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Great pleasure to introduce Charles Toogood Charles, professor of HIV Surgery in Leeds.

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He was an undergraduate in Oxford at Lincoln College to his clinical training

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here and then went on to do his transplant and HPV training in Australia,

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and then was part of an innovative training programme between Oxford and Cambridge that Professor Morris had organised.

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Please see him in the audience today. Giles is a undertakes liver cancer surgery as well as liver transplantation works in

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probably one of the largest units in Europe in sheer numbers and volume of work.

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He's published over 170 peer reviewed papers, has several postgraduate fellows and PhDs and these and in fact,

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he did his DM, which is the highest medical degree at Oxford University in Oxford.

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He is currently the external examiner for the Edinburgh University Master's in Surgical Sciences.

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He is just limited as the principal external examining surgery for Oxford,

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of which we've been incredibly grateful that he's helped us maintain our standards and give us

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insightful feedback on how we could make things better for our students and maintain the degree.

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He's president of the Association of Upper GI Surgeons and continues to be active with a big NIH all multicenter research programme.

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So it gives me great pleasure to invite him to give the Burdette lecture.

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Thanks. It's lovely to be here. It's amazing to see.

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So I think the last time I stood here and spoke, probably I had about five minutes.

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Last time was about twenty six years ago.

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So I've got a little bit longer this time, but do time to stop if I thought if I go over time, so I'm going to talk a little about my background.

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Talk about some of the stuff that we we've been doing in Leeds for the last 20 odd years

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and really sort of research on future sort of blends into one towards the end of my talk.

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For me, I suppose doing medicine was a last minute decision.

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I'm not sure what I was going to do in my sick form, to be honest with you, I hadn't done biology,

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and I certainly remember coming here and going to my first tutorial in anatomy, Dr. Claudio Coelho.

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I can still remember him now. And he asked me to go up and draw a cell on the board, so I drew a circle.

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And then I drew another circle inside that circle. And he said, What's that?

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He said. I said, I said, that's the nucleus. And then he then I sort of drew a circle inside that circle.

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And I said, That's the nucleus. And I sat down, and that was the end of my knowledge of the cell.

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And then my physiology tutor was at Trinity. And my first tutorial, I was asked to write an essay on the loop of Henley.

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And as far as I could guess, that was a bypass around Henley on Thames.

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So I probably did too much of this and too little of the other.

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In my first few years here as a student, I was lucky enough to play a lot of cricket and to play a lot of rugby as well.

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I suppose the one thing I am there is that I was the only comprehensive boy amongst a

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line-up of lions and internationals playing against a pretty good club side in those days.

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But I failed my exams in the first year and I had to spend the first summer between the first and second year revising.

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And I came down to watch the end of the Test match in 1981 thinking I'd be just watching it last five 10 minutes.

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And of course,

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that's when both of them got 150 and then Willis got all those wickets and I was stuck in front of the TV all day doing no revision at all.

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So I did get a few runs, a few wickets in the media like my name and we played some.

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We played most of the test sides and that's a picture in 1994 playing against one of the great sides of all time captain Clive Lloyd,

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vice captain Sir Vivian Richards. And I think for me, towards the end of my career as a sorry, my time as a student, it was.

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It was. It was difficult decision between cricket and medicine, and certainly in those days you couldn't do both.

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But I managed to do a bit after qualifying, lucky enough to toe the mic a few times and we went to Kenya,

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we went to Namibia, we went to South East Asia,

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in India and we we actually beat them on account that beat Pakistan, playing for the minor counties down in Marlow close to here in 1992.

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And I tended to take sort of unpaid leave to do these things.

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And then once we we didn't actually beat Middlesex, but I was fluky and got a load of wickets that day, and that was good fun as well.

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But we got well being, as you can see. So my first visit to Yorkshire was not when I went up there as a consultant.

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And it wasn't to look at the beautiful Dales, as you can see there it was to do my thesis exam, the old style exam,

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and I put those two pretty dull pictures at the bottom there because the one on the left is the was the nursing home at St James's,

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at the back of St James's and. In those days, you the exam and in fact, the, you know, the sort of contract.

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Congratulations, Sherry. Sherry episode happened in there.

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Well, I wasn't in there because I failed. I was in the car park at the back of Jimmy's.

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As you can see, that's the car park in the back of Jimmy's, and it was pouring with rain now sitting on the kerb,

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feeling very sorry for myself, for my mates had the sherry to do it again.

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So my second visit to Yorkshire was as a consultant and classic NHS.

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I had no office, I had no secretary. They asked me to do one in five general surgery and a one in two transplant for liver, kidney and small bowel.

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And and I wasn't given an elective list either. My first weekend on call was pretty soon after starting.

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I left. We had we were renting a place in Wakefield, a lovely spot.

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And.

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Went in at seven o'clock on Saturday morning, and that's what we did, and I got home 10 o'clock Sunday night and Carolyn is sitting there, said Giles.

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What have you done? And we didn't have many more weekends like that.

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Fortunately, so as Ashok says, Leeds is it.

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It's a pretty active place clinically.

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We're coming up to 5000 kidney transplants in Leeds now, and we're coming up to 3000 liver transplants in our programme.

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What is interesting here on the renal programme is over the last 10 years,

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you can see that non heart beating kidneys becoming a real feature as well as live donors.

