–

I am a Consultant Liver Transplant and Hepato-Pancreato-Biliary (HPB) Surgeon at Queen Elizabeth Hospital Birmingham (QEHB), one of the UK’s major centres for liver transplantation and complex HPB surgery. My clinical practice encompasses complex diseases of the liver, pancreas and biliary system, with interests in complex liver tumours, liver transplantation and also management of neuroendocrine tumours (NETs). 

NETs are a fascinating and challenging part of my practice because of their diverse biology and clinical behaviour. Some tumours progress slowly over many years, while others can be considerably more aggressive. They can arise in several organs, including the gastrointestinal tract, pancreas and lungs, and commonly metastasise to the liver. Their management therefore requires an individualised treatment strategy that draws on the expertise of surgery, oncology, nuclear medicine, gastroenterology, endocrinology, radiology and specialist nursing. 

My work combines clinical practice with research, teaching and service development. A particular focus of my clinical and academic interests is identifying which patients with advanced NETs may benefit from liver surgery or transplantation, and how surgical treatment can be integrated with other therapies to achieve the best possible long-term outcomes. 

Why Liver Transplantation, HPB Surgery and Neuroendocrine Tumours? 

I was attracted to surgery because it combines detailed medical knowledge with practical technical skills and provides an opportunity to make a direct difference to a patient’s condition. HPB surgery is one of the most technically demanding areas of surgery, but it is also enormously rewarding. Diseases affecting the liver, pancreas and biliary system often require complex decision-making and careful planning, with treatment tailored to the individual patient. 

My interest in NETs has developed alongside my wider interest in complex liver disease and transplantation. These tumours have a particularly varied natural history, making an understanding of tumour biology central to treatment planning. The aim is not simply to treat what can be seen on a scan, but to understand how the disease is likely to behave and which treatment strategy is most likely to provide meaningful long-term benefit. 

The liver is central to the management of many patients with NETs because these tumours commonly spread to the liver. For appropriately selected patients, liver surgery can provide effective disease control. Depending on the extent and behaviour of the disease, treatment may include liver resection, ablation, embolisation, systemic therapy or radionuclide therapy. In a very small and carefully selected group of patients, liver transplantation may also have a role. 

This makes NET surgery particularly interesting. Decisions must take into account tumour biology, the extent and distribution of disease, the patient’s general health, previous and potential future treatments, and the likely long-term outcome. The challenge is to determine not simply whether an operation is technically possible, but whether it is likely to benefit the patient. 

What does a typical day look like for you? 

There is probably no such thing as a truly typical day for a liver transplant and HPB surgeon. My working week encompasses operating, outpatient clinics, multidisciplinary team meetings, transplantation, teaching, research, clinical administration and to work in a complex web of teams. 

A significant part of my clinical practice involves complex liver surgery for primary liver tumours, metastatic cancers and neuroendocrine tumour metastases. Before major surgery, we carefully review the patient’s clinical history and imaging. In patients with NETs, this often involves assessing scans over time to understand the pattern and rate of disease progression, alongside functional imaging and the response to previous treatments. 

The NET multidisciplinary team plays an important role in these decisions. The complexity of NETs means that treatment is rarely determined by one specialist alone. Bringing together different areas of expertise allows us to consider the full range of available treatments and determine where surgery fits within the patient’s overall treatment pathway. 

When surgery is appropriate, the procedures can be complex. NET liver metastases may involve multiple areas of the liver, and surgical planning must balance tumour clearance against preservation of sufficient healthy liver function. In selected patients, surgery may be combined with other liver-directed treatments to achieve optimal disease control. 

Liver transplantation is another potential treatment for a very small group of highly selected patients with metastatic NETs. It is a major undertaking, with significant risks and the possibility of tumour recurrence, so careful patient selection is essential. Decisions regarding transplantation require detailed consideration of tumour behaviour, disease distribution, previous treatment, the patient’s overall fitness and the anticipated long-term benefit. 

Research into Neuroendocrine Tumours 

Research is an important part of my career, and I have contributed to more than 150 publications indexed in PubMed. I am currently privileged to serve as Chair of the UKINETS Research Committee, where my aim is to contribute to, collaborate on and deliver high-impact research that can translate into meaningful improvements in patient care. 

One of my particular interests is the role of liver transplantation in patients with neuroendocrine tumour metastases and for other cancers. Although transplantation can provide excellent long-term outcomes in highly selected patients, there remains much to learn about identifying those most likely to benefit. 

I am also interested in research involving various technologies and innovations that can improve the safety and outcomes of HPB and transplant surgery, as well as approaches that could increase the availability of suitable organs for liver transplantation. 

Another important area of research is understanding how different treatments can best be integrated. Patients with liver and pancreatic NETs may receive systemic therapy, peptide receptor radionuclide therapy (PRRT), liver-directed treatments and surgery at different stages of their disease. Determining the optimal sequence and combination of these treatments is one of the important areas that we are currently focused on. 

The multidisciplinary nature of NET management is one of the aspects I find particularly rewarding. Patients may interact with gastroenterologists, surgeons, oncologists, nuclear medicine physicians, radiologists, pathologists and specialist nurses throughout their treatment. Each brings a different perspective, and effective communication between these professionals is essential. 

For me, the fundamental question when considering surgery is not simply, ”Can I operate?” but ”Will this operation help this patient?” This distinction is particularly important when contemplating major liver surgery or transplantation. 

Final thoughts 

One of the most rewarding aspects of treating patients with NETs is the opportunity to develop long-term relationships with patients and their clinical teams. Because many NETs can be managed over prolonged periods, treatment decisions need to take account of not only the immediate clinical situation but also the patient’s options and quality of life over the years ahead. 

I feel privileged to work in a specialty where advances in surgery, transplantation, oncology and nuclear medicine are continually expanding what is possible. NETs are a particularly exciting example of this progress, with treatments and approaches that were previously experimental or unavailable now forming part of clinical practice for appropriately selected patients. 

Ultimately, the goal is to combine the best available evidence, technical expertise and multidisciplinary care to ensure that every patient receives the treatment strategy most likely to provide meaningful and lasting benefit. 

Mr Bobby VM Dasari