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for another session of backs this week. Our teaching webinar session will be on hepatopathy creator Billary surgery given by Mr Adam Frampton, who is a consultant surgeon at Royal Surrey County Hospital. As you're aware, back to the future is a 12 week teaching program that's designed alongside asset for young budding surgeons. Um, we'd like to give a big thank you for asset for helping us develop this course. Um, thank you for the M d u for sponsoring us. I'd like to give a huge thank you to medal as well to provide you guys with certificates. Um, as you wear every single week, we usually have a video on surgical techniques, and this week, the surgical technique video was going to be on laproscopic surgery. However, we've encountered some some technical issues with the video itself. Um, so we'll be presenting this video on next week's teaching webinar session. So apologies for that, guys this week. Um, like I said, I would like to you all I'd like to introduce you all to Mr Frampton, who is a consultant, surgeon HPB surgeon at the Royal Surrey County Hospital. And as someone specialized in HPB myself, I think this web this teaching webinar session will be awesome. It's very interesting. Without federal do. I'd like to introduce you all to Mr Adam Frampton. Hello, everyone. Can you hear me? Yeah, we can have you. Yeah. Great. Okay, I'll share my screen. Yeah. Yeah. Okay. Thanks for everyone for attending. I'm very impressed. There's so many of you, actually. Thanks for Dashi and Marta Marta for inviting you to speak tonight. Um, as that she said, I'm the consults of the little Sorry. And I'm also a senior lecturer at the university. Sorry. So this talk will be on, uh, a little bit of the surgery HPV surgery. Uh, it's just the content of my presentation. Uh, what's HCV surgery about? And then we have three cases, and then a conclusion. Why? Why would you want to do HPV surgery? And if anyone has any questions, things put them in the chat box and dashes been a monster it and let me know, um, as we go along and I'll try and ask you some questions along the way as well. So what is HPV surgery? Uh, well, it's liver, pancreas and biliary tract. Um, the HPV surgeons traditionally look after everything, um, in the GI tract, which is below the pylorus. So, um, so you imagine an esophageal and gastric surgeon would look after the esophagus and the stomach upset pylorus HPV will look after post pill oris. So that's the duodenum, pancreas, spinal ducks, um, and then small bowel as well. So, uh, the nature of the work is benign and malignant. So from the benign side, we have complex schools, well, normal gallstones and then more complex gallstones and biliary disease, including acute pancreatitis, chronic pancreatitis. And then we have the malignant side, which traditionally includes the pancreas, duodenum, liver try the liver, cancer and liver metastases and inability tract cancers. So ability tract cancers are gallbladder, um, ampullary and bile duct. So cholangiocarcinoma so reception of those type of tumor's, and then we also have. Then you're under crime tumor's, which are mainly in the small bowel. So small bowel neuroendocrine tumor, such as the carcinoid tumor of the term A island. Um, so that's small bowel and, uh, small value of the crunch ears and then also pancreatic neuroendocrine tumors would be something else that we deal with. So the common operations are uh, the Whipple's operation. The modified version. Which is the pirates preserving pancreaticoduodenectomy essentially the same operation? Uh, I'll show you a picture later. The Whipple's you take more of the stomach and the PPPD. You try and preserve more of the stomach, the liberal sections so these can be open laproscopic or now robotic, duodenal and small barrow section so you can have some duodenal cancers or benign Judea Lesion's and then small Barrow section, for example, Podcast annoyed Tumor's, uh, that require, um, perhaps the right hemicolectomy in an extended small barrel section. Then gallbladder operations. Our luck common like 30 or maybe an open cholecystectomy and Billary operations, for example. I'll show you a bit later. Some verity syndrome. Other adjuncts that some HPV surgeons do is endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. So ercp were dealing with E. U S for identifying disease. So perhaps a tumor or gallstones in the common bile duct and an ercp for therapeutic reasons for perhaps clearing a common bile duct stone, uh, example or stenting. A cancer that's causing a common bile duct construction that makes sense so far. Yeah, okay, training pathway for HPV surgery where you have to do, uh, your CT training one and two in surgery in order to get enough points, I guess to do to to be eligible to get an S t three application in and then your s t three interview. Um, so then you'd want to do an S t three in general surgery. And I guess for S t 345 and six the first four years, you would do sort of a broad range of specialties. So vascular trauma, Upper gi, lower GI um, and the training scheme seems to change every year. But when I was doing it, you had to do a year of colorectal in the first year you had to do some specialist subjects such as vascular surgery for six months. So vascular surgeries extremely important for HPV surge because we're always dealing with big blood vessels such as the portal vein, uh, and the highland and deliver, which, of course, contains the Caledonia