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Hepato-Pancreato-Biliary (HPB) Unit

Central Manchester University Hospitals NHS Foundation Trust HPB (hepato-biliary) Unit is the regional centre that provides highly individual, specialist services for patients with benign (non-cancerous) and malignant (cancerous) diseases of the liver, biliary system and pancreas. We are the designated Regional Pancreatic Centre (in conjunction with our NMG colleagues), and are the largest most specialised HPB units in the region, treating patients from Manchester and surrounding areas. We are a tertiary referral centre, and a nationally recognised centre of excellence for pancreatic cancer.

The HPB Unit works closely with the other acute hospital trusts in the Greater Manchester area - these include: Bolton NHS Foundation Trust; East Cheshire NHS Trust; Pennine Acute NHS Trust ; Salford Royal NHS Foundation Trust; Stockport NHS Foundation Trust; Tameside Hospital NHS Foundation Trust; The Christie NHS Foundation Trust; University Hospital of South Manchester NHS Foundation Trust; Wrightington, Wigan and Leigh NHS Foundation Trust;

Many patients with a hepatobiliary problem require endoscopic ultrasound or ERCP, or others may require procedures involving X-ray.

If you need to be admitted for a procedure this will usually be to AM3 or AM4 (the gastroenterology wards) or the surgical ward.

Please click here for the X-ray department.

Please click here for the Endoscopy pages.

We provide a multi-disciplinary service with a team of experienced surgeons (Link to Surgeons), gastroenterologists (Link to Gastro), radiologists (Link to Radiology), pathologists, anaesthetists, oncologists, intensive care physicians, nurse specialists and dieticians, all dedicated to providing the best possible care for each and every individual patient.

Our patients are discussed in our weekly multi-disciplinary team meeting (Wednesday's) giving the opportunity for review of your care and treatment by every member of our team. This ensures that the treatment that we deliver to you is the best we can offer and can also help speed up the organisation of any further investigations you might need.

We also have a team of HPB Clinical Nurse Specialists (Link to CNS contacts) who can provide you with advice and support on all aspects of your care, from the point of diagnosis throughout your treatment and follow-up care.

What we do

We provide all-round care for people with liver, pancreatic, biliary and gall bladder disorders. Our team offers specialist investigations and care for conditions such as:

We treat all types of biliary, pancreatic and liver diseases including:

  • primary liver cancer: hepatocellular carcinoma (HCC)
  • benign liver tumours: focal nodular hyperplasia (FNH), adenoma, haemangioma
  • biliary disease- gallstones, PSC
  • biliary cystadenoma
  • primary biliary cancers: cholangiocarcinoma and gallbladder cancer
  • pancreatic disease- pancreatitis, pancreatic cancer
  • secondary liver tumours from a colorectal, breast or other primary
  • chronic and acute pancreatitis
  • complex benign hepato-biliary and pancreatic conditions.
  • Liver disease- viral hepatitis, cirrhosis

Treatments include:

  • liver, pancreatic and biliary resection
  • percutaneous radio-frequency ablation of primary and secondary liver tumours
  • percutaneous chemo-embolisation for primary liver tumours
  • percutaneous bland embolisation for liver tumours
  • endoscopic radio-frequency ablation for biliary tumours
  • Selective Internal Radiation Therapy (SIRT) for primary or secondary liver tumours subject to individual patient funding
  • sorafenib for primary liver cancer - hepatocellular carcinoma (HCC) - subject to individual patient funding or by clinical trial
  • specialist endoscopy.

Patients are assessed and reviewed by our consultant oncologists at CMFT. Systemic chemotherapy and/or radiotherapy is provided at The Christie Hospital NHS Foundation Trust.

One-Stop Jaundice Clinic

The One-Stop Jaundice clinic is held every Monday morning by the Jaundice CNS. Patients can be referred by their GP or local hospital by contacting the Jaundice CNS (link to aileen.aherne@cmft.nhs.uk or 07973 947 137). The aim of the clinic is to provide same day definitive radiological imaging for patients presenting with obstructive jaundice not due to gallstones. The purpose is to provide for earlier diagnosis and timely referral and to improve patient experience.

Fast-track Surgery

Jaundiced patients with a suspected pancreatic head tumour or cholangiocarcinoma can be referred for consideration of Fast-track surgery by their referring hospital. The aim of this is to proceed straight to surgery (within 1 week) thus avoiding preoperative biliary drainage (if bilirubin <350).

