorted to the other side. This will make the other side larger. And we wait for about six weeks or so, and we go back and we’re going to take up this now the remnant liver is now huge, and it works well without procedure, and we have the benefit of doing split of the liver with closure of the blood vessel at the first operation. And also, if the patient have a tumor on the other side, this can be wedged out at the first operation, the second operation, the surgeon come and remove this bar altogether. And both of this actually can be done minimally invasively in our program, done robotically, both stage first both the first stage and the second stage of ours can be done robotically. The initial description of us was open for both stages. This is just a picture of how much liver growth that needs to be done, needs to be achieved to avoid liver failure, we are trying to get the liver growth at least 2% per week. So if the liver is growing more than 2% a week, at least 2% a week, it is going to be safe to do a major liver section. So this calculation of this, this is what I said about the double embolization called PVE plus hve. So the radiologist actually going with the catheter close the vessels. The tumor is on this side right. So we got to take out the right side, so the blood vessel to the right side is being close here, occluded, occluded here, and also the outflow is also being occluded. This will induce a lot more hypertrophy versus just inflow being occluded. And this is two diagram that I said before. When you occlude both vessels, the growth is much faster versus one vessel only. This is some modification of Alps in our we started our Alps program maybe about six years ago, and we have modified how we do it over the years, we tried to do it minimal, invasive both stages, and also we tried to be less invasive on the first stage, which make the second stage easier and down the down the line. So there’s a bit nuance of how to do this, and I don’t want to go into detail here, but the center has to be able to explain to you what’s what’s expected at the first stage and also expected at the second stage. So now shifting toward minimally invasive surgery. You can see here minimization surgery started with the general surgery, and then going to pancreatic surgery, and finally, go to the robotic liver surgery as the most modern, minimal invasive, live reception. This is the two pictures comparing open operation versus robotic. This is open operation. The abdomen is opened widely. The rest is used while minimal invasive, you can see this the troca, usually five or six trocar. This is a green port. This will deliver is pulled out. The patient always asks the doctor, how can you pull the liver through a small incision? And actually there’s a way to do it, because the specimen is placed in the bag, and we actually pull the bag with the liver in it, through the small incision. When the patient’s anesthetize, the abdominal wall is so relaxed we we sometimes extended the incision a little bit, but with relaxation, we are able to remove big specimen, even the right lobe through the small incisions there. The question is, why minimal in phase of surgery? Is it better or it is easier? The answer is, minimal invasive surgery is better for the patient, harder for the surgeon, actually. Now the question is, why the surgery wants to do it, because it’s harder for them. Yeah, because we do it, because we like it when it’s better for the patient. That’s why we we do it. Many publication have compared minimal invasive versus open liver section. The minimal invasive leads to less blood loss because you’re losing less blood, there’s less blood transfusion. The patient can drink on the same day, less pain medication requirements, shorter length of stay in the hospital, lower wound complication, infections, incision, open up, hernia. Yada yada, cosmis is better, and it bring a comparable, or potentially better, oncological outcomes. Now we used to be debating about this topic, whether minimal invasive lead to inferior outcome. You can see these two lines here. So the outcome of minimal in facing process open in five years are similar. So at least minimally physical surgery does not compromise the outcome of oncological treatment of this colon cancer, between cancer. So we now quit debating this, because every surgery knows the minimal invasive surgery does not lead to inferior oncological outcomes. We are not missing tumors with with minimal invasive why? Because the camera give you 20% magnification, so it’s actually easier to see the tumor on the camera versus naked eyes. There’s so many papers have been published about this, and the criticism was, well, those paper are not randomized. It is just a publication from one center and the other centers. We need a randomized trial where the patient is blinded, the surgeon is blinded. It means the patient, when they go to surgery, they don’t know whether they’re going to get minimum vegetable open. And the first randomized trial was actually started in 2015 in Oslo, comparing open versus laparoscopic for COVID analysis. The outcome was published three years later into 2018 on end of surgery. These two guys are my friends. So the outcome is the minimal invasive surgery, liver surgery leads to lower 30-day complication rate, shorter hospital stay and less