trees. Uh, and we're always looking at, uh, doing a dissection around your arteries for loop, noted the loop adenectomy. Um, it's important for HPV to do research because a lot of HPV units have a lot of have a lot of research, active research programs, and it's very competitive. So it's good to have a research degree as an MD or pity. And then you would normally do your last two years of STD training. Yes, 27 and eight in your specialist subject. So that would be HPV surgery. And you should try and do a year little transplantation that more confidence around the liver and about around big blood vessels such as Rubina Caver. How to deal with the hepatic arteries? The portal vein, for example. Um, and most HPV certainly do fellowship. So whether that's, uh, in the little transplantation or HPV or minimally minimally invasive surgery, um, you know that's something that most HPV surgeries would do. So I I fit that into my training. So between I did an S t six in N HPV surgery, and then I did an S T six out of program for experience, an extra year in black telescopic and robotic HPV surgery at the Hammersmith and the Marsden hospitalist. So I kind of I did my fellowship within my training, but most people would do it at the end. So the first case, the first case is a lady with complicated Bousman disease. So this is a 36 year old lady that presented to a and A during covid with right upper quadrant pain, which is colicky in nature, exacerbated by fatty pills and imaging. Diagnose severe acute code of societies now her past medical history into type two diabetes and schizophrenia. And she was more the the obese with the B m I of 45 that she was trying to manage with diet and exercise. So just talking about the gallstone disease, of course, uh, gallstones can cause, as you can see here, can obstruct the gallbladder. And when the gallbladder is obstructed, you get increased pressure and inflammation and bacterial overgrowth. And, of course, that leads to co societies. As the disease progresses and there's more inflammation, you get peritonitis with inflammation, and then this will you'll be able to pick this up by Murphy's sign or rebound tenderness in the right up equivalent. Gallstones can go one of two ways if they're causing problems, actually, three ways. So the first option for the gallstone is to cause a blockage of the cystic duct, and, uh, this causes pressure in the gallbladder and you get paid or biliary colic. The second option is the goal. That is the goal, that a stone gets stuck. And as we've just described before you get bacterial translocation. You get information, you get heritage, you get a coupon societies essentially with inflammation. Now, if this gallstone unblocks itself, that's fine. If it doesn't, it may go down the bio duct. And in that case you may get a common bile duct stone causing cholangitis and all acute pancreatitis. If the gallstone remains blocked Uh, the cystic duct, then, uh, this can actually lead to pressure on the blood vessels in the gallbladder wall. And it can lead to the crow, ischemia and gangrene on, and eventually the process of the ball, that which leads to perforation of sepsis. Because that's just a brief overview of cool centuries. I'm sure you all knew this already. So this lady, she had two further attacks of code cystitis during covid and on her last severe attack, actually, the closest ostomy. So I think this was at a different hospital, uh, in in the region, and her attack was so bad that they decided to hold that a drain in the closest ostomy. I think that the surgeons there felt that it wasn't going to resolve on antibiotics. And she was obese, diabetic, and it was covid. And so they needed to do something. So she had that and that covers the stuff to be drained. Stayed in for about 6 to 8 weeks, um, and eventually removed. But then she presented again so that she's had 3 4/5 attack. Now, uh, she presented again in April 2021. Uh, now with Georgia's pain and pyrexia, so does anyone know what that is? An easy question. You know, uh, I won't say it, but it starts with. See you guys. Yeah, it's a triad Charcot's Charcot's fryer. Yeah, the hallmark of a sending cholangitis. Now, this requires emergency intervention. We have to do something about this. So she had routine investigations bloods, Uh, you know, it's routine blood. She had an m r c p. And I'll tell you the I'll show you the second the MRCB showed an obstructing stone and she had an ercp to deal with the joint this in the stone. Unfortunately, she developed post ercp pancreatitis. So this poor lady has had recurrent gallstone problems. And now she's had e ercp pancreatitis. So looking at her M R c E p from this attack, you can see Well, tell me what you can see. Anyone anyone can keep you just write in the chat box. What do you see on this MRI MRCPI? What do you notice about the Hillary tree, which is the white area tree before the beginning, Someone's mentioned inflamed bull bladder, but okay, someone to mention. I think perhaps this is, uh this is the gallbladder here, maybe in Serbian thing, and I can't really tell her, okay? She's going to have it inflamed Golden, all right, because you have the current act, but someone noticeable about the bile, But someone said blockage. So this is the, uh, this is the right side of the biliary tree. This is the left duct, and then you come into the common hepatic duct, and then his basis stops. And then there's this Garrett where it stopped, and then it blocks basically and this is