Multidisciplinary Approach to Complex Cancer & GI Surgery at CRMC
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1 Multidisciplinary Approach to Complex Cancer & GI Surgery at CRMC Babak Eghbalieh MD, FACS Associate Clinical Professor, UCSF Facility Executive Committee Chair, CRMC Amir H. Fathi, M.D. Assistant Clinical Professor, UCSF Director of Hepato-Pancreato-Biliary Surgery, CRMC
2 Mission Statement To Create State of the Art and Evidence-based Approach to Complex GI Cancer & Surgery in the Central Valley of California
3 Overview 1) CRMC Infrastructure 2) Quality Improvement 3) CRMC / UCSF Fresno Programs 4) Collaboration
4 Traditional Approach Treatment Silos Sub-optimal collaboration & Fractionated care Poor patient navigation
5 CRMC Infrastructure Multi-D Approach to Pt Care 1. GI Cancer population 2. Complex GI pt population
6 Multidisciplinary Care of Cancer Multidisciplinary care has become accepted as the optimal mechanism for delivering care in oncology. The Commission on Cancer & the American College of Surgeons require multidisciplinary cancer conferences for the accreditation of health centers delivering multidisciplinary care.
7 Infrastructure: Tumor Board NCCN Statement All cancer patients must be evaluated by a multidisciplinary tumor board prior to initiation of treatment
8 Tumor Board Weekly review of Patients - Representation from 15 different disciplines: - GI, IR, Diag Rad, Path, Surgery, Genetics, Med/Onc, Rad/Onc, Palliative, Navigator, Social Work, Research, Nutrition, Clinical Trial, PCP, Residents - Open Forum Model - Review Volume: : 325 pts : 369 pts : 440 pts!
9 Infrastructure Education Patient CRMC Staff CRMC Facility core Community Providers
10 Infrastructure: CRMC Support Services Dedicated NP Compass Clinic Navigator Social Work Nutritionist Support Groups Palliation FOREGUT
11 Quality Improvement Projects CRMC Centralized inpatient care CRMC 7 th floor Med/Surg Oncology & Complex GI Surgery Dedicated CHMG Hospitalists Case management, Nutrition, Volunteer Services Animal Therapy, Music Therapy, Chaplain Services Get Well Network Dedicated OR teams: Anesthesia OR Staff, Rooms Advanced Technology: Ablation, IntraOp US, Liver infusion pump, HIPEC system, TEE, Vigelio Next Generation Robot
12 Quality Improvement Projects Inpatient & Outpatient Nursing education Scheduled Lecture Programs (OR, ICU, Med/Surg) Perioperative care Surgical postop care Surgical complications Discharge planning Postoperative Care-path implementation
13 Quality Improvement Projects CRMC Quality Paradigm Shift NSQIP LoS, ReAdmit ERAS DVT & SSI Reduction Programs Care Path protocols
14 CRMC / UCSF Fresno Programs
15 CRMC / UCSF Fresno Programs Pancreas Liver and Biliary System HIPEC & Cytoreductive Surgery Surgical Nutrition Program Robotic Surgery Comprehensive Abdominal Wall Reconstruction Program
16 Pancreas 1. Pancreatic CA Screening Program 2. Pancreatic Cyst Clinic 3. Chronic Pancreatitis Program 4. Pancreatic Cancer Patient Support Group 5. Pancreas Research
17 Central Valley Cancer Stats Each year more than 10,000 residents of the Central Valley are diagnosed with invasive cancer ~ 4,000 deaths from cancer occur each year as well. Due to the rapid growth of the population in the Valley, these numbers will increase in the future despite the fact that rates are declining for many types of cancer.
18 In 2017 an estimated 53,670 Americans will be diagnosed with pancreatic cancer in the U.S., and over 43,090 will die from pancreatic cancer. Pancreatic cancer is the 3rd leading cause of cancer-related death in the United States surpassing breast cancer. It is expected to become the 2nd leading cause of cancer-related death in the US by the year 2020, surpassing colorectal cancer.
19 Pancreatic Cancer Judge Ruth Bader Ginsburg Fred Gwynne Michael Landon Patrick Swayze Gene Upshaw Luciano Pavarotti Sheikh Zayed Joseph Cardinal Bernardin Archbishop of Chicago Count Basie
20 Screening Program International Cancer of the Pancreas Screening (CAPS) Consortium summit on the management of patients with increased risk for familial pancreatic cancer Since the incidence of PC in the general population is low (lifetime risk 1.3%), screening is not recommended for the general population, but instead for individuals considered to be at high risk of developing the disease (ie, >5% lifetime risk, or fivefold increased RR) - Surgery - Genetics - Radiology - GI
21 Pancreatic Cyst Clinic Multi D approach GI Endoscopy, Surgery, Pathology and Radiology Database Regular Follow ups
22 Support Group Meets Monthly Buddy System Annual Meeting Community
23 Chronic Pancreatitis Program
24 Chronic Pancreatitis Program
25 Neoadjuvant Therapy for Pancreatic AdenoCarcinoma
26 Surgery-First approach to Pancreatic Cancer 1-2 wks 6-10 wks OR Adj Therapy Recovery from surgery CT Diagnosis, staging and preparation for surgery What we know: No progress in decades What we do not know: The biologic impact of surgery first
27 Surgery-Frist Approach
28 Neoadjuvant Systemic Therapy
29 Surgical Options Whipple Vascular reconstruction (Portal Vein and Hepatic Artery) Central Pancreatectomy Robotic, Laparoscopic Distal Pancreatectomy Robotic, Laparoscopic Total Pancreatectomy