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And I know it's the very it's a very similar picture, excuse me, picture here.

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And with similar sort of size to your department here, you know, you can see Leeds there in the middle and Oxford slightly to the right,

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doing some of the numbers, which is fairly favourable compared to that one.

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It's only one or two other centres that are doing doing more as far as liver transplantation is concerned.

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We're we're a fairly large centre. We did about 180 last year.

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This is big and it just big data showing the numbers there.

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Obviously, Birmingham King's remain the busiest programmes, and if you've got a liver transplant, you've got a pretty good chance of survival.

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There's data again,

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national data showing pretty much a 95 percent one year survival after liver transplantation with a first time transplant patient at five years,

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you've got over an 80 percent chance. And again, that line shows good survival with five year survival.

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I think what I'm trying to show here is that the number of organs, you know, it's been a huge push to to to to make more organs available.

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And you can see over the last 10 years the numbers of liver transplants have gone up from in the 500s to now in the hundreds.

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And part of that is we're using these non heart beating donors, which you can see in light blue.

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But part of the reason is we're accepting incredibly marginal grafts.

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You know, this sort of thing is not uncommon now and old grafts and you know,

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and all sorts of marginal grafts that we're using far more readily than we ever did before.

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When you've got nice, beautiful graphs, you can split them, you can divide them either right and left, graphed or more commonly and more effectively.

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Excuse me. You can divide them so that you have a small left lateral graph that you can put into a PDA to a child.

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And we're one of the three paediatric centres. And then you put the large bit on the right loaded into into an adult.

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And you, first of all, you've got is you can see the difference in this liver, which is, of course,

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is just like yours in the audience here compared to the other one which was made in the pack.

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So you split the portal vein, you can see that and you split the.

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So he's the portal vein and the artery divided already and only got to the left

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now is the bile that and even cutting the bile duct when there's no blood around.

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No, no, nothing around makes you think twice and if it doesn't, you shouldn't be doing the surgery and then you divide.

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It weaves Tatsumi, obviously in the real situation in situ in vivo.

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Sorry, we were using different different instruments go through the parent coma and then you end up with two two grafts.

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Part of the problem, suddenly in the last, I've got a colleague called Steve Pollard, who some of you may have know may know he's a well known guy.

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He rarely does a bit of research,

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but he did research the other day and he looked at the fact that only six years ago we did 135 transplants and one of them started after midnight.

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Last year we did 180 transplants and 75 percent of them started after midnight.

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So the the it's a completely changed game.

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And when you're on call now, maybe it's just my age, but when you're on call now, you certainly fatty feeling it by the end of the week.

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Peter Friend is doing similar work to this. We've been trying out this, this bit of kit, which is wonderful.

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It is against everything we've ever learnt about all the organ perfusion and organ preservation where we've used cold, profuse ice and ice.

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This is warm blood pudding passing through the organ in this machine and the actual liver produces bile.

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Peters Typekit and these these these machines are fantastic because they allow

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you to identify the livers that are going to work so you marginal grass,

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which I've already talked about, you can identify those. But the other great thing I think personally on a very selfish point of view is it may mean

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we might all get a bit more sleep because they stay on these machines for several hours.

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So you can come in at eight o'clock and to get transplant rather than start at three in the morning.

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Live donor organ transplantation,

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I think Leicester were the first wave of the second to do laparoscopic live kidney transplantation, a great friend of David's here.

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Adrian Joyce and I did the first live laparoscopic kidney donation in 2004.

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It was pretty stupid. We had the BBC in filming it live and it was the first one we'd ever done.

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I call that naive. It went okay, fortunately.

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And then in 2007, we did the first NHS Live Liver Donor transplant, and we've now done over 80 of these and have the biggest practise in this country.

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But it's nothing compared to what's going on in the Far East, where places like Seoul now have done over 1500 2000 of these things.

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It was an exciting thing to do. You know, when you become a consultant, you suddenly start operating on, you only rarely operate with colleagues.

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So, you know, to some extent you have extremely fast learning curve.

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But on the other hand, you just kind of teaching yourself,

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you're not learning from operating with other people who are going to necessarily influence you.

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And the great thing about doing this was that we started operating as teams and we started

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operating colleagues and Pete Large and I did the first donor and the recipient team.

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Equally important, worked together through through these first sort of 10 20 cases, but it was a major undertaking.

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You know, finding extra theatres in our hospitals is not easy.

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Same old simultaneously operating is not easy. They need huge amounts of work up and it takes a lot of time.

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This is our first case in June of 2007, where our son gave his his right lobe to his father.

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We we do seats on our donors and we send the software.

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We send the C.T. off to a place in Germany called Mavis Software Company, and we get these wonderful pictures back 3-D and 2-D.

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And they, you know, they kind of show you where to cut, really. So it makes it very easy.

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But here's the portal vein. This is 2D, but you can fiddle them around and look at them in 3-D as well.

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You get pictures of the Apache Khatri, and perhaps most importantly,

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you get these lovely pictures of the three hepatic veins draining the liver, including the middle vein.

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And most of us who work in liver surgery will say that if God had been liver surgeon, he would not have invented the middle vein.

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So the middle vein is is sometimes difficult to deal with in broad pop figures.

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We get an estimate of the graft size, depending on what type of.