all swollen and dilated and distally to that. The bile duct continues. Uh, but it's, um, not that dilated. So she's got a dilated biliary tree with the destructing stone. What would be the differential diagnosis if you didn't know her history? And you just saw this? What would the differential diagnosis with the knees? Anyone? Anyone. So this is exciting. Uh, if you just try in the chat box, guys. Sorry. Could you repeat the question? If you didn't know the history of this lady having gallstone disease, what would be the And you just got shown this MRCB? What would your differential diagnosis be? So someone's mentioned Tumor? Yeah, Tumor. What tumor? Anyone? Well, bile duct. So it'd be a bile duct tumor or cholangio carcinoma towards the highland. There are Hailo cholangiocarcinoma. Perhaps, um, it's not gonna be a pancreatic tumor because you can see the see movements of their Dhiman. This is the C of the Judean. This is the distal bio duct. This is the pancreatic duct here. So the tumor of the pancreas is going to present in this region. Okay, so then she had an ercp and ercp. They put the guidewire up and they did a gland er ground. And again you can see here, right and left bile duct and an obstructed common bile duct. With this filling defect school stone. So they put a stent up, and then it all looks very inflamed here. She got, uh, ercp post the article Pancreatitis and you can see she's a large lady, right? You got a lot of pattern. So this is a Maurizi syndrome. Okay. Maurizi syndrome is classified by the Sundays Classification 125. So, in type one, you have a large gallstones. Obstruct into harm's pouch and you can see a little 20 lil a cystic duct. Here, type two large gall stone starts eroding towards the common duct. Type three a little bit more. Type four is completely obstructing the conduct. This is what she's got. And then type five, you've got large gallstones, which perhaps it road towards the common duct. For more importantly, former coli system Judean, all fistula. So a bile, a biliary enteric fistula where the gallstone passes into the bowel. So she had type up four. So type four, you can see here the big bar, the big gallstone eroding into the bar, that causing obstruction and join us. Now, traditionally, this is treated by excision of the gallbladder and the stone, and then reconstruction with a loop of judgment called hepatic Oh Jejunostomy. So our ongoing management for her was analgesia a low fat diet, weight loss, rehabilitation. Yet her time to diabetes under control. She had a very high HBA. One c. I think it was something ridiculous, like 100 and one. So she needed to get her diabetes under control. She had antibiotics and cholangitis, and then she was given two options, and the first option was she was offered a gastric sleeve by Saint Peters for weight loss. So the surgeons at Saint Peter's and Saint Helier Well, I told I told you where they were now So, uh, Saint Peters and say hello. They said, Oh, well, if you can lose some weight, we can do a safer surgery with you And that's quite sensible. Um, but she had a plastic pigtail stenting and the plastic pigtail stent in the bile duct can't last forever. I think, uh, some of the surgeons like Mr Weller than I I think he says it probably in the last 12 weeks, like three months in the maximum. But they're likely to get blocked and need further ercp and stent change. And she already had the ercp pancreatitis. So you don't really want to do a second? Ercp can avoid it. So anyway, we talked about this at the year that amongst the consultants and we decided to go straight for robot coder suspect to me. Because now we've started a robot programmer at the off it She went for a robot close cystectomy and CVD claims. And so what we did was that we we remove this this thick and gold butter this this remnant basically chopped it off. There, we removed the big stone, and then we sutured it up with five Oh, PBS, um, suture. And, uh, in that way we avoided doing a hepatic oh, jejunostomy on her. And she did very well. Now we left the plastic pigtail stent in situ. And the idea for that was that Well, you know, we want the bile to go down her common bile duct and not leak out of, uh, sutured called that a remnant. So she had a She had a Robinson drain. She had a post operative drain. Uh, so you have, you know, an interpretive drain. The Robinson drain. And we left a sentence issue. And the next day she had no bile of the drain, the bile. The drain came out that she went home the next day, but she came back to Guilford with cholangitis because unfortunately, when we did the operation, we stirred up a bit of infection. And I think because the pigtail step was there, it was colonized and it just she got cholangitis. So unfortunately came back. I had to have antibiotics, but she had no by Ali, which is a good thing. She settled with antibiotics and then she's had an endoscopy to remove her pigtail stent. And she's fine. That's the first case. Does anyone ask, Ask any questions? Any questions? Guys, just give me a few seconds for people to type anything. Okay, fine. I'll go to the second case. Second case. Necrotizing gallstone pancreatitis. So another young lady, 37 year old presents the any same symptoms require recurrent reported an abdominal pain, apology and age exacerbated by fatty meals. But now the pain is staying with her is severe in the epigastrium radiating to her back. She's vomiting the last 23 days. She can't keep any fluids down. She can't keep any food