premedication requirements, similar or time similar blood loss. And they also follow the survival at 60 months, 60 months, meaning over five years, look at the survival are equal, the same as recurrence free survival is actually be better laparoscopically. But the bottom line is, oncological outcome is not inferior with minimal face of surgery. Now, as soon as the first trial is done, the second trial came. This is two, 2019 This is a year later, after first trial, this is from Spain, that also compare open versus minimize surgery. And the outcome is well, almost similar. The minimizing surgery bring lower morbidity, shorter hops will stay with similar or time, blood loss, trans fusion, rate, mortality and similar, three, five and seven year disease free and overall survival. So you can see here if, if a patient able to get minimal assisted surgery, that is what they should get, unless it cannot be done, minimally invasively. Minimally invasive. It needs to be done open, then they need to be done open, shifting gears to what is press what is the future of liver surgery? Technology is getting better. We have more modern robotic surgical system. You can see here. This is how the equipment for liver surgery now, the robotic liver surgery is now expanding for a Baltic cancer surgery, benign biliary surgery, if the surgeon needs to put together the blood vessel used to be the surgeon is very scared doing this so the patient that has tumor close to the blood vessel, they do it open, because the technical skill is not there. So today, however, in our program, at least, we started to do vascular surgery robotically. We don’t have to open the patient for a portal, very constructions, or hepatic vein sections. And it is something that we continue to push the envelope for to make this operation as safe as possible and more more minimal invasive, which enable the patient to go back on the systemic chemo quicker. Now the 3-D is coming, the artificial intelligence is coming, more modern technology for liver surgery. So this is just a few paper we published in cooperation with the European centers for a billion surgery. We have also a. Have actually developed this, what we call Tampa, because we live in Tampa, Tampa Difficulty Score, a scoring system for difficulty of robotic liver surgery. We have a training center for robotic liver surgery for us and the world. So a lot of surgeons come to the Center in Tampa to learn how to deliver surgery from me, and we designed this scoring system to see how difficult the liver surgery will be, so that the surgeon can get prepared. Am I ready to undertake the surgery? Or I have? I have to have my partner or my senior surgeon to help me doing this in order to arrive in the best outcome and safe outcome. So then we develop this. We can, you can actually check this on the website, and you can come with with a score, the higher the score, the harder the liver surgery will be. The lower the score, the easier. So this is a website that is alive. You can, you can play with that. Actually, it is useful for surgeons. We published this on the general gi surgery two months, two months ago, so you can see here, this is how the blood vessel being cut and put together robotically. We used to have to open the patient for this. We can do this with robotic surgery. The conclusion is, liver surgery for metastasis is safe. It can be done aggressively, and it should be done aggressively however. You need to find a an experienced surgeon for this, because not all the liver surgery are straightforward. Some of them needs a two stage. Some of them needs vascular reconstruction. Some of them meet bad reconstruction. Those are not easy. Those are much harder than doing a weight resection. And if possible, always ask for a minimum physically for surgery, unless technically not feasible. Now, they are, they are cases that needs to be done. Open, for example, in our center, if the patient have more than eight tumors throughout the liver, we give a consideration to do it. Open, can we done minimal invasively? The answer is yes, we can, but it is not practical, because the operation can take six seven hours to do, versus open it may take three hours to do so that we also take into consideration the time on the operating table, so we try to determine the difficulty of all the aspect not not just the cutting of the Liver, but the timing of the operation, how much time on the operating table, how old the patient and how complex the operation will be, the best long term outcome come from multimodality treatment, where the surgeon was work together with the radiologist, IR, medical oncologist, radiation oncologist and other people. Now I want to show you a video clip, so then you guys know how the liver surgeon robotic looks like. So the video on the left is resection of the liver tumor after a local recurrence from ablation. We know that ablation has about 6% of recurrence in this patient. He’s only 52 years old. He had colon cancers on the back of the liver get ablated somewhere else, and he came to to our center with single tumor occurance. And you can see here the cancers on the upper side, the ablation on the lower side. And we decided that this needs to be cut out the the the interesting part is the tumor actually grew to the diaphragm, so we have to cut out the diaphragm as