Research

The National Institute for Health Research (NIHR) demonstrates that the clinical research network (CRN) for Greater Manchester is nationally, the lead recruiter for HPB. The CMFT HPB Unit is currently participating in the following NIHR portfolio studies:

PANasta: Cattall Warren versus Blumgart techniques of panreatico-jejunostomy following pancreato-duodenectomy - a double blinded multi centred trial (now closed).

ESPAC-5F: a multi-centre, prospective, randomised, feasibility Phase II trial comparing neoadjuvant therapy to immediate surgical exploration in patients with borderline resectable pancreatic cancer.

What to expect

Your first appointment

You may have had your first appointment in your local hospital and then been referred on to the CMFT HPB team. During your appointment with us we will discuss possible diagnoses and any investigations (tests) that we may need to do. You will meet a dedicated HPB Clinical Specialist Nurse (CNS) who will keep in contact with you and give you all the information you need.

We may need to carry out certain investigations to help find a diagnosis. These are performed as quickly as possible and your CNS will keep in contact with you with up-coming dates.

After your first appointment and investigations

Every Wednesday members of the HPB team including surgeons, specialist nurses, radiologists, histopathologists and oncologists meet to discuss the results of patients' investigations in the Multi-disciplinary team meeting (MDT). They will decide on a management plan for each patient, which could include surgery, chemotherapy or palliation (relieving) of distressing symptoms caused by the cancer.

We will ask you back to the clinic soon afterwards so that the HPB surgeon and your specialist nurse can explain your treatment options. If surgery is planned you may also see a physiotherapist who will advise you on breathing/coughing and mobility after abdominal surgery and a dietician who will advise you on nutritional supplements and healthy eating during your treatment.

Pre-admissions clinic

If surgery is planned you will be asked to attend a pre-admissions clinic at the Elective Treatment Centre. At this appointment a nurse will assess take your bloods, perform an ECG, and arrange any additional tests needed and give you any relevant information about your hospital admission. You may also need to have a CPET (Cardio Pulmonary Exercise Test) to assess your level of fitness prior to any planned surgery. An invitation for Surgery School will also be sent to you, where you will have the opportunity to meet the anaesthetist, dietician and physiotherapist. The CNS will try to co-ordinate these appointments for the same day.

Surgery School

Pre-habiliatation

On the day of the operation

You will be admitted the evening before your surgery and this is usually to Ward 8 (HPB Ward). The nursing staff will prepare you for surgery and you will get another opportunity to see the surgeon and meet the anaesthetist. Please feel free to ask any questions.

We will discuss your anaesthetic including the use of specific intra-operative monitors and methods of post operative pain relief such as epidurals and morphine PCAs. We will also discuss where you need to be cared for after the operation. For smaller operations such as laparoscopic cholecystectomies, you will have a bed on a general ward after the operation, and may be able to go home later that day. For major operations such as liver or pancreas surgery, you will probably need closer monitoring and care on a critical care ward (HDU or ICU). If this is the case we will have to confirm that this bed is available before surgery can go ahead.

The anaesthetic room

When you are brought down to theatre you will meet an ODP (operating department practitioner) who works with the anaesthetist. The team will go through a few further safety checks before they start your anaesthetic.

You will have a cannula (small plastic tube) put into a vein and routine monitoring will be attached. If you need an epidural, this will normally be put in with you awake at this point. You will be given oxygen to breathe as you are given the anaesthetic drugs that drift you off to sleep in your cannula. You are kept asleep by breathing in special anaesthetic gases through a breathing tube. These gases are continuously monitored by your anaesthetist to ensure you are safely asleep throughout the operation. Whilst you are asleep other monitors may be inserted to help your anaesthetic team care for you. These may include an arterial line (measures your blood pressure), a central line (allows the administration of drugs) and a urinary catheter. Depending on the complexity of your operation you may be asleep from between one and six hours.

Post operatively

Once your operation is over you will be woken up and taken to the recovery room and then moved on to either the ward or critical care, or very rarely you may be kept asleep and moved to the ITU to be woken up later on.

This depends on your pre-operative health, the complexity of the operation, how well you have coped with the surgery and how well the surgery has gone.

In recovery

Following HPB surgery the majority of patients go to the recovery area. During this time, as you wake up from your anaesthetic, specialist nurses monitor your vital signs and ensure your pain relief is effective and any nausea is treated. Once your condition is stable you will be moved either back to the ward or to critical care.