down, and, uh, she's a little bit yellow. So we did. Imaging and blood. We did imaging because we did a CT because she was acutely attendant. Um, um, normally you would do ultrasound for gallstone, but she came in. She was acutely attended. She had a CT. She had an amylase, which was 3000. She had a CRP of, uh, 400. I think Billy Ruben of about 40. So she had acute gallstone pancreatitis, her background, another morbidly obese lady. I don't know what happened in covered, but new ladies all got bigger and more problems. VMI 40. She's trying to do diet and exercise. This is her CT scan. So the CT scan shows that here you can see this is the pancreas. The pancreas has a head, the body and the tail going towards the spleen like a fish. You can see that There's a lot of fluid and scrambling around her head and body and pancakes, pancreas. And this bit of pancreas here is looking a bit more darker. Is not really enhancing as much. So this perhaps early signs of necrosis here again, not enhancing lunch, uh, for those sneaky slice again. Same picture. Nice looking, very nasty looking frankly, folks, that on the Corona view same thing, really a lot of stranding in the fact, I guess, every pancreatic fluid, un enhancing pancreas. It's not very nice, really. And the small bowel loops here are looking a bit prominent. You know, small bowel is not really happy with all this pancreatitis contributing to, uh, the fluid around her stomach. She is vomiting because of all that. You can see that she's got a calcified gallstone in her ball butter, the cause of her pancreatitis. So should we do a hot lot Cody in this baby? Anyone? Anyone? Dashi shook his head. Anyone else? Who's going to do a hot lap coli on this lady? Someone said no, no, we didn't decided not to, uh, we did. An M R C P first chose the viaduct in it. Plump, but no, no blocking stone. Uh, all done is fat, but we already know shadowed. Also. We'll start on the CT for books. Don't beneath. We decided not for surgery because really, she, uh crp was very high. I she was in a lot of pain. She had nasty pancreatitis. She wasn't eating and drinking. She was vomiting. This is not the right person to do a hot lap coli on Really the person for a hot lap coli. They've got biliary colic or Q colecystitis or they've got acute pancreatitis, second bit of gallstones. But they are managing with analgesia, and they are able to eat and drink like they have to be. At a certain level, they almost have to be rated. You know, they have to be able to go home almost. But those are the type of patient you can do a hot lap curly on. Not not CRP. 400 vomiting and dehydrated. It's not the right person so hard that Cody is suitable for patients with acute gallstone pancreatitis, but not just type of severity. So we gave her energy Zia. We had to optimize her nutrition. She actually had an O. G. D and N J tube feeding so that we could feed her distal to her pancreas and antibiotics for her cholangitis. She went home and she came back and get with pain and fever. She had to have a new CT. Does anyone know what was happening now for her pancreas? Any ideas? Guys? Uh, it looks like Bishnoi nose. Uh, is that just because it's always on the screen? No, no, I I actually have no idea. Oh, sorry. That's all right to someone said Pseudo cyst formation. Oh, yes, Right. Pseudo cyst formation. CT scan shows that that pancreas that was looking nasty now forming into a collection behind the summit. And you can see it has this thick wall around it on another slice again. Here. Lower down. You can see pseudocyst with thick wall. So this is a probably pseudocyst is That is yet is what we would call it. But I guess the correct term is warmed up in the process. Uh, this requires drainage. So in Guilford, uh, we do this endoscopically by what's called a Axios by endoscopic ultrasound. Now, the alternative way of draining this is percutaneously. So you can get an interventional radiologist. Go straight through the skin through the stomach into the collection. That's a trans gastric drain. Percutaneously. So one of our radios, just Doctor Horton used to do lots of these before we had have Axios, you just put, uh, we're going on the CT or an artist and probably in the CT, and he would go straight down and, uh, puncture the stomach and the drain would go straight through. And the good thing about that is is that he can then put another little stent in between the stomach and the pancreatic, pseudocyst or necrosis, and all of that fluid drains into the stomach. Yeah, but it requires a drain that goes through and through is quite invasive. Now, with heart attacks, ius and disc optically, you don't have to go through the skin. Um, through the organ, you can go straight into the stomach and join the stomach to the Sisk by products IUs, which is here. This is Mr Worthington doing an endoscopic ultrasound. He can see the collection from inside the stomach, then punctures the stomach. But this is the product. See a stent and blue big toe. Puncture the stomach into here into this collection, then some fishing out some pancreatic necrosis. You can see the fluid from the pancreatic pseudocyst or the water pill crosis draining into the stomach. And then here you can see this is the nice little stent that he's put the hot actual stent, draining that fluid collection from the pancreatic, uh, pain medication into the stomach and that can stay in for about 16 weeks, at which point there has to be removed. Otherwise, the body sort of grows over. It