well. So this is the tumor we’re going to cut it this way. The picture on the right side. Let me pause on the right side. So otherwise too confusing. So this is how the surgery is done with the robotic you can see the scissors. You can see the the grasper. You can put a stitch on it. We can pull on it. We can dissect the blood vessels that bring blood to the liver. It is almost like open surgery, except it is done with small incisions. This patient have five ports, and each of the port is about eight millimeter in size, eight millimeters, less than a centimeter. And you can see we can we can tie the blood vessel to the liver to be resected. And we can really clean up and see the festival, the structure that we need to see. This maneuver takes some experience, some training to do it. We can call. Encourage the surgeons to learn how to do this in order to gain the benefit for the patient, it is important to apply (-inaudible-) , ICG, it is technology where we inject into the bloodstream to see the perfusion of the liver, and also to help us to see where is the cutting line for this case, you can see here we have a scissors that can deliver energy. And you see here on the diaphragm, there is something that is stuck, that is the cancer that is stuck to the diaphragm. A brick vessel being skeletonized is a stamping device that actually can seal both side and cut in the middle. It is a question that I hear from the patient a lot, Doctor, how do you cut the liver, not bleeding? Not bleed? The answer is, we have a technology that will help us do that. We can cut in the middle, and the device will see both sides, so both sides will not bleed. This is an ultrasound. We can see the liver tumor deep in the liver. On the ultrasound, you can see how now we are cutting, the liver is bloodless, and we will see the crossing branches, and those branches is clipped. You can see the white stuff there. It’s the clip. We place it, we cut in the middle. They don’t bleed. And sometimes the clip is not perfect. It bleeds a little bit. We can just put a switch on it and tie it many times we tie first and then cut second. I’m going to start a second video now the second video is actually alt procedure, except it is more than ALPS. Why? Because the patient have a single metastasis in the left adrenal gland. So Betsy asked me to talk about, what if the patient have tumor outside the liver? Obviously, the patient need to be selected. But both both videos shows you the tumor outside the liver. One is in a diaphragm. One is in the right adrenal so the video on the right lower quadrant, right side, I am taking down the blood supply to the adrenal gland that got canceled it. So you can see here the the clip is done cuts, and in about 10 seconds, the adrenal will come out. You see the adrenal gland got canceled in them, it’s removed. The left video now is going through the deep liver. We are splitting the liver inside the liver. Is this how this look like? It’s a little bit of oozing here and there. This is not a big deal. On the right side, I’m trying to find the portal vein in the artery because I need to like it. This as a first stage of alt procedure. The goblet is taken out the first stage, obviously. And you can see here we set this operation to be successful or easier for the second stage. The video on the left side, move towards the end of the operation. You can see here we can cut the liver with very little bleeding, as long as it’s done well. Now the specimen now is being removed. The last staple was done. Now the clamp is released. Now the tumor is stuck to the diaphragm. We can see the yellow stuff. This is the prior ablation cavity. So I clean up that, I suction out the yellow stuff as I try to remove the specimen, I knew that the the diaphragm needs to be reset it now we have resented the diaphragm. You see the lung at the background, and now we’re closing the diaphragm. So this is relatively difficult for surgery. It can be done well. It took about six hours to do. It is done minimally invasively, depending on five days. Now, the video of the right side now we’re going to the second stage of alt procedure. We actually combine the second stage with the reversal of the ileostomy. The patient have a temporary ileostomy. Now, the volume of the liver increased from 25 to 35% so you can see here on the second stage, we go back, and this is a different instrument for Synchro seal robotically as well. We cut the liver, the liver to be removed on the right side, on the on the left screen. So. You see the vessels being ligated, clip divided, safe, no bleeding. The vena cava is at the back there with the robotic instrument you see here, we are creating a tunnel to split the liver. So in this patient, essentially, I remove tumor from both sides of the liver, tumor on the diet, on the adrenal gland, and tumor in the rectum, and those who are done during this alt procedure, combining first and second stage. So this is a tumor outside the liver as well, because the adrenal gland, they’re outside the liver. This patient is only 40 years old. He’s doing well. This case was probably done about maybe a year, a year ago or so. Patients doing well, no recurrence, enjoying life, two kids, and we are very happy to see him. This is the website of mine that you can see if you like to read few things, and thank you.