30 Research Publication & Presentation ACS and North Cal SAGES Projects: K-Ras detection in Liquid Biopsy SEER & NSQIP database Outcome research Next Generation Genetic Sequecing
31 CRMC / UCSF Fresno Programs Pancreas Liver and Biliary System HIPEC & Cytoreductive Surgery Surgical Nutrition Program Robotic Surgery Comprehensive Abdominal Wall Reconstruction Program
32 Liver and Biliary Tree 1. HCC Program 2. Cirrhosis and Portal HTN Optimization Program 3. NASH, NAFLD Program 4. Liver and Biliary Research
33 Treatment Options CRMC 1. Surgical resection (Robotic, laparoscopic & open) 2. Liver Transplantation (UCSF) 3. Radiofrequency Ablation (RFA)- percutaneous, lap, open 4. Microwave Ablation 5. Trans-Arterial Chemoembolization (TACE) 6. Radio-Embolization (Yttrium 90 beads) 7. Systemic Chemotherapy 8. Intra-arterial chemotherapy pump infusion 9. Radiation Therapy (SBRT, IMRT) 10. Isolated Liver Perfusion 11. Multi-modality approach 12. Clinical trials 13. Palliative Care
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35 Complete response of giant HCC after Tran-Arterial Chemo-Embolization (TACE) Tumor Initial CT scan Follow-up CT AFP 1,596 AFP 3 Tumor Residual calcified fibrosis at HCC sites
36 Liver Research Cholagiocarcinoma Fresno County mapping HCC Screening Program in Fresno County Collaboration with Fresno State and County Ablation Plus TACE for Unrestable HCC Clinical Trial: TACE vs. Y90 Treatment for Unresctable HCC City Wide Collaboration
37 CRMC / UCSF Fresno Programs Pancreas Liver and Biliary System HIPEC & Cytoreductive Surgery Surgical Nutrition Program Robotic Surgery Comprehensive Abdominal Wall Reconstruction Program
38 HIPEC New Hopes for Stage IV cancers Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy (HIPEC) Few centers in California are offering One of the centers with good results National and International collaboration
39 Current Indications for CRS & HIPEC Large volume of noninvasive peritoneal carcinomatosis or sarcomatosis. Peritoneal mesothelioma. Low volume peritoneal seeding from invasive cancer. Perforated gastrointestinal cancers. Cancer adherent to adjacent organs or structures. Gastrointestinal cancer with positive peritoneal cytology. Gastrointestinal cancer with ovarian involvement. Tumor spill intraoperatively. Systemic chemotherapy for recurrent ovarian cancer after a long disease-free interval. Palliation of patients with malignant ascites.
40 CT example Preoperative CT scan demonstrating extensive metastases from appendix cancer (cancer outlined in red) No residual disease 8 months following complete cytoreductive surgery and HIPEC
41 Prerequisite for HIPEC surgery: Complete macroscopic cytoreductive surgery (CRS)
42 HIPEC Closed Technique Belmont Hyperthermia Pump
43 Appendiceal Cancer CRS+HIPEC Yan et al. Ann Surg Oncol 2007;14:484
44 Dr. Paul Shugarbaker Dr. Jesus Esquivel
45 CRMC / UCSF Fresno Programs Pancreas Liver and Biliary System HIPEC & Cytoreductive Surgery Surgical Nutrition Program HPB Robotic Surgery Comprehensive Abdominal Wall Reconstruction Program
46 Surgical Nutrition 1. Perioperative Nutritional Assessment Program ASPEN Malnutrition Criteria Perioperative Nutritional Conditioning Immunonutrition (Impact) 2. Postoperative Diet Optimization & Education 3. Postoperative Diabetic Control Artificial Pancreas
47 Surgical Nutrition Research Clinical Trials: Effects of perioperative conditioning on postoperative outcomes Grant from Fresno State Enzyme replacement conditioning for patients with pancreatic head cancers during Neoadjuvant treatment
48 CRMC / UCSF Fresno Programs Pancreas Liver and Biliary System HIPEC & Cytoreductive Surgery Surgical Nutrition Program Robotic Surgery Comprehensive Abdominal Wall Reconstruction Program
49 Multi-Disciplinary Robotics Program Urology Urogynecology General Surgical Oncology Gynecologic Oncology OMFS Oncology Thoracic Oncology
50 Robotic Surgery Program CRMC Case Observation Site One of a dozen programs nationally performing Robotic HPB Cancer surgery Advanced Robotics Research Application of new Tech Firefly Intuitive Grant Robotic Hernia Repair outomes
51 Firefly Fluorescence Imaging Improved visualization using Fluorescence imaging Tumor visualization Vascular supply Biliary tree (Cholangiography) Margin status
52 Robotic Surgery Program CRMC CRMC was the 1 st Hospital in Central California 1. 1 st Robotic Common Bile Duct Exploration 2. 1 st Robotic Single Site Cholecystectomy (Si & Xi systems) 3. 1 st Robotic Nissen Fundoplication 4. 1 st Robotic Distal Pancreatectomy 5. 1 st Robotic Central Pancreatectomy 6. 1 st Robotic Liver resection 7. 1 st Robotic Heller Myotomy 8. 1 st Robotic Gastrectomy (partial and total) 9. 1 st Robotic Distal Esophagectomy st Robotic Splenectomy st Robotic Small bowel GIST resection st Robotic Pelvic Melanoma excision st Robotic Excision of mesenteric tumors st Robotic Base of tongue tumor resection 15. One of the 1 st to use Firefly technology in the nation Robotic Colectomies Robotic APR
53 CRMC / UCSF Fresno Programs Pancreas Liver and Biliary System HIPEC & Cytoreductive Surgery Surgical Nutrition Program HPB Robotic Surgery Comprehensive Abdominal Wall Reconstruction Program
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57 Program Coverage Overview
58 Thank You CRMC HPB/Complex GI Multi Disciplinary Team
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