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So when we send these sets off to us, we we tell them what we're planning.

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And they give us an estimated growth weight. And what you're looking for is a graft to recipient ratio weight of over 0.8.

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So this particular example, this first case we did was well over. That is one point one seven.

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So that was safe. And then the other thing you want to be sure about is that the liver you're leaving behind is enough for the donor.

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And we tried to keep it over 30 percent, and again, that was 36 percent.

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So that was that was again going to be safe. We're really high tech in leads and, you know,

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we say we put all these pictures on our high tech computer on the side of the theatre before we started.

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And then, you know, we've it's I mean, it's it's scary and that's a scary surgery, but it's beautiful anatomy.

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So you know, the artery in the portal vein slung that right hepatic vein at the back there,

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and you can see the caver for those of you who aren't familiar with this part of the world.

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And then we would we'd probably use ultrasound to identify where the middle hepatic vein is and then divide the parent comment.

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And all we left with here is the bar that in that lock there.

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And again, that's when you tighten your sphincter and cut the bile duct.

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And often we use cleanser grams to identify exactly where we are before we actually get your knife out and cut it.

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So then you ended up with a with a graft and you profuse it like we kind of do already on the bench.

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And then sometimes we have these going back to the middle vein.

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You have the middle veins sort of passing down in between the right and the left lobe.

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But you have these big branches, we call them the five and the eight going into part of the right lobe.

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And the problem is that the dissection line is here.

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So you're got these parts of the liver are going to lose their their drainage.

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So what you get and this is in a donor is, is you get you can get if you're not careful, these sort of badly perfused, badly drained.

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And if you clamp V8 and the right paddick artery, you can you see where the patches are?

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And again, V5 and the Rods podcast, you take the tip right at the artery because then you get the if you if you left the artery flowing,

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you wouldn't see these, these demarcations. And then when you clamp both of them on the right after you see what area of the liver you wouldn't have,

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well, profuse once you put it into the into the recipient.

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So what we do is we reconstruct those small vessels and in simple terms,

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if you come across those vessels as you do the transaction, if they are greater than about four a.m., you would reconstruct them.

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And if they're less than that sort of size, you probably wouldn't bother.

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The interesting thing is, these orders from those are fairly soon after you've done the transplant, actually.

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So it's to get it's to get them over the sort of first few days over the first week with with with the liver function and you on the bench,

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you'll do these various types of reconstruction. These middle vein branches off the right lobe onto the caver, as I've shown.

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And there you are, there's the there's a v five conduit and there's the portal vein being done.

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The back was already done in the anterior, which was just about to be done.

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But even when you've got them confusing and they are, you can see the camps are all off now.

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You've got the veins running, you can. You still see you do see this patchy reperfusion on occasion despite those efforts, so you don't do the artery.

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And these are some of the early examples of of the of of the of the couples we we we transplanted or did very well.

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So liver cancer and liver resections in most of the units in this country, most of our work and I'm sure it's the same as I hear in his team here.

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It's colorectal cancer, but clearly their primary cancers and other benign conditions that we deal with as well.

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In Leeds, we've now done nearly 5000 liver resections.

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I arrived here. Pete was already doing them.

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Pete Lodge was probably one of the few guys in the country doing the liver resections that time, and we're now doing sort of 250 300 a year.

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And there are about six of us doing it now with at least four all day lists every every week.

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I mean, and that's a big number, and it's probably the biggest in the country. But I mean, I had a meeting earlier this year.

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We have some Chinese guests and they do four thousand a year.

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Unbelievable. In Shanghai. And that's that's what I call big numbers.

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Four thousand a year with about nine theatres all going, doing lots of sex, of course, and fibrotic and sclerotic livers.

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And they're very brave. So colorectal cancer is a big problem in this in many western worlds.

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And we like to think that the people who get liver disease, which is about half of those patients,

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probably 10 to 15 percent of them, will be amenable to liver resection and potential cure.

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What is still amazing in a, you know, in a in a in a organised,

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western civilised world that we live in is the variation in the country of who's going to get a liver resection because of that colorectal cancer.

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So we happen to be here. I mean, I think it's just historically we've been doing it longer than other places.

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And this is clearly data from a few years ago now.

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But I know this sort of variation does still exist because even Morris and others in Leeds have looked at this again more recently.

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But you know, there's a bit of a postcode lottery going on.

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Still, your likelihood of getting liver surgery for colorectal cancer varies even in a place like the UK.

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So what is survival? This is one of our papers that we published with Basingstoke, which is probably the other big centre in the country of race.

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And you can see that, you know, five year survival 40 percent and there still be cynics out there who say,

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Well, it's all about biology, and these people will probably done well anyway.

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Who despite you doing a liver section? Well, I would argue that the ten year survivors.

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Surely that has to be due to surgery. You know, chemotherapy is rarely curing these people.

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I've got I've got one example. I can think of one example in my whole career who has been, I think, cured by chemotherapy, but they're rare.

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So I think ten year survival, but just about to publish exactly on this.

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This topic actually does give you a real indication of feeling of cure and because of surgery.

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We've published a lot on there's a huge dogma about margins, is we all anyone who does any type of cancer surgery?

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We ought to always talk about margins and the dogma for years and years and years was that you needed a centimetre margin,

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excuse me, in liver surgery to do any good at all.