Betsy Post 46:06
Thank you so much. That was amazing. And we definitely have some questions in the chat. Also, if you have time, you should look in the chat, because you have people thanking you for what you’ve done for them and for being here, which is great to see. The first question I see for you is, how long after liver resection? Do you usually recommend to wait before a lung resection? This would be a second liver resection for me, much more minor than the first. So the surgeon is expecting an easier recovery, but it is an open resection, right?

Dr. Sucandy 46:39
So, so just just to review the recovery from liver section. So the most common question is, how quick can you put the patient on chemotherapy after liver section? For open liver section, typically wait for two months, for minimal invasive typically one month. So it is easier to go back. Now the recovery is easier for minimal deficit as well. So to go on to long resection, I would say six weeks is enough time to go back to lung resection. I We actually have a lot of patients who needs a lung resection afterwards. So we have thoracic oncology service as well. I don’t do lung resection, but I have surgeon that does the resection, and this is obviously a part of our comprehensive cancer center. The lung infection also actually done robotic so minimal invasive lung resection after minimal invasive liver section, so the recovery from lung section, middle, invasively, also much, much earlier, much easier for the patient. As long as it’s it can be technically done safely.

Betsy Post 47:59
Then, oh, sorry, it was the next question. If you’re, are you ready for that one, or are you going to continue to answer that one?

Dr. Sucandy 48:07
Look at this. There’s my patient here. Can you believe it? I remember.

Betsy Post 48:14
You definitely remember. She’s unforgettable.

Dr. Sucandy 48:20
She gave me, okay, good.

Betsy Post 48:26
I wanted to go to the next question, which is, are the guidelines for tumor size, amount of tumors and tumor location? The same for open surgery and robotic surgery?

Dr. Sucandy 48:39
The answer is the same, the answer the same. There have been a lot of discussion that is basically revolving around, can you take more liver if you do minimize phase CT versus open, because it’s technically less stress for the body, in theory, minimally invasive resection should should be able to remove more liver because less stress. But for now, we are using the same the same cut off of having to preserve 20 or 30% of the liver behind. Now the difference is, though, if you need a stage resection, meaning that you will need more than one resections, it is better to do minimal invasively, because, as we know, every surgery in the abdomen, including the liver, it will leave scar Tissues behind, scar tissues, and it is difficult to go back to do the second time, third time, if the patient were done all open you see, because open surgery will leave a lot more scar than the minimal in festival sections. So we know that the colorectal bone analysis is. Not a one time deal. Many time patient have a recurrence, they need to go back. The surgeon needs to go back. Do do some more work. So at the beginning, giving the minimally invasive resection will preserve the window. We don’t burn the bridge for the future resection. It is, it is LA, it is less problematic to do resection in the future after minimal invasive less problematic means it is easier with a surgeon, but also it is less chance of developing complication. From the patient’s perspective, there are patients that operate actually five times over the last 10 years or so, so we have to redo the operation every two three years or so because the new recurrence even with chemotherapy. So it is quite common to have to redo the operation. Therefore, we believe that minimum active surgery is the way to go for this

Betsy Post 51:01
great this is a question on I’m hoping to have liver transplant. I’m doing chemo preparation. I watched another doc talk with Dr Hernandez, who said every liver he’s removed from a cancer patient for transplant came back positive with microscopic tumors. So recurrence is, you know, going to happen? That thought alone leads me to want transplant. I don’t want multiple surgeries and long term chemo and treating Whack a Mole every time something comes up. Are there other ideas and technologies that don’t use surgery? I know about histotripsy, but my mets are in the right lobe, unfortunately. Also curious, if you do transplants?

