A diagnosis of advanced liver cancer or colorectal liver metastases does not necessarily rule out surgical treatment. Advances in minimally invasive techniques, liver-directed therapies and multidisciplinary care are creating new opportunities for patients who may not previously have been considered surgical candidates.
In this UCI Health physician discussion, Robert Redfield III, MD, joins hepatobiliary surgical oncologists Reed Ayabe, MD, and Zeljka Jutric, MD, to explore the evolving management of primary and metastatic liver tumors. They discuss the advantages of robotic liver surgery, treatment strategies for colorectal liver metastases, hepatic arterial infusion (HAI) chemotherapy and techniques to optimize liver regeneration before surgery. The conversation also highlights the importance of collaborative surgical planning and specialized evaluation in identifying potentially curative treatment options for select patients with advanced disease.
Topics discussed
Primary liver cancers and metastatic tumors involving the liver
The liver's regenerative capacity and its implications for complex surgical procedures=
Multidisciplinary surgical planning and the role of specialized hepatobiliary and anesthesia teams
Advances in laparoscopic and robotic liver resection, including potential benefits for patient recovery
Staged and repeat liver resections for patients with colorectal liver metastases Surgical evaluation and the potential for curative-intent treatment in select patients with stage IV colorectal cancer
Hepatic arterial infusion chemotherapy to downstage initially unresectable liver metastases
Portal vein embolization, future liver remnant optimization and emerging liver-directed technologies
The future of personalized liver cancer treatment and expanding surgical eligibility
All right. Well, um, I'm very happy to have, uh, two of my esteemed colleagues here, uh, today, Doctor Reed Ayabe and Doctor Zeka Utrick, both hepatobiliary surgeons here at UCI Health. We're doing this to kick off Liver Cancer Awareness Month for October. Uh, so, uh, welcome. Thank you so much for having us. Happy to be here. All right, so, um. Let's just dig right in. So when physicians hear liver cancer, um, and that's a big specialty, uh, of yours, can you give us a sense of what that entails because it's more than just hepatocellular carcinoma, right, Doctor AB? Yes, so hepatocellular carcinoma is the most common primary liver tumor, the second being cholangiocarcinoma, cancer of the bile ducts. But the liver is actually the most common site for metastasis or tumor spread from gastrointestinal primary tumors, um, most commonly colorectal and neuroendocrine tumors. And actually the most common malignant liver tumors are metastatic tumors, um, from colorectal primaries. Um, so liver cancer, as a, as a general term could refer to any of those. Right. You know, I've thought of like, um, you think of the liver almost as like a filter for the body. So it makes sense that tumors either primarily Start within that filter, but actually more of it is just filtering all the stuff throughout the body, right? That's right. The liver does have a filtration function. Also, all of the, the blood from our gastrointestinal tract goes through the portal vein into the liver and so it often is the most common first site where, where cells can exit the bloodstream and, and take root. Yeah, it really is that hematological pathway that the tumor cells land in the liver because so much blood is filtered through the liver and that is why we see really um any, you know, most malignancies that do that can spread to the liver. Right, right. So what really got you guys interested in, in liver surgery? Um, how did you kind of get into it? Uh, why specialize in it? How did it become your, your passion? Yeah, it's uh, I think the liver is a really fascinating organ. It's, it's unique. It's one of the few organs in the body that can regenerate. You can take out upwards of 30 70% of the liver and, and it will regenerate in a healthy liver. Um, it's an organ that's irreplaceable aside from a transplant. There's no dialysis machine for the liver. There's no heart lung machine for the liver. Uh, it's very anatomically complex and so the surgeries have a lot of thought and planning to go into them. Uh, and they're, they're technically challenging, which, which we do like, and it's a field that's constantly growing. Um, there's a lot of technology involved, there's a lot of different techniques for how to transect the liver parenchyma, um. Uh, there are a lot of liver-directed therapies that are adjuvant to the surgery. It's, it's a field that's always growing in leaps and bounds, and, and we like to stay on the, on the cutting edge of that. Um, for me, I, um, was also drawn to liver surgery because the liver is such an interesting and, um, intriguing organ as we've already talked about, um, it, it does so many functions for the body. Um, one of them is filtering toxins, um, filtering, you know, other things, and, and, um, similarly, the reg the regeneration, um, regeneration capacity of it is, um, really interesting that you can actually take out large volumes of it and it does grow back, um. And the other um reason that I love liver surgery is uh similar to what Doctor Ayabe said in that um there's a lot of space to create, to innovate, to, um, think about ways to um to make the surgeries better, um, and the surgeries are very complex and very detailed and fine. They require a lot of um ahead of time planning. Um, it's a very 3D organ with um lots of like a whole network of blood vessels and bile ducts. Um, and so when we plan and prepare for these surgeries, we form like a mental 3D map in our mind of what needs to happen. Um, the other thing that really drew me to the field is that, um, these surgeries