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That is not the case. You just have to have a margin. You know, it's better not to be positive.

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But even so. Patients who wear you get back in the histology, it says positive margin.

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You've got to remember the kooser, which a lot of issues is an instrument that probably takes out about two mil of tissue,

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as you do to actually do the resection. So there's still what matters is what's in the patient, not what's not to know what's on the bench.

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And then if you use argon or something else like that, you've probably got yet another middle of tissue that you've destroyed.

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So there's probably even with the sort of so-called positive margin on the histology report,

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there is still at least three millimetres of of of margin in those patients and the recurrence that you see.

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And we have published on this as well. The recurrence that you see is rarely actually on the surface.

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It's it's it's actually in other parts of the liver and they've just got bad disease.

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So for those of you who aren't familiar about this, the anatomy, I just thought I'd show a quick video of a speedy right.

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How many have attacked me? This is the pace we do it in leads.

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So that was just a bit of rubbish. That's the right Patty Khatri conclusion.

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The. I think that's the right, the right portal vein, so here's the port main portal vein.

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This is the right portal vein. So. Take out the artery, snake down the snake down the portal vein, you see the demarcation line there.

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I love these guns. I keep my car is reasonably clear.

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I had to buy the porcupine. That's the right kind of thing going on.

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Lift up onto the liver so you don't get a narrowing of the quiver.

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And then I use I still use the kooser. Call me old fashioned, but I use the kooser.

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It's a wonderful instrument. You can use it fairly quickly, identify vessels.

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But. And that's that's kind of all there is to it. They.

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So and then you end up with that, you know, it's bit like Blue Peter's, you know, something I prepared earlier.

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So these patients, you can do two or three of these in a day.

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You know, I'm going to show bit of laparoscopic surgery in a minute.

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You know, I, you know, that takes three quarters of a day to do one of those if you've got the patients and then you convert at three o'clock.

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So. I still think there's a place for open surgery and in the liver, if you get lung mass, you still do pretty well.

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You still got a survival of 50 percent at three or four years.

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And the thoracic guys are great at doing these, often minimally invasively,

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even if you present with pulmonary and IMPATTO Mets and you're able to reset both.

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Again, we've just published this. You've got a good survival.

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Clearly, if you don't go on to do the second part of the operation, they do badly,

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but they're not people who you should give up on, redo liver resections.

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We scan these people every six months for two years and then every year for at least five, sometimes seven years.

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And it's worth doing the scans because it's worth something it's worth doing about it if they're operable.

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And my what I say to patients in theatre,

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if you need a second liver S. Your chances of survival the same now as they were for the first liver resection.

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They do well. So I think I mean, I remember doing one of my first liver sections here in about nineteen ninety something six.

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And I was talking with Julie in Britain, and I can't remember the easiest name,

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and I wouldn't mention it because it would be embarrassing, but he obviously thought we were going to lose lots of blood.

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So he filled the patient up with at least three litres of crystal before we started.

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And funnily enough, we lost that probably about 12 units, just doing a straightforward right Hemi.

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So there have been massive advances, and I think really the most important advance in liver surgery is this line here.

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And in keeping that CV pairs as low as possible, if the blood pressure goes down during the operation,

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you don't get fluids, you give you give on a trip. But all these things in surgery are hugely important to stage operations.

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Port Vein embolisation We're doing more and more of I don't know what you guys are doing here.

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We're doing more and more of this. And almost a right hemi with a with an elderly patient would just send them off the port of Aden embolisation now,

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and we're rarely seeing any degree of liver, liver, liver failure post-op now.

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So it's amazingly rare.

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I mean, I can remember patients who would stick with him with Billy Ribbons of six 700 four weeks after an operation that finally went home with it.

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But they would they would get real cold, Stacy's post-op. And we just do not see that now.

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And I think it's because of a liberal use of port vein embolisation where you get this sized liver so that size liver before you start.

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And clearly, chemotherapy is a common, you know, it's a team effort. It's surgery and chemo that allows us to get these patients such good results.

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And basically the inoperable cases of neoadjuvant treatment getting you to this sort of thing, this sort of thing to this sort of thing.

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And suddenly they become potentially operable candidates.

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The pitfalls of chemo, you can get these sorts of levels with still had to stay inside hepatitis and big fatty livers.

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And this problem we all have of disappearing lesion.

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What to do about the disappearing lesion when you cut your grass? None of us have got perfect grass, but home other than the.

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Oxford colleges, of course, but you know, you cut you cut that and you think you've sorted it.

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Well, you haven't because this is one of those that underneath.

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And you know, you can't see these disappearing lesions,

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but they 50 percent of the time they will come back and liver is amazing because it regenerates, you know, right?

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Hemi, there becomes so that but that is this is the same patient three six months later that becomes that.

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And what you've got to produce that is all these growth hormones.

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We don't know really what they are, but you get this amazing hypertrophy of hyperplasia.

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I should be is the correct terminology. And you get these growth hormones released and.

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That causes problems sometimes, and that's saddening things sometimes when you see that with the early scans,

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and it's because there are cells left behind tumour cells and that you get it,

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you get a sort of rapid response of the tumour cells, which are responding to these growth hormones that are released because of the hypertrophy.

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So that's when you do need weed killer. You need chemotherapy. So what about prognostic factors?