In critical care

Once you have recovered from the general anaesthetic you will be able to start drinking on the day of the operation and eating the day after. This is important because improved nutrition after the operation has been shown to speed recovery and reduce serious complications.

Intensive care consultants and your surgical team will review you on daily ward rounds to ensure you are progressing well after your operation. As your condition improves over the first two days after surgery abdominal drains, urinary catheters and other drips will be removed. If you have an epidural, this will be reviewed on a daily basis by the acute pain team and it is usually removed on the third post-operative day, when you will be converted on to tablet pain killers.

Once the critical care team is happy with your progress you will be moved to the dedicated HPB ward where your post-op care and rehabilitation will continue until you are discharged home.

The enhanced recovery programme

In Manchester, we use an enhanced recovery programme to help you recover from the operation and return to normal activities faster with less chance of developing complications like blood clots in the legs and lungs or chest infections. It also means that you will be able to get home earlier. On average patients undergoing open liver resection are discharged six days after surgery. The majority of patients who have had complex surgery such as operations for liver or pancreatic cancer will spend their first few post-operative days in a critical care unit. Here you will have your own dedicated nurse who will monitor you round the clock and will ensure that your vital signs are stable and that your pain control is effective. We will monitor your temperature, pulse, blood pressure and fluid balance.

Regular breathing exercises, sitting out of bed and walking reduce rates of chest infections, blood clots in the legs and lungs and help you get home quicker. After you wake from the operation you should start breathing exercises. Support your abdomen with your arms. A physiotherapist will take you through these exercises every day. You can help reduce the risk of developing a blood clot by performing specific leg exercises, wearing compression stockings and having daily injections of a drug that thins the blood.

The day after the operation the staff will help you out of bed. You will spend several hours out of bed each day and will be encouraged to walk around (with the help of the staff initially) 3-4 times per day. At first this will feel like hard work but being out of bed and mobilising early improves lung function and reduces the risk of blood clots. You will be seen every day by your surgical team who will review your progress and decide when it is safe for you to go home.

Follow-up clinic

You will normally be seen in the out-patient clinic, at Manchester Royal Infirmary, four to six weeks after you are discharged home. This allows us to check you are progressing as you should be. This appointment will be given to you before you leave hospital or sent to you at home. Your doctor may discuss with you the need for further treatment such as chemotherapy. If necessary, arrangements will be made for you to see an oncologist (a doctor who specialises in chemotherapy treatment). He/she will discuss this treatment option with you further and give you chance to ask questions. You will be given time to recover from your operation first before undergoing any further treatment such as chemotherapy.

Following this appointment you will have a CT scan three months after your surgery to look at the re-growth of your liver, which will act as a baseline for all future scans. You will then have CT scans yearly and will be contacted or seen in clinic with the results.

If you experience any problems before your hospital appointment, please contact your consultant's secretary or you Clinical Nurse Specialist, who can advise you accordingly. If you feel it is becoming an emergency then the Emergency Department at CMFT is open 24 hours and will be able to make sure you are reviewed by the appropriate doctor.

Meet the team

Our gastroenterolgy consultants who specialise in hepatobiliary medicine are:

Dr. Richard HammondsDr. Alistair MakinDr. Jo Puleston and Dr. Joe Geraghty.

They work very closely with the hepatobiliary surgical consultants who are Mr Nicola De' Liguori- Carino, Mr Rahul Deshpande, Mr Saurabh Jamdar, Professor Derek O'Reilly, Mr Thomas Satyadas, Professor Aali Sheen and Prof. Ajith Siriwardena.

Specialist nurses include Sr. Aileen Aherne, Sharan Ingram, Adele McNeillie, Alison Maugham & Sr. Claire Newton.

 

ajith siriwardenaProfessor Ajith Siriwardena


Professor Ajith Kumar Siriwardena MBChB, M.D.FRCS, Is the current professor of hepato-pancreatico-biliary surgery at the University of Manchester, and a consultant hepatobiliary surgeon at the Manchester Royal Infirmary. Qualified in medicine from the University of Manchester and trained in surgery in Manchester and Edinburgh. Undertook advanced liver surgical training in Paris and worked as a consultant in the national liver surgery unit in Scotland. Currently provides expertise in liver surgery and pancreas surgery, especially for patients who have had bowel cancer and have then developed metastases in the liver.