are really profound and big and serious for patients, um, and their families, so I think the whole process when somebody undergoes a major life event like this, um, it's, it's a big thing, um, for that patient and their family. Um, and it can be scary, and I think it's really meaningful, um, to be part of, uh, that journey for these patients. I think it also really shows us the resilience that people have when faced with, um, a serious surgery like this. So it's really, uh, meaningful to be part of that. Yeah, just to put a pin in it, you know, um, the liver is, it's one of the most fascinating organs of the human body. It's this organ that you can't live without, right? You can't just remove it, you need it. There's no replacement for it other than a liver transplant. There's no liver dialysis, at least yet, um. And it has this amazing ability that you can remove a large portion of it and with some expertise, even a majority of it. And have it grow back. Um, safely, it's wild, kind of like the salamander's tail. I mean, it's one of these few things that actually can, can, um, um, regenerate, and we can teach you so much. And I think one of the really interesting things is that the regeneration happens so fast because patients often ask, like, you know, patients are really fascinated with that aspect too, um, and it does happen within 4 weeks, you know, so from when. The time that you do the hepatectomy, most of the regeneration will happen within the 1st 4 to 6 weeks. And then the last maybe 20% of it will continue on for the next several months, but it is, it is a really um fascinating aspect of it. So, um. This is some of the most complicated surgery you can have done as a human being is to have your liver operated on. Um, you have all these different indications. Patients are getting referred in. Throughout the community, um, either from their primary care physicians or medical oncologists, or they found something on a CT scan, right? You know, that they got done incidentally after a trauma, and they get referred into your guys' clinic. Doctor Utrick, you're the, now the division chief of hepatobiliary surgery. How do you Organize the team and decide where patients kind of go or what are the different services that your group offers um uh our patients of Orange County. Um, I think that for liver surgery, you know, whether, um, the patient gets sent to Doctor Yabe or myself, I think we really work as a team and so it really is equivalent, you know, service that that person is get is going to get, and oftentimes chances are that both of us are gonna be, um, present at at surgery. I think that we're really lucky that we have, um, a great partnership and we have very similar oncologic views, um, and as you mentioned. Some of these cases are rather complex, um, you know, maybe something that we haven't seen in the past, so it's really great to be able to bounce ideas off, um, your partner. We kinda have a key thing that we send to each other like have a scan to look at, um, and so that's the clue that the, um, other person will, will take a look at the scan and I think that's really great because some of these things were, um, you know, as, as an example, maybe there's a tumor that would be much easier removed with the right hepatectomy, for example. That's, you know, gonna be straightforward, um, known surgery, etc. but we have to take in all these other factors as far as like how much liver is gonna be remaining, etc. um, so it's really great to sort of, um, brainstorm, you know, different ways and more creative ways that we can tackle that operation. So maybe, you know, we can remove, um, just a smaller portion of the liver that's gonna be more complex, more central surgery, but it's gonna benefit the patient, um, it's gonna spare liver. Um, so I think that's, that's a really great, um, part of our service line that we offer. And you know, it's not just taking the liver out, right? I mean, that is it that in of itself is complicated and, and dangerous as, as, as you, as you pointed out, um. It it is one of the more complicated things that we can do in surgery. So can you talk about the team that is required to do this safely? You can't just get this done at any hospital, um, in the area around the country, right? That's right, um, here we, we do have a very mature liver program we've been doing, um, liver surgery and minimally invasive liver surgery for a long, long time. Um, I definitely think, you know, from the morning that the patient comes to the surgery, every person that they. Meet that day will have done this many times day in and day out and so they know what to expect they know what's gonna happen they know what we need in surgery so that's from nurses circulating nurses etc. anesthesiologists that's a huge part so um we you know always say that. Liver surgery is as much anesthesia management as it is the technical management of what we do, um, and that's I think where the field really has grown a lot in the last, um, you know, decade or so is that we've really gained a much better understanding of the anesthetic considerations that go into it. There's, um, you know, lots of, lots of things that the anesthesiologists do on their end to make the surgery smoother for us, such as keeping the field dry. Um, there's also like variations and things that they can change with the vent settings, um, and it really requires very close communication with us and our anesthesia team. Again, we're very lucky to have an anesthesia team here that really, really understands liver physiology, and I think it's really allowed us to push the envelope a little bit more and grow our program in in those and have excellent outcomes. Absolutely. Can you, when I, you know, and I didn't train in general surgery that long ago, but when I did. Nobody was doing really