Dr. Sucandy 51:48
This is a very loaded question. So liver transplant has become a new… it’s actually not new. When I was in Pittsburgh back in the days, liver transplant for colorectal metastasis has been tried with the poor outcome, actually. So this is not a brand new idea. This is old idea that is brought back with the hope of improving the outcome with with a tighter selection process. The issue is, many times this patient, they have multiple lesion in the liver, and this is what this patient actually concerned about. But you have to remember that most patients, they have a systemic disease. So the idea of replacing the liver, unfortunately, it is not kind of like, you know, one time deal, because the issue with liver transplant is many times the cancer occur in the new liver. Why? Because the bloodstream got cancer. So it is not only the liver got cancer, right, the bloodstream also get cancer. So the downside delivers last month is the recurrence in the new liver is high. So unfortunately it is, it is not easy to say, I’ll, I’ll I’ll be away from recurrence, because even the new liver will return too. There are many other treatment that is available today. Obviously, systemic chemo is one of them, regional chemotherapy with hepatic artery pump to try to keep the recurrence lower. The new case in the block is called histo trip C the issue of digital trip. See, is it is such a new technology, the outcome has not been studied well, I actually know very well histo trip. See, at this time, it is difficult to do histo trip see in the very deep tumor behind the rib, because the energy cannot penetrate rip. So it is still limited. In the future, I hope the technology get better so we can reach the deep, deep tumor. So it is, it is a bit difficult to do on the right low because right lobe is deeper at this point. We still don’t have we still not offering liver transplant in the future, maybe the selection criteria is strict, and actually it is different from center to centers, and even on the same centers, they keep changing the criteria, because everyone wants to select the patient see how they do before transplant in order to really maximize the benefit of it, because, you know, you need to use an organ. For this. Some program use a living donor. Some program use a DCD. DCD is as kind of like donation after cardiac death. So this delivers a bit marginal to use. So sometimes to do that in order to, you know, to be able to get the graft, because otherwise, how are you gonna do? How you’re going to get the BRAF? So I think it is, it is something that we need to use in a very selective manner, only about maybe 1% of patient ended up getting transplant, maybe, maybe less even so we need to maximize all the other treatments before a user transplant. Now sometimes the patient go to a center and the surgical oncologist told them, you know, you are not resectable, but if the patient go to the different surgeon who have a lot more experience, they’re going to say, Yes, you are resectable. So you see the definition of resectable is different from center to centers, and many times the oncologist is the one who tell the patient you are not resectable. It is, it is actually something that needs to be. It is something that needs to be to be done by surgeons. This is my daughter, so it is, it is good to console the surgeon to really know, am I resectable or am I not resectable? Because even if you go to a center that offer liver transplantation for this, they have a protocol for this study protocol, because this is our study protocol. At this point, this is not standard. They will still first evaluate whether you’re acceptable or not, and if you’re acceptable, they’re going to reset you. They’re not going to give you transplant. So that is probably what I can tell for. Now,

Betsy Post 56:58
Great. Another question would be, would checking for cancer outside the liver be a reason to do open versus robotic

Dr. Sucandy 57:08
No, no, a tumor outside the liver, as you can see on the video, the tumor on the adrenal gland, we actually remove it robotically. Those are outside the liver, right? So this the look the organ involvement, which organ actually does not, does not lead to whether open or robotic. The decision to do robotic, mainly depending on the number of tumors, the location of tumor, the size of the tumor, and, more importantly, the technical experience or family familiarity of the team to robotic surgery. I think that’s probably the most important. You know used to be when I started this program, 2016 we only offer about 70% of patient robotic, and 30% patient got open operation because at that time we are learning how to do this, and we got no teacher back then we are inventing this operation pretty much over The years we we perform many hundreds of this so we become more confident, technically improved, to be able to undertake more complex, difficult operation, minimally invasively, even the patient with y 19, which is usually very difficult to do after 190 We are able to minimally invasive patient after prior operation, stomach resection, gas intersection now can be Daniel invasively. So our rate, our rate of robotic reception today, is about 90% so there are still 10% of patients. We still do open so it is, it is not like a center do only one thing you have to do everything. You have to be able to do everything, even open or even memory facing. It is, it is all depend on the patient condition and the tumor condition.