 

 

aali sheenProfessor Aali Sheen

Consultant General & Gastrointestinal Surgeon MD MBChB FRCS(Eng) FRCS(Gen)

Professor Aali Sheen was appointed Consultant Surgeon at Manchester Royal Infirmary in 2005 as a General Surgeon with a specialist interest in Hepatopancreatobiliary (HPB) and Gastrointestinal Surgery. In his time as a Consultant he has taken an interest and developed a reputation in both Laparocsopic Liver/Pancreas & hernia surgery, the latter for which he has a seat on the council of the British Hernia Society and on a subcommittee for the European Hernia Society.

Professor Sheen is well published in the field of hernia and hepatobiliary surgery and has been granted a Hon/Vis personal chair in surgery by Manchester Metropolitan University (MMU).

Professor Sheen has undertaken almost 500 operations on the Liver for Cancer as well as over 100 on the Pancreas and now with over 10 years experience as a Consultant undertakes many of the difficult laparoscopic cases. Along with Prof Siriwardena he has published Manchester's experience in the surgical treatment of Cholangiocarcinoma (cancer of the bile duct), which is the most challenging cancer of the liver to treat, in addition to the care of patients with severe acute pancreatitis in the Annals of Surgery which is the World's highest ranked surgical journal.

Professor Sheen's main interest in HPB surgery is laparoscopic and now Robotic surgery.

In March 2011 he was awarded a 'Visiting Professorship' in the United States for his hernia expertise. He has a reputation for undertaking difficult and challenging cases as well as being a recognised laparoscopic surgeon in his field.

Professor Sheen was born and educated in London and went to medical school in Scotland. His main social interests include skiing as well as physical fitness.

 

derek o'reillyProfessor Derek O Reilly

PhD FRCS

Mr Derek O'Reilly PhD FRCS is a consultant surgeon at the Manchester Royal Infirmary, specialising in Hepatobiliary and Pancreatic (HPB) Surgery. He is the Greater Manchester Cancer HPB Pathway Clinical Director for and an Honorary Clinical Professor at the Institute of Cancer Science, University of Manchester, Manchester Academic Health Science Centre, United Kingdom.

He is an NCEPOD Clinical Coordinator and was the lead author of 'Treat the Cause'  - A review of the quality of care provided to patients treated for acute pancreatitis. He is currently a member of the National Institute for Clinical Excellence (NICE) clinical guidelines committee for pancreatic cancer.

 

nicola de ligouriMr Nicola de Liguori Carino

Mr Nicola de' Liguori Carino is Consultant General Surgeon who specialises in laparoscopic (keyhole), hepatobiliary and pancreatic (HPB) surgery. His main interests are in disease of the liver, gallbladder, biliary system and pancreas. He also has an extensive practice in hernias repairs. He completed his surgical training in Italy with a period spent at the Ohio University Hospital, Columbus, USA. Before being appointed as a Consultant in Manchester, Mr de' Liguori Carino spent 4 years training in HPB and transplant surgery at the University of Liverpool and Leeds. His unit at Manchester Royal Infirmary, University of Manchester, is one of the largest HPB unit's in the UK and Europe.

He has experience in the treatment of gallstone disease with the most modern techniques with emphasis on rapid access to treatment and recovery. Mr de' Liguori Carino performs laparoscopic cholecystectomy, laparoscopic and open hepatobiliary (liver), pancreatic and digestive surgery, including very complex liver, biliary and pancreatic resection. He also treats a consistent number of hernia cases with both laparoscopic and open approach. He is committed in liver and pancreas cancer research programs taking part in multiple ongoing clinical trials.

 

Mr Deshpande image 2Mr Rahul Deshpande

Mr Rahul Deshpande is a consultant surgeon MS, FRCS (Ed), FRCS (G. Surg) at the Manchester Royal Infirmary,specialising in Hepatobiliary and Pancreatic (HPB) Surgery.

Mr Deshpande completed his higher surgical training in London and his specialised HPB and Liver Transplant training from The King's College Hospital and The Royal Marsden Hospital. He has also completed a year's fellowship in Liver Intensive Care at the King's College Hospital. His main clinical interests are primary liver and biliary tumours.

Apart from clinical work, his other interests lie in postgraduate teaching and training. He is a member of the Higher Surgical Training Committee of Health Education Northwest and is a regular faculty member of numerous National postgraduate teaching and training courses.

 

thomas satyadasMr Thomas Satyadas

Consultant General Surgeon

UMD, DipHPB, FRCS (Ed), FRCS (Eng), FRCS (GenSurg). Qualified in 1995.