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You know, that's thousands of papers on prognostic factors.

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I keep saying to our guys in these in our trainings, you come through our unit, picked the right horse.

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It's all about picking the right horse, even someone with terrible prostate prognostic factors, if their age,

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you know, if they're young and fit, you're going to go for it because it's still a chance they might come through.

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But there's there's lots of prognostic factors, and I'm not going to go through those we've got.

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We published one which is all about inflammatory response to CERP and the the neutrophil, the lymphocyte ratio and which showed.

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Sure. If you're if you've got a pre-op, if you've got an inflammatory response, a low inflammatory response score,

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you did a lot better than if you had a high rate inflammatory response score.

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But actually, you know, I think the most useful thing about CRP and it's the only blood test I look at post-op,

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so I do a big liver resection on Thursday. The only blood test I want to know on the Friday or Saturday is the CERP.

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And to see our over 30 I can, I'm happy.

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So I don't know that I'm happy because if there's enough liver left behind to give you a copy post-op, they'll do fine.

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They will not get liver failure.

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But if they get complications after liver surgery, they do a lot worse, their overall survival is a lot worse than if they don't get complications.

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That kind of fits in what we would all instinctively think, but wish we showed that Pringle manoeuvre when none of us like losing blood.

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And I'm fairly liberal with a Pringle, which is a clamping technique of the inflow of the liver.

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When you're doing the cross section and we've shown there's no there's no, you know, there's no problem in doing that.

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You're not compromising the liver. The overall survival is just as good.

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So I mentioned that periscopic surgery, I think it's absolutely superb for left sided lesions where you've got often say, say,

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say, say, some of these primary adenomas and young women, for example, it's perfect solitary lesions in the left lateral lobe.

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You can do these operations reasonably quickly and certainly no slower, really, than an open procedure.

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And I certainly have a different view about these than doing the right sided resections.

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And you know, I think it's fair to say that even the pioneers now of right sided surgery are backing off on doing right side of dissections.

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There are few that feel mavericks out there who are still doing them.

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Now, this is the Pringle laparoscopically, so it's a tight this is the gall bladder.

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This is the liver lifted up and it's a sling around the inflow subdivided.

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The lesser mentioned there come up round the frame and Winslow and the clamp is outside the body, so you've got complete control.

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Here's the sort of it looks like the old Concorde accuse a laparoscopic kooser.

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There are lots of other instruments you can use. I tend to use the kooser even laparoscopically.

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And then once you've thinned out the the tissue, you can then come in with a with a clamp.

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I don't know why it's sticking. I'm sorry, guys.

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But again, the kooser will sort of take you to where these blood vessels are, liver surgery's pretty straightforward.

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It just all the kit does it. It just does it for you, really. And then you can come in with a clipper kit, the vessels.

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I should say this one, I like the one. And then you can come in once you get down to the high, the plate that you can see the hot plate down,

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the influence of the bar that's in the artery and portal vein on be there and come in with the chopper.

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And there are guys, you know, I mean, colleagues, you'll see videos like this where they just come in and do jump front right from the start.

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It's probably a bit quicker, but it's a bit messier. And then you put them, put it in its bag and take it out.

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But in contrast to that is this sort of case where you have got.

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So we're coming down onto the liver, this huge tumour involving outflow up against the left panic button,

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so it's taken out of middle and left and then inflow as well. And with these sorts of cases,

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we've done a reasonable number now of what we call in such hypothermic perfusion where they all bypass that we use for transplants regularly.

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We don't use this anymore.

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Now where you have, you can divert the portal vein blood flow and the Caven back to the heart and isolate the liver and cool it down.

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And then do you and then do your transaction?

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And this is a short example of that, this is a huge HCC.

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And you can see as a fit this up, it was. Densely adherent to the Navy SEAL Royal Air that took an hour, I think, to just mobilise that level.

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It was completely stuck to the diaphragm and then the anaesthetist preoperatively will put the lines in, to be absolutely honest.

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You usually don't need the cable line now, and the portal flow is is probably enough.

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It's I always find it amazing how quickly these patients actually recover from this, you think they perhaps wouldn't, but they they do.

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So this cannula here, so the portal faces the portal vein in here, one cannula is down into the portal vein and you've already got him on bypass.

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So this is blood coming. So blood's coming up the portal vein down here, back to the pump and then back to the to the neck.

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And then I'm about to up up the other way into the liver.

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Put another cannula. Which will all use to call the liver down.

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And then and then open the cave at the back to vent, to vent the blood out so that you empty the liver of of blood.

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And then the transaction actually is very straightforward, and I haven't shown you that, but it's very straightforward.

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The fun starts, there's the clump at the top and you've obviously got a clamp at the bottom and the cable.

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Here's the caper and the fun starts when you take the clamps off and it does get a bit wet.

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And you just have to do a bit of sewing and be patient and put a pack on it and go somewhere else.

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Have a coffee. So this is another good example,

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is a lady who had a big new year and the consumer she'd been turned down about five years before came to us and we did the same sort of thing.

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Huge, huge mess. But again, we did vascular isolation, called it down and took it out.

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I don't know whether it's going to come across and maybe, but I don't have any.

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There aren't many junior people here, so I'm probably talking out of turn,

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but I think one of the most important things in theatre generally is to create an atmosphere that people can say something.

