Dr. Roberto Hernandez-Alejandro didn’t expect a conversation over a couple beers at a Miami hotel bar eight months ago to lead to a surgical first in North America.
Presenting his own research at the Americas Hepato-Pancreato-Biliary Association annual meeting, the Schulich School of Medicine & Dentistry professor quickly became enthralled with a presentation from a group of German liver surgeons. They spoke of a two-stage hepatectomy (liver resection), discovered by chance, that saw 70 to 80 per cent re-growth of the liver in just a week’s time.
“A lot of the international liver surgeons were thinking this guy was crazy and they pounded him with questions,” Hernandez-Alejandro said. “I thought there was something interesting about this, so when he finished (his talk) and went to the bar in the hotel, I followed him and his colleagues and sat next to them and said, ‘Guys, this next beer I’ll cover. I just have to know more.’”
Hernandez-Alejandro proceeded to take a napkin and pen and spent the next hour talking and exploring every detail surrounding the procedure, taking his scribbles back to his hotel room, where he analyzed it over and over.
Just a month later, Hernandez-Alejandro was back at University Hospital completing his first ALPPS (associating liver partition and portal vein ligation for stage hepatectomy) for liver cancer.
The surgical first is that both stages of the hepatectomy, or removal of the liver, were completed in just one week to ensure cancer did not spread to other parts of the liver. In the past, such a procedure would have taken three to four months from start to finish, not including recovery time. Now, patients can be out of hospital within a month.
When he initially spoke to the first patient, Hernandez-Alejandro was asked what experience he had with this type of surgery. He pulled out the paper written by the German doctors. He said he could make a copy for the patient.
“He told me ‘I’m not going to understand any of it, but I trust you doc,’” Hernandez-Alejandro said.
During the first surgery, which took around six and a half hours, Hernandez-Alejandro first removed tumours from the left side of the liver (leaving approximately 30 per cent of the liver) and then cut the blood supply to the right side of the liver. Without blood flow, the right side of the liver shrank, and the left side of the liver grew due to excess blood flow.
After just one week, he then performed another surgery on the patient, approximately two and a half hours, to remove the right side of the liver and, therefore, all cancer from the liver.
“In this new surgery we split the liver, giving nothing to the right side from the portal vein. You’re giving all the flow from the portal vein to the left side, while the right side gets artery only to keep the patient alive for one week. Then, bang, you go in and remove the right side.”
Since that first surgery in April, Hernandez-Alejandro has completed four additional surgeries.
“I have done a lot of liver resections, but normally, we cut out parts of the liver which have tumours, but this one is a challenge because you have to cut it open like a book, and it has to be clean,” he said. “It’s a more challenging and technically demanding operation.”
Along with the excitement, Hernandez-Alejandro realizes this sort of procedure will not be for everyone dealing with liver cancer, since it is very aggressive for a patient to go through two major abdominal surgeries in such a short period of time.
He has also teamed up with surgeons in Switzerland and Argentina, also performing the ALPPS procedure, to get more long-term information and validate results and compare them to the previous surgical method.
Thus far, they have a total of 35 ALPPS procedures, which they are comparing to 46 prior surgical approaches. He also plans animal studies to learn more about how the liver regenerates so quickly.
“While it’s very aggressive for the patient, you’re not letting the tumour progress; we’re learning more,” Hernandez-Alejandro said. “And at six months with the registry, which is new, we’re finding results have been better than the standard procedure.”
Hernandez-Alejandro now finds himself in high demand to share his results across the country. Returning from Hamilton this past week, he will soon be heading out to Edmonton, Calgary, Ottawa, Montreal, Kingston, Windsor and Owen Sounds, to name just a few, to share his expertise.