Betsy Post 59:19
Thank you. One question would be, also, is there a limit to how many lesions you can remove robotically? This would be for a recurrence five lesions in the liver and two in the omentum.

Dr. Sucandy 59:33
So this is, this is actually a good question, because this is a moving target. So, you know, back in 1980s the recommendation was only to remove three lesions, only three. So if you got four lesions, you’re unresectable. And this probably holds through maybe about three years only the guidance was changed if you have more lesion five. Five, you can resect more than five, no and it probably stay for maybe another two years and change again. Basically, the bottom line is this, the number of tumors actually do not determine whether the patient can be resected or not, but what determine is how much liver to preserve. If you can preserve the tumor, the liver enough 40% or 30% of the patient to live, you resect them. So it is important to preserve as much liver as possible, because if the, if the patient needs to further resection, you need to have liver to work on, right? I have seen, actually, a colleague of mine who work in Italy, who actually resected 72 tumors at once. So you go figure that in America we are discussing, we are arguing about 1015, tumors, how about 72 so go figure that sometimes they have or mental nodule two or three. The guidelines is now becoming more clear about this or mental lesion, because the patient with limited extra hepatic disease in the omentum, in the small bowel. Medicine theory, they should be resected. This patient will gain survival benefit. When I was in residency, when we see a tumor one.on the ormental we cancel the case, you know, but it is no longer true now, if the patient have limited disease in the omentum, you scoop them out and then do the liver section. Patient go on to systemic chemo and get observed periodically by the oncologist, and this has improved the long term outcome as well.

Betsy Post 1:01:57
Great. Think I just see one or two more. Can you do this procedure if a patient has a non functional HAI pump, so if they already have the pump, and then also this follow up to that is, is the robotic surgery available if there are lung mats?

Dr. Sucandy 1:02:18
The answer is yes to both I mentioned before many, many patients I do a robotic different surgery to clean up the liver, and then after that, four to six weeks later, I send them to my colleague to do a robotic lung surgery. So they get robotic both. Many patients come with the HAI pump as well. I actually, recently, actually offered somebody with the non functioning pump. I end up removing the pump, actually, because it’s no longer working and it’s actually causing problems. So the bowel is tangled around, around the tubing. So I removed the tubing so presence of presence of pump, make the opposite be complicated. But it doesn’t mean that you cannot offer the patient robotic surgery. You can. I think what I want to say is this, I’m happy that there’s a lot of enthusiasm about liberal transplantation. I do enjoy, I do love liver transplantation, but I think at this point we have to be very cautious. We have to look at the data. The data from Norway, CEA one, CEA two, is promising, but the criteria is very tight. As I mentioned before, even the criteria in the United States are evolving. Used to be its offer for everyone, like when I was when I was in Pittsburgh, the early days of Pittsburgh transplant service, they used to offer to a lot of people, and the outcome is bad. Why is that was bad? Because the selection criteria is bad. So a patient with a big tumor with the high CEA, they offer transplant, and sure enough, the the tumor occur in a new liver within three months. So if you see the criteria for this, the CEA has to be less than 80, and the tumor size and yada yada yada. So people are kind of learning what is the best selection process for this? And, you know, it is very selective in offering design. I don’t, I don’t want people to think like, this is just like, you know, you know, kind of like, okay, I can get it anytime, and this going to fix the problem. No, it’s not. It does, because there’s still things afterwards, tumor, cancer, new liver is a new problem as well, you know. So I hope it doesn’t occur, but it does occur in your liver.

Betsy Post 1:04:59
You. Thank you so much. And we have one last question. This is our last question for the evening, and hopefully you don’t mind, are you able to see a CT of the liver well without using contrast?

