Innovation, expertise and precision in the treatment of disorders of the liver, pancreas and bile ducts.
The management of patients with malignant and complex benign conditions demands a multidisciplinary approach. Given the diversity of diseases affecting the liver, biliary system, and pancreas, a variety of treatment modalities are available that are tailored to the individual needs of each patient. A team of experts including a hepatobiliary surgeon, a diagnostic radiologist, an interventional radiologist, an oncologist, a pathologist, and a gastroenterologist collaborate to determine the best course of treatment for each patient. We believe that arriving at a consensus regarding the most appropriate treatment plan for each patient is vital to achieving the best possible treatment outcomes.
The regular use of intraoperative ultrasound allows for the detection of tumour lesions that were not confirmed by preoperative visualization diagnostics. Intraoperative ultrasound is applied by every member of the surgical team to ensure accurate visualization of the relationship between the tumour and the vascular structures in the liver, as well as to plan the type of resection.
The use of intraoperative ultrasound in liver surgery was introduced into clinical practice in the 1980s and is now of significant importance. This method is completely safe and does not cause any adverse effects on the patient. In modern liver surgery, the application of intraoperative ultrasound is crucial for precise, ultrasound-guided resections of the liver. With routine use of intraoperative ultrasound, small tumour changes deep in the liver parenchyma can be treated by ablation, which involves the thermal destruction of malignant tissue. Each member of the surgical team is skilled in the application of intraoperative ultrasound, which ensures a precise assessment of the progression of the tumour process in the liver and enables the planning of the type of resection.
In order to perform any surgical treatment, such as liver transplantation or resection, a thorough knowledge of the liver’s anatomy is necessary. The preoperative CT scan provides fundamental information on the liver’s structure and the location of any tumours. Although CT scans can provide details such as the size, location, and number of tumour nodules, as well as the main blood arteries anatomy in the liver, it is vital to know the precise interactions between them to determine the type and extent of resection required. Therefore, preoperative 3D visualisation or simulation, generated using specialised software, is necessary. By building a preoperative 3D model, we can identify the boundaries between the vascular territories in the liver, which is crucial in determining the volume of certain liver sections. As a result, the surgeon can plan the optimal surgical intervention for each patient and significantly reduce intraoperative and postoperative complications by performing a virtual liver resection based on its actual anatomy in the designated 3D model.
Surgical removal is the only treatment that still has the potential to cure primary and metastatic liver cancers. Advanced liver cancers that affect both lobes can now be treated with a two-stage procedure. During the first stage, the tumour is excised from the part of the liver that will continue to function after the procedure but has insufficient volume to do so. In such cases, a branch of the portal vein is obstructed (portal vein embolization) to encourage the remaining portion of the liver to hypertrophy (expand in volume). The second procedure involves removing the diseased portion of the liver, which is done between the second and sixth weeks following the first procedure. Two methods are available for this: portal vein occlusion and the ALPPS technique.
In addition to standard percutaneous biopsies of tumours guided by ultrasound or CT scan, our programme includes percutaneous biliary drainage as a definitive therapy for malignant obstruction or as a preoperative intervention to drain bile and help the patient to recover before surgery. Portal vein embolization is performed during the two-stage hepatectomy. Transarterial embolization (TAE) and transarterial chemoembolization (TACE) are used to reduce tumours volume and potentially make previously inoperable patients into operable, or as a palliative treatment for multinodular tumours, especially hepatocellular carcinoma, cholangiocellular carcinoma, and metastatic tumours in various locations.
At our centre, we offer diagnostic and interventional endoscopic ultrasound, a minimally invasive endoscopic procedure that allows for a comprehensive assessment of all gastrointestinal system changes and biopsies of the liver, pancreas, and lymph nodes tumour abnormalities. By using endoscopic ultrasound we can also drain bile ducts and the gallbladder in inoperable patients, as well as treat certain surgical complications and perform gastro-entero-anastomosis for palliative purposes in incurable patients, with high success rates and minimal complications.
Our experienced specialists also perform a complex diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP), which examines the bile ducts for existing calculi and allows for biopsies of benign and malignant tumour bridging bile duct strictures.
Both procedures are well-supported by operative treatment, allowing for the greatest benefit to patients with minimal invasiveness, and close collaboration between surgeons and interventional endoscopists is an integral part of our clinic’s daily routine.
As part of our multidisciplinary team, our expert oncologist coordinates the administration of systemic therapy. Preoperative chemotherapy is used to treat micrometastatic illness, improve long-term treatment outcomes, and reduce the size of tumours in some individuals. The combination of chemotherapy and biological therapy may allow for radical surgery and the complete eradication of the malignant disease.
Systemic therapy is essential for advanced primary liver cancer, characterized by extrahepatic metastases or microscopic invasion of blood vessels, as it can improve quality of life and extend survival time.
Our team of surgeons specialises in a wide range of resection procedures on the liver and pancreas, including complex operations with excellent results that are comparable to those achieved by reference centres around the world. Led by Professor Vladimir Dugalić, an experienced surgical team performs extensive resection procedures on the liver combined with biliary reconstructions in hilar (Klatskin) cancers, extensive resections in two acts in multiple bilobar metastases of colorectal cancer, complex parenchyma-sparing liver resections, and liver resections combined with resection of the veins and primary reconstruction or reconstruction with grafts.
Additionally, the team carries out pancreatic resection with venous and arterial reconstructions in advanced pancreatic cancer. In cases where the malignant disease is advanced, multi-visceral intra-abdominal resections may be necessary, involving resection of the stomach, small and large intestines, or pelvic organs. Although rare today, bile duct reconstructions due to injuries during laparoscopic or open gallbladder surgery are complex interventions, particularly if the injuries are associated with liver blood vessel lesions.
Our centre is involved in both basic and clinical research, in which our team actively participates, alongside renowned scientific and clinical institutions, both nationally and internationally. Our approach to translational medicine aims to apply knowledge gained from various research projects in our daily clinical practice, with the ultimate goal of improving the quality of treatment and the quality of life of our patients. Ongoing projects include the analysis of the molecular and genetic basis of metastatic colon cancer, primary liver tumours, and aggressive pancreatic cancer. By determining the immunological profile of cancers of various origins and understanding the sensitivity of tumours to particular groups of cytostatics, we are able to apply an individualised approach to treatment, which forms part of a broader model of integrative treatment.
Our surgeons are committed to the education and training of residents and young surgeons interested in liver and pancreatic surgery. We are available to provide consultation on any clinical problem within our field of expertise to surgeons both nationally and regionally.