grows into the body, and you can't get it out, so they have to be able to take it out. Otherwise, it was an accordion problems. Believe it now. She had to have her, uh, her, uh, collection washed out and disc, probably a few times in order to clear all the infection. So she first presented in January 2021. And now this is her latest CT scan. You can see things have settled down. Um, she's eating and drinking better, and she's still quite large, which is a lot of it away. You can see her gallstones is still there. It's not just one a lot. So now she's coming for elective laproscopic pill is affecting me at the end of September. Hopefully, I'm I'm hoping it won't be too bad, but it's not gonna be easy. Anyway, there we go. Anyone ask any questions? If you've got any questions, please pop on the chat, please. Guys. Mhm. No, I think so. What are the indications for a hot lap, curly like I said So now in Guildford, we are part of the Kerley Quick project, which is a quality improvement project launched by the Royal College of Surgeons. I think where now? The third best hospital in the UK doing Cody quick. And the curly quick project essentially says that we should try and do, um, lack komis in 80% of patient's within eight days of their presentation. And the indications would be pain. So full stone pain due to ability, product acute cholecystitis societies do two gallstones because you can have a calculus to which is usually gallstones and then gallstone acute pancreatitis. So those would be the main indications. Um, but like I said, you have to choose your patient. So, uh, you can't be doing the in patient's that have got severe. If you kind of tight this with crps of 400 that can't you can drink. So but those would be the main indications. I think that's about it. OK, uh, so the third case is pain is instructive. Joined us. Now this is a 73 year old baby who presented with a four week history of worsening jointness. Know of this pain, she had a weight loss of 4 kg of the last month. Jed pale stools and dark urine. So what's the differential? Diagnosis? Um, so someone's mentioned cancer? Yeah, but you're gonna say which one? Uh, which ones? I think so, Before we head off Mr Frampton with regards to the previous, um, presentation. Does ward off necrosis contain pancreatic enzymes? By any chance? Uh, yeah. So it would contain some families. Rich food? Yeah. Um, so someone's mentioned. Head of pancreas, pancreatic head, cancer, pancreas. So, like everything. Yeah, OK, I said painless obstructive jaundice, which suggests it's malignant, but, uh, you know, so any any obstructive dryness can be benign and malignant. The benign causes can be gallstones, inflammatory strictures such as pancreatitis, which can be acute or chronic. For example, you should really common benign course is Malaysian causes could be a tumor such as ahead of pancreas cancer and ampullary cancer. The gold bladder cancer, the cholangiocarcinoma, a duodenal cancer. So any of those cancers you can also have obstructive short roadrunners due to metastatic disease such as colorectal cancer can spread to the lymph nodes around the portal and practice which can cause external compression with the bio duct, So, yeah, in the in the Communist one would be pancreatic cancer for your, uh so her past industry is hypertension. She's an independent. No smoke industry and no water. And anyone could have always say she actually does yoga every day. This way. On examination, there was nothing to be found. Part of the joint juice, Of course, there's no mass felt. She had blood tests which showed the range of teas and a bilirubin of 114. So clearly joined us. And then she went on to have a CT scan and a pet scan. So this is her CT scan. Can anyone tell me what you can see here? Any idea what this black line line? Um, so someone has mentioned the liver, but yeah, that is the liver. But what are the black clients that you can? What? The black black tube? I think you've been away. This is the liver. That's a good start. All right, So this is biliary duct. Violet ation. Yeah. So this is this is an obstructive biliary tree. This is biliary duct validation. This is the portal vein. That's portal vein. And this is the smaller and bile duct biliary duct validation. And here, can anyone see anything here? So this is the bio duct, which is swollen. Anyone see anything in this area? It's probably Yeah. Any ideas, guys? Um, someone's mentioned fluid. So it's a gallbladder, which is extended. And this is a tumor. Yeah. So here you can see it again. So you got biliary duct Dilatation in swollen gallbladder, dilated, obstructed common bio duct coming down to the ampulla. You see this taper this triangle tapering. And then here. So you've got the Georgina and this C shape, right? And you can see here There's a mass at the end of the bile delights in the duodenum. You see that? This has got an obstructing tumor. Uh, the level of the ampulla. So probably an ampullary cancer or duodenal cancer causing wild duct obstruction. Yeah. And then because the bile ducts obstructed the gold that ever comes to send it because all the bile is just swelling up the golden. It can't get anywhere else. Yeah, she then went on to have a pet scan, and it showed that this mass is pet avid. You can see the light bulb right? This is a hot, hep, avid mass suggestive of a cancer. Mhm. So what we're gonna do next? Any of these guys she's doing this, Uh, someone's mentioned the Whipple's, but before doing a week polls. That's