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You know, they're not afraid to say something because often the person at the back,

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most junior person is actually the person who spot something that you're doing stupidly,

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and they need to be allowed to say something if that's what they feel.

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And you can't hear this, but there's music going on.

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Bit of Phil Collins. I was trying to get the noise working, whereas that's during that case that you could say it's a big lump.

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There's a gall bladder over here, whereas this one, we're doing something pretty serious and we do turn the music off and it's all quiet.

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And I think when when I go to the theatre and it's quiet, there must be something serious going on.

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So that's the clamp being put on the top before we call down the liver.

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So in summary, on that sort of surgery, I think ultimately biology's is the winner.

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We still have survivors with poor prognostic groups.

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So, you know, show you need to think about prognostic indicators, but sometimes you just have to ignore them.

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There are all sorts of things we're doing now, and I mentioned vaccinations in a minute and trials,

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but it still remains to a large extent and not and not a science.

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Just a quick mention about the Trangie carcinoma. We do, we do.

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We do a lot of these and we've we've compared our data with some one of the Japanese groups.

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We do all right. We don't do as many as them. That's probably one year's work for them, whereas this might be, you know, five years work for us.

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But you know, Hala, cholangiocarcinoma is now a patients do pretty well.

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So I'm just going to add on to move on to the future now and some of the things we've been looking at.

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I hope you're all taking your fish oil, fish oil we've been working on.

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I've been working with a guy called Mark Hose, Professor of Gastroenterology in Leeds now for about 15 20 years and.

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It works through Cox two modulation, and it reduces the pro-inflammatory effects of prostaglandins,

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and it has lots of effects, which I'm sure you know about, we've shown that it reduces the number of polyps in the colon.

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And a few years ago, we showed in this small, randomised trial where we were looking for angiogenic a laboratory type changes.

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Inadvertently, we saw this difference in survival. These are patients who've undergone liver surgery for colorectal cancer that the

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guys that took the EPA took the omega three took the fish oil were surviving.

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This wasn't statistically significant, of course, better than the placebo group.

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So we've now got a big randomised trial, got a couple of million quid to to look at this.

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I'm hoping Oxford will come into this as well.

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And basically, we're looking at about 500 patients and we're giving them either omega three or placebo over a three year period,

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rather than just a two week period that affect you. So it was just over a two week period.

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That's quite exciting. The problem is that people are hearing more about fish oil and that the only resistance you have to people

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getting this trial because they only want to take the fish oil when they go to the shops and buy the fish oil.

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This is this is this is exciting. This is under the leadership of David, Jane and Leeds.

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We are now the sort of medtech technologies and nature centre for the UK.

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We had this meeting this week in Leeds. We're talking about apps,

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we're talking about that you can do laparoscopic surgery without gas and that's

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particularly helpful for underdeveloped countries where getting gas is really difficult.

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We're talking about 3D ultrasound, we're talking about amazing laser kit.

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We've got all these companies coming to Leeds now looking for ideas, but this is really for everybody, not for just Leeds.

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It's and we had this wonderful meeting where, you know, we had about certainly had about 15 liver surgeons came because we've got a theme of HBP,

373
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we've got a theme of colorectal and we've got a theme of vascular led by Julien Scott.

374
00:41:40,280 --> 00:41:45,080
That nanotechnology is probably the smallest bit of technology we're dealing with in Leeds,

375
00:41:45,080 --> 00:41:50,270
and viruses are probably the nature's self-replicating nanoparticle.

376
00:41:50,270 --> 00:41:55,160
And we did this trial, which is published in Science Translational Medicine a few years ago,

377
00:41:55,160 --> 00:42:00,260
showing that we could get of virus in these colorectal cancer liver patients.

378
00:42:00,260 --> 00:42:06,740
So we were detecting these in the tumour cells, which is very exciting and in vitro game with fluorescence.

379
00:42:06,740 --> 00:42:14,480
We showed that the virus is the rare virus was getting into the cells and killing cells at about three or four days.

380
00:42:14,480 --> 00:42:19,670
We've also shown with coxsackievirus, there's the direct and indirect way of killing tumour cells.

381
00:42:19,670 --> 00:42:30,560
We know that can the colon cancer cells have an increased ikem on their surface and that's shown here with these different cell lines.

382
00:42:30,560 --> 00:42:33,020
And then we've shown that with irradiation.

383
00:42:33,020 --> 00:42:43,850
So a combination of radiotherapy and and virus treatment, the more you irradiate the cells, the more I come as expressed.

384
00:42:43,850 --> 00:42:49,250
And therefore, with your virus, you get more killing, the more radiation they've had.

385
00:42:49,250 --> 00:42:58,900
So the combination of irradiation and virus that is increasing cell death of these cancer colorectal cancer cells.

386
00:42:58,900 --> 00:43:02,560
We've been looking at fluorescence with ICG.

387
00:43:02,560 --> 00:43:10,720
We all know about HPV in general, surgeons know about this sort of carlos triangle and the fear of the bile duct and all the rest of it.

388
00:43:10,720 --> 00:43:19,960
And one of the things we try to do is see if this would help, particularly with an acute cities.

389
00:43:19,960 --> 00:43:27,390
Someone with, you know, lots of inflammation and see if that would.