Dr. Sucandy 1:05:16
The answer is no. So some some lesion, some tumors can be seen without contrast. But if we are talking about trying to see all the tumors in the liver with this disease, having a contrast, enhanced CT scan is very helpful, because the tumor can be easily highlighted when the background liver is a bit brighter, colorectal liver metastasis is hypodense on the portal venous phase. So there is a way of looking at the CAT scan, and there is a way to differentiate tumor versus non tumor based on the timing of contrast being perfused in the liver, the same as MRI as well. The MRI is also done with contrast. It’s just a different contrast. Both are good. MRI is a bit more sensitive than CAT scan, but the Cath is better at looking at vasculature, so both are complementary in terms of a diagnosis. The you know, over the years, we have issues with the patient with the contrast allergy, actually, so we develop a protocol of how to get a good quality imaging, despite of having a contrast allergy. So, you know, sometimes it’s better to get an MRI if they have a contrast allergy with the cat skin or vice versa. But the worst thing that can happen is the surgeon miss your tumor. So you want the surgeon to be able to see the tumor, because otherwise, you know, after the surgery, oops, you still have tumor, by the way. So so you want to have the best look during evaluation, so the surgeon can do a complete job in your liver. You

Betsy Post 1:07:23
Oh, someone said I missed a question. So is it okay to just do one more or anything? Any questions? Sure, let me Oh, I see it now. Just so you know, when I scroll down the chat, it kind of bounces if someone’s seeing a question below, so it bounces around. So I apologize. So is it true, in your experience, that every liver will have microscopic tumors remaining after resection?

Dr. Sucandy 1:07:52
That’s actually not true. So let’s put it this way, right? It is common. It is common that the patient have a micro metastasis. But it doesn’t mean that all to all liver will have micro metastasis. I mentioned earlier, at the beginning of representation, 20% of patient, 20% patient actually cured with surgery alone, without chemo. So, so So think it this way, right? 20% patient cure with surgery alone, no chemo, if all liver would have had micro metastasis. There is no way they can be cured. 20% right? If all liver had metastas, it means they will recur at some point. So it means that 0% patient will be cured. But that fact is not true, 20% of patient will be cured without chemotherapy. So a lot of people have micro metastasis, but some people don’t, because they are pure with surgery alone, we learned this on the liver section. It is quite often that I remove half of the liver and the pathology report came back as no no viable tumor. Actually, it means the patient did not need the operation, because they’ve been treated before and there is no viable metastasis. So you know, it all depends how reactive the tumor to the chemotherapy. Sometimes the chemotherapy wipe out the whole tumor. So means the patient got no tumor deliver. So I think it is all depends on the circumstance, but to say all the metastasis will leave with the micrometas with all liver is not true.

Betsy Post 1:10:20
Well. Thank you so much once again for all of your time and your attention, and also your family for sacrificing your time tonight. It was sweet to see your kids, but thanks to all the patients and families that showed up. Thanks for your attention and your great questions. And thank you, Dr sukhandi, very much. We really appreciate this. And as I said, this will help people, not just now, but in the future, as we put this out on COLONTOWN University, and refer back to it, and you had several patients here, and they said, one patient, I don’t know if you saw the comment, but said, Thank you, and you’re our hero. That was from the Durand family. So so so we are.

Dr. Sucandy 1:11:02
I work in Tampa, and basically we see a lot of patients from from far away. Actually, if we look at our statistics, we have about 20% 20% of patients actually come out of state. So 80% patient come from Florida. Like I said, we have Canadian patient on the floor today is we’re going tomorrow, we offer a lot of robotic liver section. But it doesn’t mean that, you know, everyone will have liver section robotically. It’s interesting to me that everyone that come to the office before I talk, they said, Doctor, it’s going to, it’s going to be robotic, right? I said, Hang on, let’s, let’s look at the CAT scan, press, okay, and let’s, let’s actually sit down and talk about this. But, but a lot of patient they have, it’s like the you order pizza. You order pizza, they make pizza. You know, I think it’s important to look at case by case. It’s true that in our service, most of the time you’ll get the liver section robotically. But sometimes, if I feel like it is better to be done, open with it, open. But the goal is to enhance the recovery with minimal infer,

Betsy Post 1:12:28
perfect. Well, thank you so much once again. Thanks for your time and attention, and we’ll see you all around COLONTOWN. Good night. All right. Thank you

Dr. Sucandy 1:12:35
Thank you. Thank you everyone. Thank you. Bye. Bye.