right, actually. So her bilirubin level is 114 which is not very high. I mean, she's joined. This is not very high. So now there's a There's two options, right? You can either do Billary drainage, or you can go straight for Whipple. And at Guilford, we do what's called fast track. Whipple means that you avoid Billary drainage. So Billary Drainage. I'll be about PTC to percutaneous, transhepatic, cholangiogram, thick drainage, PTC Drain or ercp stenting. So those are the two ways of draining ability system. So you either do that or you go for fast track. Whipple and so Guilford just tend to be fast tracked with, for now, in suitable Patient's. So she's 73. She does yoga every day. Um, she's slim. She's got no metastatic disease on her pet scan. Her bilirubin level is only 100 and 14, so she's suitable for fast track. Whipple, the cut off level for bilirubin for a fast track 11. Whipple is about 250. In some centers, they go higher. So in burning, they go as high as 450 untold. So you could have a bilirubin of 450. And they'll still do a whipple on you in Birmingham. Here in Guilford. Probably 250 is our limit. After that, you would need drainage. Uh, and then stenting or drainage. Maybe not even sending you could have an external drain and go to work, or maybe a week or two later, or stenting and then come back later for for work. Well, if you're going to be stented, some people would say, Well, you might as well do in the U. S. And a biopsy. See what it is and then go for near our drinking therapy, depending on what it is, that's a different story. Um, so in this instance, her biliary was 100 and 14, and she's super fast back. So she went for that. This is, uh, PPPD, uh, which I said to you before. Is the pylori preserving? I'm going to go do colectomy. So if you have a look here, so it's a bit blurred, but you hope you can understand what's going on. So, of course, your head of the pancreas is here, and the tumor hurt Uber's in this region, and they're pulling region. So we have to move the head of the pancreas. You have to remove the duodenum C shape up to the level of the first loop of the judgment. We have to remove the bile duct with the gallbladder. Yep, leaving the common Hispanic duct open. And we have to remove, you know, pylorus preserving. We remove the first part of June of them, but we have we preserve. The pylorus. Pylori is preserving, you know. Now, in a formal whipple, you would do antrectomy. So you take it here. So you lose that digital part of the stomach in a formal whipple. What? Why would you do one over the other? Well, some people believe that pylori is preserving improves your gastric function and reduces delayed gastric emptying. Studies have shown that probably doesn't make any difference. But in Guilford we try and preserve the pylori as 19. Why would you do a formal Whipple where you do a formal whipple? If a tune was so big that he was encroaching on the pylorus. But to get an oncological margin, you could take more of the stomach. So the vast majority of PPPD Now, of course, you've got one, 23, uh, full holes. Yeah, uh, all of this is coming out. You have to then reconstruct. So you've got, uh, pine credit. Go jejunostomy. So the loop of judge this loop of judgment broiled upwards Prime credit card jejunostomy, which is the most high risk of joint or anastomosis. Approximately 20% fix with pancreatic leap or anastomotic leak. And that's dependent on the texture of the pancreas. Whether it's soft or hard, hard, pancreas is leak. Less soft Pancreas is like butter. So you put the stitch in and it's very soft and very likely to be gland texture and then duct side. So big ducks you can see nicely. You can put lots of stitches in are less likely to leak small ducks, which are tiny. You can't see. You can't get any stitches in a more likely, so are more likely to eat. So soft gland and small duct, high risk hard gland, big duct, low risk. That's the pancreatic joint. Then you've got the hepatic Oh, jejunostomy on the same loop of jejunum So down street hepatic oh, did an ostomy And then you've got your high Loro jejunostomy or gastrojejunostomy your stomach content. And we have 1/4 joint in bill print. We joined the judgment of the judgment. Um, and that is to prevent any Afrin groups in the road. So that's your work or procedure. Or you could be the in this case, any questions? Oh, sorry. I forgot to say we leave drains, right? So I routinely two drains one drain over the pancreaticojejunostomy to collect any pancreatic juice or leave. We test on day three for amylase, and then I leave another drain in this direction underneath the bio duct to collect any bile leaf. But bile leaks are very uncommon after reports more likely to get tranquility. So this lady had her drained fluid families on Day three. It was raised at 622. Um, we were quite confident, actually, was. Well, that's not too bad. On Day five, the fluid started leaking from her wound, which was a disaster. So I already told you what's going on. She's got the post operative hydrotic fistula or pie critically. So you can see here on the CT scan. Um, this is her drain, which is going in this direction. Wasn't really doing a good job. There is some fluid coming through the muscle and the fat here towards the skin staple. Yeah, that's one of the skin clips on this view here. I think you can see more clearly than some fluid here, and it's going all the way through here into the wound bag that the nurses put on the on the skin wound. So she