Hepato-Pancreato-Biliary (HPB) Unit

We are the designated Regional Pancreatic Centre (in conjunction with our NMG colleagues), and are the largest most specialised HPB units in the region, treating patients from Manchester and surrounding areas. We are a tertiary referral centre, and a nationally recognised centre of excellence for pancreatic cancer.

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

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

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

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

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

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

What we do

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

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

Treatments include:

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

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

One-Stop Jaundice Clinic

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

Fast-track Surgery

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

Research

MFT is part of the Greater Manchester Clinical Research Network (GM CRN) with both National Institute for Health Research (NIHR) research studies, and local clinician led research studies running within our HPB unit. We have a team of Research Nurses, who work alongside our clinical team to support the delivery of research studies and provide patient support for trial participants.

Below is information on our current recruiting research trials and contact information for the research nursing team;

ORANGE II Plus – An international multi-centre, randomised controlled trial, laparoscopic vs open surgery in patients having parenchymal sparing resection of the postero-superior liver segments.

ASPEN – Prospective evaluation of the management of sporadic asymptomatic nonfunctioning pancreatic neuroendocrine neoplasms ≤ 2 cm in size.

PROCAP – A randomised controlled trial evaluating a procalcitonin based algorithm for antibiotic use in acute pancreatitis.

For more information on our clinical trials please contact:

Danielle Wilcock – Senior Clinical Research Nurse

0161 701 0517 / danielle.wilcock@mft.nhs.uk

What to expect

Your first appointment

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

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

After your first appointment and investigations

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

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

Pre-admissions clinic

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

Surgery School

Pre-habiliatation

On the day of the operation

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

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

The anaesthetic room

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

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

Post operatively

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

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

In recovery

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

In critical care

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

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

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

The enhanced recovery programme

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

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

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

Follow-up clinic

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

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

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