University of Leicester HPB Referrals and USS Interpretation by Mr. Giuseppe Garcea
"University of Leicester's Hepato-Pancreato-Biliary (HPB) program led by Consultant Surgeon Mr. Giuseppe Garcea focuses on 2WW referrals, abnormal imaging interpretation, and endoscopic interventions like ERCP. The program covers various tumor sites including the liver, spleen, gallbladder, pancreas, and bile duct. It discusses the incidence of cancers in the HPB region and the number of cholecystectomies performed. The HPB MDT referrals and confirmed cancer cases from 2001 to 2013 are also highlighted, showcasing the program's significant impact and patient numbers."
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Universityof Leicester 2WW HPB Referrals and USS Interpretation Mr Giuseppe Garcea Consultant Hepato-Pancreato-Biliary Surgeon & Hon Clinical Lecturer http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Aims Referring with abnormal Imaging Referring without abnormal imaging 2WW pathway in HPB http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Tumour Sites Covered by HPB http://classconnection.s3.amazonaws.com/376/flashcards/598376/jpg/bile_duct21335312360083.jpg Liver Spleen Gallbladder Pancreas Bile Duct Ampulla Duodenum http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Incidence http://classconnection.s3.amazonaws.com/376/flashcards/598376/jpg/bile_duct21335312360083.jpg Liver 8 per 100,000 Spleen No Figures Breast Cancer 123 per 100,000 Gallbladder 1 per 100,000 Pancreas 9 per 100,000 Bile Duct 2 per 100,00 Ampulla 1 per 100,000 Duodenum 0.4 per 100,000 http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Endoscopic Intervention e.g. ERCP Number http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Cholecystectomies 900 800 Total Number of Procedures Undertaken 700 HPB Contribution 600 500 400 300 200 100 0 Cholecystectomy Hernia Repair http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Number of Cancers Discussed HPB MDT REFERRALS 2001 - 2013 SW. November 2013 1600 1400 1200 3,000 Patients Discussed Annually 1000 800 600 400 200 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 341 428 338 460 369 603 476 699 544 917 622 828 1023 1121 1260 1237 1231 1519 578 755 819 865 Referrals to MDT Confirmed Cancers 277 881 893 1028 http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Catchment Area http://www.cps.gov.uk/assets/images/east-midlands-map.jpg 2.5 Million http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester 2WW Referrals Type of Referrals 60% Benign Disease 24% Liver 12% Pancreatic 4% Bile Duct 70% Referred by GP because abnormal imaging Snapshot of 12 months of local MDT referrals by GPs. Of note is that all patients were inoperable at the time of diagnosis (in fact 3 died whilst still on the pathway). 95% required further imaging 100% discussed at MDT 50% required re-discussion 12% required a biopsy or staging laparoscopy 24% referred to oncology NO resectable cancers http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Fatty Liver (especially if bright ) Coarse Liver Meaning of Buzz Words Cirrhosis Metastases Hypoechoic or hyperechoic lesions Metastases Adenoma, FNH Metastases Target Lesions Cystic Lesions (liver) Benign Cysts If complex ? abscess http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif Biliary Cystadenomas
Universityof Leicester Gallbladder Polyps Most gallbladder polyps are cholesterol deposits within the gallbladder wall or turn out to be stones True gallbladder polyps are linked to increased risk of gallbladder cancer The causation is not as clearly defined as for colorectal polyps Malignancy risk correlates to size http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Gallbladder Polyps http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester USS Rescan with HPB radiologist MDT Under 5mm 5 to 10mm Over 10mm High risk group Young Unwilling for surveillance Pain Surveillance USS 6 monthly for 2 years. Yearly After Surgery http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Fatty Liver and NASH Fatty liver and NASH are increasingly common Fatty liver in a patient with metabolic syndrome and only mildly deranged LFTs will probably have a marginal benefit from routinely seeing hepatology Fatty liver with raised ALT needs viral screen and autoimmune screen Any features of cirrhosis, needs referring to hepatology http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Typical Abnormal Imaging on USS 45.0% Biliary Tree 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester USS Reports in those Patients who Ultimately had a Benign Diagnosis 45% 40% 35% 30% Percentage 25% 20% 15% 10% 5% 0% Cancer? Cancer Needs Excluding Pancreatic lesion Seen Gallbladder Cancer? Ascites "Coarse" liver CBD/IHD with Gallstones CBD/IHD without Gallstones http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester USS Reports in those Patients who Ultimately had a Malignant Diagnosis 80.0% 70.0% 60.0% 50.0% Percentage 40.0% 30.0% 20.0% 10.0% 0.0% Cancer Cancer Needs Excluding Pancreatic lesion Seen Gallbladder cancer? Ascites "Coarse" liver CBD/IHD with CBD/IHD without Gallstones Gallstones http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester I f imaging is very clear Abnormal Findings on Liver USS When to Refer as a 2WW with Abnormal Imaging? Liver , Coarse liver with jaundice (ETOH history or Hep) gallbladder or pancreatic Mass Adenoma FNH Any Mass in Conjunction with a coarse liver Coarse liver with ascites (ETOH history) Liver Cyst > 5cm with symptoms Fatty Liver Further Imaging Advised Features of newly diagnosed cirrhosis Liver Cyst(s) <3cm Ascites HEPATOLOGY REFERRAL (urgent if decompansating) 2 WW REFERRAL (HPB) No Referral Needed HPB Referral or Advice Clinic http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Abnormal Findings on Biliary Tree USS When to Refer with Abnormal Imaging Gallbladder polyps <5 mm with no pain Dilated CBD with gallstones & abnormal LFTs Dilated CBD with GS & normal LFTs Dilated CBD with no gallstones +/- jaundice Dilated CBD post- cholecystectomy with normal LFTs Dilated CBD post cholecystectomy with abnormal LFTs Dilated CBD with IHD dilatation Gallbladder polyps between 5mm to 10mm Duct dilatation with mass in liver or pancreas. Gallbladder Polyps >10 mm 2 WW REFERRAL (HPB) Surveillance USS Annual HPB Referral or Advice Clinic URGENT HPB REFERRAL http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester When to Refer as a 2WW Without Imaging? http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Intercept Policy of the HPB Unit http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester USS Form Intercepted Intercept Policy of the HPB Unit Further Imaging or Clinic Review Decided Imaging or Clinic Organised within 2WW of USS CT Pancreas or CT Chest, Abdomen & Pelvis MRI or MRCP MDT Clinic Follow-up MDT http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester 2WW Referral Received 2WW Referral Pathway for HPB Definitive Cross-Sectional Imaging Discussion at MDT Patient Seen in Clinic Further Imaging Biopsy or Laparoscopy Sign Off http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Choose and Book Advice Clinics Will be running for HPB from April 2014 This will be attached to the following service on Choose and Book HEPATOBILIARY AND PANCREATIC SPECIALISED SURGERY- H&P-LGH-RWE Happy to give advice on any aspects of HPB benign and malignant http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Questions http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
Universityof Leicester Summary Most GP 2WW referrals are triggered by abnormal imaging Systemic signs e.g. weight-loss or jaundice coupled with abnormal imaging is a strong indicator for a 2WW referral Most HPB benign disease will still need referral to HPB Choose & Book Advice clinics available for further information http://www.zircadian.com/images/logo.leicester.gif http://www.zircadian.com/images/logo.leicester.gif