had, unfortunately, had pancreatic pan official or pain, the leak coming through her wound. And so we managed that by stone, back of the room, know by mouth with Sips supporter. Only because anything orally is going to stimulate the pancreas. The pancreas reacts, buy food and drink. It pushes out pancreatic juice to your digestion. You have to go nil by mouth and sips of water to reduce the amount of pancreatic juice being produced and therefore, reduce the lead. A normal amount octreotide again a somatostatin analog to reduce pancreatic um uh to find function. So reduce the amount of juice being leaked, and then TPN to maintain nutrition IV antibiotics because this leak is going to get infected because it's connected. The pancreas has been connected to the judgment, so there's gonna be gut bacteria there, albeit small bowel, uh, bacteria. So some IV antibiotics to treat that So the principles of treating a fistula are always the same for anything. Whether it's a pound credit lead, a colonic lead, a small battle lead suffered your league. You know all the leaks. You need to, um, ensure there's no distant obstruction. There's no blockage, because if there's a blockage downstream, you're going to get more leak. So in this case, we didn't have any construction. But we try and reduce the amount of, uh, pancreatic secretion you have to treat any infection. Yeah, I'm going to work. And you have to maintain nutrition with the sort of the rules of treating any history of swelling. So in can, uh, any questions about that so far? Um, any questions, guys? No, no, I think we can head off. Go on. Continuing with Ms Franklin. Okay. Uh, five years of parents. So, in conclusion, why would you choose HPB? Well, these are some of the reasons I chose HPV. So HPV is a very, um, team orientated specialty. Uh, because it's complex, the disease is complex. The surgery is technically demanding and challenging. You need load of, you know, other specialties involved and friends to help you with these patient's. So you need radiologists, especially interventional radiologists. I mean, I think we're probably the one specialty in the hospital that relies heavily on Inspector. We'll go over all the time. Uh, oncology, our HPV dieticians are cancer. Those specialists, gastroenterologists, videos, pharmacists. It's all very important to get these patient's through. Uh, they're complex surgery. Um, I've mentioned these bits. There are many unknowns in HPV. There's a lot of scope for research. So there are a lot of things we do in HPV that are not evidence based. Um, and so there's a lot of lot of scope for research. And then there's a lot of new technology in HPV. Yeah, it's a fast moving field. Um, and you know, we've got a robot now in Guilford. So the Da Vinci Robot there are the robots, but we're now starting to do HPV surgery robotically. Whether it's benign disease and the living disease, you can see, this is that's one of the robot arms. Uh, Maryland. The robot now has three D view and it's got other adjuncts such as this firefly, which is in designing green I c g, um, that can help us to highlights where the lesions are or perfusion of the liver so that you can make sure that you take out this tumor and leave, you know, the Norbert to liver behind, and you might not see that otherwise, there are other three D programs now for reconstructing the liver and doing three D printing in order to plan your surgery so you can actually see in your hand where these lesions are in the liver multiple lesions and have a strategy from cutting them around. And then there are percutaneous devices now for dealing with, for example, liver metastases and also advanced pancreatic cancer. These probes This is a I think this is I R E or electric operation, uh, that can help to burst tumour cells. You can also have microwave ablation, radio frequency ablation, so other technologies to help you to their disease. In patients' cancer disease, there's a lot of new technology. What type of person seat HDB. Um, well, it's hard work HPV as long hours long training. Um, you have to become technically proficient. It takes a long time. You have to be a team player. It's complex disease. Like I mentioned, it has high mobility and high mortality. So you need those other team members, your friends, to help you out with all these patient's. Because, um, it's very stressful looking after these patient's, you have to be able to cope with stress. But in a team such an MD T approach, you can manage these these complications more easily. You have to be a good communicator. Um, and I think it helps to have an academic interest. Uh, for example, I'm interested in bio markers and molecular biomarkers and molecular mechanisms of cancer. Uh, and all be an innovator. So you have to think outside the box because there's no one way of treating all of this disease when the operations are standard. But your work up application is not always going to be a standard approach collaborator. So working with other units, other centers, whether the national national unity within, within the UK, so naturally boy internationally. So I have, uh, collaborators abroad. Uh, and sometimes I even asked HPV surgeons. I have a very good friend of Germany. I have. Sometimes I asked for advice about cases because it gives a different slant. You know, you've got very eminent surgeons like Professor Transistor Worthington. You have a lot of experience, but sometimes you ask someone else to see what they think. Because they may