390
00:43:27,390 --> 00:43:34,500
So it's just so so you can inject this this stuff literally in the anaesthetic room and then look at that.

391
00:43:34,500 --> 00:43:38,730
I mean, it just shows up. It just is a roadmap for you. That's about it.

392
00:43:38,730 --> 00:43:43,650
Thank you very much. This is a typical Yorkshire patient. Nice and thin.

393
00:43:43,650 --> 00:43:50,460
No fat anywhere. The trouble is, we've now tried it on several acute patients because of course, I'm joking.

394
00:43:50,460 --> 00:43:54,410
And the penetrance of this stuff is very low.

395
00:43:54,410 --> 00:43:58,710
It's only like five mil. So it doesn't really help if I'm honest with you.

396
00:43:58,710 --> 00:44:07,080
But it's a nice video, isn't it? And it shows you nice pictures so sticky on the gallbladder theme and finishing up.

397
00:44:07,080 --> 00:44:13,110
This is going to occupy me for the next five years. I can't see myself having much time to do anything else.

398
00:44:13,110 --> 00:44:23,330
This is a four and a half million pound grant from NIH to look at the role of animal sleep in our regular, you know, gallbladder patients.

399
00:44:23,330 --> 00:44:29,750
So we're doing 70000 of these in the country and.

400
00:44:29,750 --> 00:44:39,710
I think there's, you know, I'm someone who's done a aynsley done operative transgressions for the last 30 years and I've stopped.

401
00:44:39,710 --> 00:44:49,820
So there you go because I think there is the Kolya study, which was thanks to our registrars in this country, they're becoming a real force.

402
00:44:49,820 --> 00:44:53,840
The surgical registrars in trials at the moment are fantastic.

403
00:44:53,840 --> 00:45:03,080
But the study was published a few years ago in the BJS, and it showed then that 26 percent of people who got gallstones are getting in Mississippi.

404
00:45:03,080 --> 00:45:07,370
Twenty six per cent and each going to speak to your radiology department here and

405
00:45:07,370 --> 00:45:13,130
they'll tell you that's going up and up and up and I don't know is in this hospital.

406
00:45:13,130 --> 00:45:17,660
So I think it's probably about a third of patients now includes your punter

407
00:45:17,660 --> 00:45:23,030
who's coming from the GP with normal lefty's 14 percent in the Kolya study.

408
00:45:23,030 --> 00:45:28,400
Of those patients were getting MLC pace. So how can we avoid creep?

409
00:45:28,400 --> 00:45:35,510
We can't. Do we really know what's happening to these bardach stands that are shown on MRC?

410
00:45:35,510 --> 00:45:38,870
Do we know which stones are the ones that are going to cause the problems or not?

411
00:45:38,870 --> 00:45:43,460
No, we don't. We're all paranoid HPV surgeons, general surgeons.

412
00:45:43,460 --> 00:45:47,990
We're all paranoid about duct stones. We're defensive.

413
00:45:47,990 --> 00:45:52,640
We think that if we miss about a stone, someone comes back in and gets pancreatitis.

414
00:45:52,640 --> 00:46:00,300
We're going to be sued. We're going to end up in court. And I'll have to be honest, that's kind of how I thought for many years.

415
00:46:00,300 --> 00:46:05,870
And no one in this country likes doing eight, six, seven percent patients in this country getting out.

416
00:46:05,870 --> 00:46:09,510
So you go to Brisbane. Ninety five percent, you go to Scandinavia.

417
00:46:09,510 --> 00:46:19,740
Ninety five percent, but pretty much everywhere else in the world, it's down to the sort of level we have in the UK.

418
00:46:19,740 --> 00:46:24,210
So I suspect we're over investigating Stones, I think was certainly over treating them.

419
00:46:24,210 --> 00:46:26,420
We do not know which are the ones that caused the problem.

420
00:46:26,420 --> 00:46:32,340
So I think there is what we call genuine equipoise and this is all new terminology for me being a thick surgeon.

421
00:46:32,340 --> 00:46:36,420
So this is your typical sort of patient is probably going to come in today.

422
00:46:36,420 --> 00:46:40,500
50 year old lady with an ultrasound. She comes in, she has an ultrasound.

423
00:46:40,500 --> 00:46:48,060
She's got about up to seven mm. She got stones in a gall bladder in Nigeria lefty's, and she will get one of those.

424
00:46:48,060 --> 00:46:58,110
I promise you. And now the big tragedy would be that there's a flack on the MRC pay, and so they then go for an NAACP.

425
00:46:58,110 --> 00:47:04,920
They then get pancreatitis and stay in hospital for six weeks. And the LCP was normal, by the way.

426
00:47:04,920 --> 00:47:06,540
So the risks to the most.

427
00:47:06,540 --> 00:47:14,040
So what we're going to do is this trial, which show the second of 13000 patients very optimistic, I know, but that's ambitious.

428
00:47:14,040 --> 00:47:23,070
I know that's what we're going for. 50 50 hospitals in the UK.

429
00:47:23,070 --> 00:47:28,890
And we're going to put them either into an MCP group or two straight to the only group that will be a third.

430
00:47:28,890 --> 00:47:36,000
This will be two thirds. And that's because financially it will be much the same balance what it is now.

431
00:47:36,000 --> 00:47:42,360
So there won't be an extra cost of radiology. The risk to the MCP group is that they we over treat.