anything substantial in a minimum like a liver resection minimally invasively. All the liver sections I did with my faculty members were open through uh a large subcostal uh incision. You two are one of the country's leading minimally invasive surgeons. I think you really were at the forefront of laparoscopic liver resections and Reed, you're now coming up and, and helping. Lead the charge on robotic resections with Doctor Utrick. Can you, can you speak about the evolution of that and, and also the advantages of a minimally invasive approach, laparoscopic versus robotic as well? Yes, um, so we did do the first, uh, laparoscopic right hippotectomy, um, at UCI Health in 2017, um, and at that time less than 5% of major hippotectomies were being done through a minimally invasive fashion nationwide. Um, and I remember when I was in training the first time I saw a laparoscopic right hippotectomy I thought this is really cool, but there's no way this is actually gonna be possible, um, because the open surgery is so difficult so then to add that piece onto it seemed really impossible. Um, but I think that you know with the help of um our anesthesia team we've really perfected um the way that we do the surgery over the last, you know, 10 years and then we, um, switched to the robotic platform a couple of years ago which has a lot of advantages. Yeah, I think the, the robot has really changed the game, um. It, you know, allows such good visualization, ambidexterity, 7 degrees of freedom in each hand, um. And the recovery for patients, especially for liver surgeries, I think is, is much faster. I mean some of these patients can have a large liver resection and go home in 24 hours, even within 24 hours of surgery, which, you know, with an open operation could be 7 to 14 days, right, yeah, yeah, I think the incision really plays a big role in right-sided resections particularly because, you know, that midline. Incision with the right sided extension is pretty morbid incision. Um, there can be a lot of problems with it. It is painful. There's a hernia wrist down the line. Um, it's a major incision when you see it. Um, so to be able to do these surgeries, um, you know, and, and. Take that part out of the equation is really, really helpful for patients. And there's some disease processes that you all treat too, the metastatic diseases, uh, colorectal mets that you might have to go back in multiple times over, uh, a patient's course, right, to resect sequentially. Would this, is the robotic approach help? Absolutely. So it does. The adhesions are less. And so for every, you know, if a patient has bilobar, so both sides of the liver, liver mets for colorectal, for example, we try as much as possible to do the first stage hepatectomy, meaning usually meaning clearing the left side of the liver robotically so that the adhesions when we go back in will be less, right, right. Yeah, and we do know that patients benefit from um repeated resections, particularly for colorectal liver metastases, and we've definitely had patients that have, you know, the first surgery done minimally invasive, then they have a second one, and then they may even have a 3rd or 4th resection. So definitely doing these surgeries um through the minimally, minimally invasive approach helps. Um, I wanted to also add that um the robotic platform I think has really helped us um sort of advance in what we can do. Minimally invasively, so for example we used to do the most more complex resections when we really had to preserve certain pedicles um to the liver, etc. um, we felt more comfortable doing those open but now with the addition of the robot I think that we're really seeing, um, you know, these intricate delicate dissections done that way too so that's a really, really great thing so you know. Here, um, at UCI Health, we have leaders in minimally invasive liver resections. You guys are on the cutting edge. The other thing that, that I think it's important for other people to know is not just the techniques, but you're on the cutting edge of what you're actually offering. Again, when I trained, nobody was doing colorectal meds in like, Any definitive way, right? It was a lot of times a contraindication. Um, that is another thing that you have pioneered, um, and really, uh, nationally and brought, uh, to this community, um, and shown very good outcomes in patients with colorectal metastasis. Yeah, I think that colorectal liver metastasis is such an interesting field because it truly is a paradigm shift in the thinking of cancer care, you know, and I've, I, it, it brings up so many discussions because again we're for so many years we believed that when cancer cells leave the primary tumor and they land in the liver. Going into the liver and they set up shop that patients are non-operative candidates exactly and that they just have to go on chemotherapy and that's it. Yes, right. And what we've seen is that these patients respond really well to surgery, um, and you know they're of course the higher the tumor burden, the more frequent the recurrence will be, but we know that. Even treating recurrence surgically um works. And, you know, and and the the fact that stage 4 disease can be cured is another, it's just a paradigm shift in thinking. It's it's something that depends on the tumor biology, but it requires a multidisciplinary approach and you can cure patients with metastatic. Colorectal meds to the liver, you know, and provide them, if not even a cure, 5, 1015, 20 years of life with their family members and their loved ones. Yeah, I think unfortunately there is still a pretty widespread misconception that stage 4 cancer. People just put the patient on chemo forever. Um, I really think that pretty much every patient with colorectal liver image should see a surgeon cause even patients who have pretty