have been her idea or some other ideas. So that's about it. Really? Um, if anyone has any questions, please ask now or email me, uh, if you want to get involved. Thank you very much. Um, thank you, Mr Frampton. Um, I think it's great presentation. Um, and I actually did HPV You surgery at Guilford myself as an F one. And I fell in love with It's great specialty. Uh, really complex surgery that, you know, it's very good. Like Mr Frampton said, a lot of team specialties involved gastrologist and so on. Uh, it's great, actually, I love the specialty. Uh, Friendly? Yeah, the super friendly. Actually. Everyone's really nice on the HPV. Uh, amazing talk, Mr Francis. I thought I'd enjoyed it. Uh, even I let something new. I thought Patient's with high bilirubin would always go for a P. D. C drain before undergoing, um, if they had over 100 bilirubin, you know, before going for Whipple's. But even I've learned something new that in our trust. Anyway, the cough is 2 50. Very interesting talk, Mr Francis. Thank you. Any questions? Uh, do you like to ask Mr Frampton? Guys, I've got the chat box here. Oh, nice. You did nice. Anything anyone wants to ask? Anyone wants to get involved? The next few bringing, um, just to cut you off, Miss Frampton. Guys, just put the link for the feedback forms. Um, and once you filled out these feedback forms, you'll get your certificates. And these feedback forms are also really important for us as well. So if you can complete them, that'd be really great. Thank you, but yeah. Anyway, we all need feedback for our portfolio, by the way, As a consultant, you still have to do portfolio. There we go. Keep going. Um, yeah. Any questions, guys, you can always ask Mr Frampton. Uh, I think there's one question that's actually been directly messaged to the one second. Uh, okay, there is. So you're a Q tip. So you ask you A in view of acute, typical acute kind of virus and very high amylase. Should one proceed with M R. C P or doing ercp. So, uh, if you've got acute pancreatitis, not with the and valleys, whether it's high or very high gives you to lead you towards the diagnosis of pancreatitis. Of course. Um, you can have a raised amylase for other reasons. So, for example, a completely benign disease would be monks. You can have raised amylase with months. You have to do an isoenzyme to differentiate between monks and pancreatitis. Okay, but usually your guy with a patient with monks. So the guy or girl with monks not going to have acute abdominal pain going to get the gastro etcetera. So other causes of high under layers would be something like a perforation in the abdomen. A triple A can give you, uh, how many rounds other things. So you think about peritonitis, perforation, triple A things like that. So if you're worried, then, um, you should probably do a CT scan. If you're not so worried, then you need to try and find out whether this is gallstone pancreatitis. because that would be the commonest cause, um, secondary to alcohol. So also have been commerce course second common cause would be alcohol, and then the other things on you will get smashed. Uh, differential diagnoses. So I would do an ultrasound if you were not too worried about the patient. And then if the patient's joined this, then, yeah, you may do an MRC thing to see if there's any common bile duct stone, and then go to the r. C. I wouldn't go straight with Ercp, because, of course, the risk of the RCP is closely RCB pancreatitis. You want to make the situation worse when you don't need to, uh, do that kind of intervention? Yeah. What do you enjoy that asked the question of you? Yeah. Do you enjoy most about HTV surgery? I think, uh, I think it is the fact that it's a it's complex disease. You have to. Every patient is different. You have to keep thinking about how you're gonna manage them. Um uh, medically and surgically. And it's very team orientated specialty. You know, that's that was what I was trying to say. What, actually trying to say you have to speak to a lot of people to manage these patient's You can't manage this patient on your own. Now, you might say that Everyone's DT approach now, whether you're, uh, care of the, uh, the physician or colorectal surgeon or skin surgeon, Um, I just think that in HPB we we do more in detail than other specialties. Yeah. Uh, would you be willing to take in? Medical students are elective. Yes. Email me. Where are you from, though? Are you in the UK post? By if you're it doesn't actually matter. I guess Cyprus, Uh, yeah, and we're willing to take one of the students. Of course you'll have to get Make sure there's the covid situation is okay for you to come here, and we have to get you sorted out with the observer department. And also, yes. Any other questions guys at all? Mm. Yeah. Um, thank you, Mr Frampton, for your time today. Amazing talk. Very interactive. And I thoroughly enjoyed and hope everyone else enjoyed it as well. Um, like I said, guys, please do fill out the feedback form so you can get your sitter thicker, but, uh, it's also very important to get these, uh, feedback forms. Uh, once again, thank you for joining us today. Uh, next week, Uh, the talk will be on on bariatric surgery, actually, But remember, these are all recorded sessions, so you can actually watch them at a later time. Uh, like I said, Hve surgeries. Interesting. And I would always tell people to go for that surgery myself. All right, guys, Thank you so much for joining us. And thank you, Mr Frampton. Thanks, everyone high.