432
00:47:42,360 --> 00:47:48,570
They go three ACP and we we they get complications from their ACP.

433
00:47:48,570 --> 00:47:54,300
The advantages we find biotech stones in the LC group, the straight to that priority group.

434
00:47:54,300 --> 00:48:02,760
The risks is that we're missing that stones that then represent down the line and the advantages they get on with their operation,

435
00:48:02,760 --> 00:48:07,950
and they probably have a quicker patient pathway. So the primary outcomes is going to be complex.

436
00:48:07,950 --> 00:48:15,760
But and a group of primary outcomes, really any complications of those things I've just talked about,

437
00:48:15,760 --> 00:48:20,280
we're going to look at quality of life and economics as well. But this is just how it's going to look.

438
00:48:20,280 --> 00:48:28,890
We got basically a third two thirds MCP no MCP class angiograms are not allowed intraoperative cleanse gram.

439
00:48:28,890 --> 00:48:35,310
Intraoperative ultrasound is not allowed other than if you're worried about anatomy, which is obviously fine.

440
00:48:35,310 --> 00:48:41,850
And the other patients who can have that in the patients on MRC Pay, you have about that stone, and that's how you normally treat them.

441
00:48:41,850 --> 00:48:46,530
If they get a MCP and they've got a viaduct stone. Most people would send them off for iOS pay,

442
00:48:46,530 --> 00:48:56,940
but there are a few places which will do operative exploration and removal of the stones laparoscopically.

443
00:48:56,940 --> 00:49:01,230
I think this is probably the future. I probably won't be doing it.

444
00:49:01,230 --> 00:49:05,880
Certainly liver surgery, I don't think it's really got its place yet.

445
00:49:05,880 --> 00:49:15,750
There is a few, a few guys in Italy and other places in the world who are doing lots of this, obviously in other areas.

446
00:49:15,750 --> 00:49:22,320
It's it's it's happening and it's going to happen. You know, we're all going to be doing these operations in our offices.

447
00:49:22,320 --> 00:49:29,400
You know, maybe on holiday we can do operations. I don't know. But it's it's amazing how exciting all this is, is and I'll be.

448
00:49:29,400 --> 00:49:30,870
I'll certainly be watching with interest,

449
00:49:30,870 --> 00:49:38,280
but I can't imagine I'll be doing this because I don't think it's going to happen in the surgery for a while.

450
00:49:38,280 --> 00:49:41,190
I'm going to finish off by that.

451
00:49:41,190 --> 00:49:49,290
These are one of the things I'm probably most proud of, despite everything I've said is is the number of people we've trained in Leeds.

452
00:49:49,290 --> 00:49:55,110
At one point, we had probably trained between a third and a half of all the liver surgeons in Leeds,

453
00:49:55,110 --> 00:50:01,230
and they've gone through all these different places and around the world. We've got a big contract with Australia.

454
00:50:01,230 --> 00:50:06,960
We now get a training from Australia every year on the whole.

455
00:50:06,960 --> 00:50:16,020
Pretty damn good. Most of the time, professor.

456
00:50:16,020 --> 00:50:22,990
And as I always say to my juniors, you know, work is always go, OK, if if it's OK at home.

457
00:50:22,990 --> 00:50:31,150
It's a team game as well. This is Steve Pollard who I mentioned earlier, this is a guy called Ernest Hidalgo's psychos faster than I can drive a car.

458
00:50:31,150 --> 00:50:34,330
But it's a massive team effort, isn't it? All the fields we all work in?

459
00:50:34,330 --> 00:50:38,230
It's a massive team effort. There's huge people, they these people.

460
00:50:38,230 --> 00:50:45,940
I did when I was on a course the other day doing some live surgery in a in another hospital.

461
00:50:45,940 --> 00:50:54,910
And it makes you realise how much you rely on your own, your own environment and the people you work with.

462
00:50:54,910 --> 00:50:59,830
Every week you put your hand out, they'll give you the instrument you want.

463
00:50:59,830 --> 00:51:05,140
I arrived in this hospital to do straightforward lap coley, and I didn't even have a shot.

464
00:51:05,140 --> 00:51:12,640
Anyway, you know is it makes you realise how much you should appreciate these people.

465
00:51:12,640 --> 00:51:19,510
So I'm going to finish with this, this. This was nineteen eighty four.

466
00:51:19,510 --> 00:51:28,240
Gordon Greenwich, Desmond Hinds out in the batting. Clive Lloyd, Viv Richards, Courtney Walsh, Malcolm Marshall.

467
00:51:28,240 --> 00:51:38,260
Not a bad team. And we drew actually complete only because it was two days and we didn't have time to get us out the second time.

468
00:51:38,260 --> 00:51:42,670
But you know, here in Oxford, you're surrounded by amazing people.

469
00:51:42,670 --> 00:51:52,440
And I think in Leeds we've got some pretty good people as well. So I've read a bit about Walter Bird and thank you to him.

470
00:51:52,440 --> 00:51:57,090
I couldn't work out whether he actually is American or English or whether he worked here.

471
00:51:57,090 --> 00:52:01,020
I know he's a thoracic surgeon. But thank you to him and his family.

472
00:52:01,020 --> 00:52:08,880
And thanks for listening. Thanks a lot.