advanced disease, a lot of, you know, lots of tumor in their liver with modern multi-agent chemotherapy, sometimes plus minus local regional therapy, a lot of these patients can be brought to surgery and, and like Doctor Uri said, surgery can prolong life significantly or even cure a large proportion of these patients. Um, and if somebody presents with unresectable disease, there are other local regional things that we offer such as, um, HAI, which is hepatic arterial infusion therapy. We were the first, um, program to offer that in Orange County. We started the program in 2022. Um, and it's what, what it is basically is a pump much like a port just larger, um, and we implant the pump into the abdominal wall, um, it's connected to a catheter that goes directly into the hepatic artery that can bring chemotherapy directly to the liver, um, and then the patient actually gets. Chemotherapy injected directly through this um pump in the abdominal wall and what that allows us to do is to deliver a much higher concentration of chemotherapy to the liver so it it you know the liver extracts like 97% of the chemotherapy through this method um and so we use this to downstage patients so if somebody comes and they're not upfront resectable we can't take them to surgery right away. Um, we can put them on this therapy and hope to downstage and maybe get them to surgery. Um, we also, we also would like to use it for recurrence reasons. We know that patients with high, uh, disease burdens, you know, there is a high chance that that they will recur in the liver. And so using this in the adjuvant setting can also, um, potentially reduce that. So I think it's a really great therapy that we would like to use, we would like to see its use a lot more. Yeah, I mean, for referring, uh, physicians, um. Uh, that are referring into you, you can offer them a ton of options for your patients, whether it's HAI, minimally invasive approaches, um, any other, um, uh, innovative technologies coming down the pike at all? I mean, there are a lot, there's always a lot for liver. I mean, you know, istotripsy is one that a lot of patients will have heard about. I think we're still studying it and trying to figure out the, the proper indications for that, um, and the robot is actually getting better and better with the DB5. They have a much smaller vessel sealer, we can do much finer dissections with that. Um, you know, it's, it's a field that's Evolved like even over the course of my training has evolved so much um so I'm it's really exciting to see where it's gonna go in the next few years. I, I think also the um optimizing and augmenting the liver volume is another you know space that we've seen a lot of improvement and so now um we can actually measure um how much liver somebody will have left over we call that the future liver remnant so we can. Um, measure the size of the future liver remnant and then decide if we need to increase that, um, volume, so we do that by, um, portal vein embolization, um, that actually helps us grow the liver and get the regenerative, you know, capacity of the liver prior to surgery. Um, those are all things that have made liver surgery a lot safer and have allowed us to again do. Surgeries, you know, on patients that maybe would not have qualified in the past so I think that, um, you know, ongoing improvements in measuring the actual liver function and volume afterwards and really sort of, um, you know, playing on this ability of the liver to regenerate and how we can augment that is another field, um. Where I think things will get better and also some of the um integrated 3D imaging capabilities um you know especially with robotics I think there's a lot of interest in that on how to take the 3D you know imaging of the tumor um with the you know relationship to the blood vessels and the bile ducts and how to integrate that real time um when we're actually doing the surgery. Well this is really great um. What do you guys think in 10 years, um, you know, just to, to, to wrap it up, um, with personalized cancer care, personalized medicine, um, how do you see the, the future for, for liver cancer and liver cancer surgery? I think our patients are going to be doing better and better, and I think that with improvements in our ability to tailor treatment to patients, I think that The pool of patients who are candidates for curative intent liver surgery is actually going to grow. So I think we are going to be able to offer more patients surgery, take out more tumors than than we are now. Yeah, and if you look at the major improvements, you know, it used to be that liver surgery carried a high mortality rate. You know, up to, you know, the teens sometimes, um, and that has really gotten a lot better. I think that it's much safer now. Patients require blood transfusions much less often. Offering it to older patients or patients that may have more comorbidities, you'll feel more comfortable. Yes, and I, I think with the older patients that's definitely where the liver, um, you know, volume augmentation will come into play because we know that a patient's liver regeneration. Capacity decreases as we age. So those are some of the things that we're really interested in, in looking at. We also know that chemo traditional chemotherapy damages the liver. So when we do a big surgery on somebody that's had a lot of chemotherapy, um, we worry about the regeneration capacity, and that's something that Doctor Ayabe and I have talked about a lot in actually studying, um, those aspects and then, you know, thinking of ways to improve, improve that for patients. Well, thank you guys so much. We're so honored and lucky to have you, uh, to be on faculty here and for caring for our patients and thanks for sitting down and chatting with us. Thank you so much. Thank you.
Related Presenters