Mr Thomas Satyadas is an advanced laparoscopic surgeon with extensive subspecialty training in liver and pancreas surgery (Hepato-Pancreato-Biliary - HPB  surgery). He is one of the seven specialist liver and pancreas consultant surgeons at the Central Manchester NHS Foundation trust.

After completing his Basic Surgical Training in London, Mr Satyadas undertook a period of surgical science research at the Royal Free University Hospital, London. Following this Mr Satyadas obtained a travelling fellowship to the world-renowned European Pancreatic Cancer Centre in Heidelberg and The Liver Cancer Centre at the Virchow-Klinikum Hospital in Berlin.

Mr Satyadas completed his specialist training at the liver and pancreas surgery unit in Cambridge. From there he pursued further specialist training by obtaining the fellowship at the Liver and Pancreatic Cancer Unit at the University of Adelaide, Australia for a period of 16 months. On completion, he worked in Paris for 6 months as a Laparoscopic liver and pancreas fellow under Professor Brice Gayet (an international expert on laparoscopic liver and pancreatic surgery).

The specialist training and prestigious overseas fellowships Mr Satyadas received in the UK (London and Cambridge), Europe (Paris, Heidelberg, Berlin) and Australia has provided him with extensive experience in performing complex operations with the specialities of General Surgery and HPB Surgery.

Mr Satyadas has been trained and has excellent experience in performing repeat hepatectomies (liver resections) for colorectal liver metastases. He has also developed specialty interest in minimally invasive laparoscopic (also known as key-hole) surgery, which, when indicated, he will offer to his patients e.g. laparoscopic cholecystectomy, laparoscopic removal of bile duct stones and laparoscopic groin hernia repair and laparoscopic liver and pancreas surgery.

Mr Satyadas has a passion for surgical innovation, evidence based medicine and believes in enhanced recovery after surgery. Mr Satyadas continues to provide patient centered care, tailoring management and surgery to suit the individual patient. He receives excellent feedback from patients, which can be seen on www.iwantgreatcare.org

 

Mr Jamdars 2Mr Saurabh Jamdar

General and Hepato-Biliary Surgeon  BSc(Hons), MB ChB, MD, FRCS (Gen Surg)

Mr Jamdar graduated from the University of Manchester. He undertook his surgical training in the North West of England including a period of research studying pancreatic disease at the University of Manchester. He completed his surgical training with a fellowship at the prestigious HPB and Liver transplant unit at Addenbrooke's hospital in Cambridge.

His main clinical interests are diseases of the liver, pancreas and gallbladder. Mr Jamdar has an interest in advanced laparoscopic surgery and abdominal hernia repair. Mr Jamdar supports the principles of enhanced recovery after surgery (ERAS) and provides this evidence based care to all patients undergoing surgery.

Since completing an MD thesis at the University of Manchester as a surgical registrar Mr Jamdar has a maintained a keen interest in high quality research and is actively involved in a number of research projects related to liver, pancreas and gallbladder surgery. He is currently the local principle investigator for a large multi-centre study examining the outcomes from gallbladder surgery (The CholeS study).

 

Research

The CMFT HPB Unit is currently participating in the following NIHR portfolio studies:

PANasta: Cattall Warren versus Blumgart techniques of panreatico-jejunostomy following pancreato-duodenectomy - a double blinded multi centred trial (now closed).

ESPAC-5F: a multi-centre, prospective, randomised, feasibility Phase II trial comparing neoadjuvanttherapy to immediate surgical exploration in patients with borderline resectable pancreatic cancer.

 

Useful links:

AMMF - The Cholangiocarcinoma Charity:  www.ammf.org.uk

Cancer Research https://www.cancerresearchuk.org/

Macmillan www.macmillan.org.uk

NHS Choices: Pancreas Cancer:  http://www.nhs.uk/conditions/Cancer-of-the-pancreas/Pages/Introduction.aspx

Pancreas Cancer UK https://www.pancreaticcancer.org.uk/

Pancreas Cancer Action https://pancreaticcanceraction.org/

PBC Support: https://www.pbcfoundation.org.uk/

PSC Support:   http://www.pscsupport.org.uk/

St Anns Hospice http://stannshospice.wpengine.com/

Willow Wood http://www.willowwood.info/

Winstons Wish http://www.winstonswish.org.uk/?gclid=CMyOiKni2NICFSIL0wodPZgBgw