Why did you decide to become a Consultant Hepato-Pancreato-Biliary and Liver Transplant Surgeon ?

When I was still at medical school, I saw myself becoming a surgeon and nothing else, so I focused on a surgical career. As my surgical training progressed, I became more fascinated by oncology and wanted to help patients with cancer. I did basic science research on the signalling pathways in pancreatic cancer cells, which introduced me properly to pancreatic cancer and its biology. That was about 20 years ago, and it is only in the last year that new drugs targeting those pathways have started to come out.

That interest brought me closer to hepatobiliary surgery. During surgical training you do rotations, and in my hepatobiliary and transplant rotations I saw that this is a very challenging area of the body to operate on. It involves major blood vessels, so you need oncological skills and thinking, and you also need to be comfortable doing vascular work. HPB and transplant surgery combine both, and their skills are transferable.

I finished my training in the UK in HPB and transplant surgery, did a fellowship in complex HPB surgery in the US, and then came back to the UK to become a consultant in Birmingham. It was a process rather than one single thing that guided me to the subspecialty. What made me want to do this is the complexity of the surgery, the skill and attention to detail it demands, and the focus needed to take patients through their whole journey, from removing the cancer to providing the surgical part of the multidisciplinary care these patients require.

What are the common symptoms that your patients tend to present with?

It depends on the condition. For a simple benign condition such as gallstones, the common symptoms are pain after eating in the right upper abdomen, which can radiate to the back and the right shoulder. Many patients self-diagnose, then see their GP, who runs the appropriate tests, identifies the stones and refers them to a specialist. Benign conditions of the pancreas or liver can present with a variety of symptoms, or with deranged liver function tests or other abnormal blood tests.

A lot of my patients have cancer, and in most cases they arrive already diagnosed. They typically first present with jaundice (turning yellow), unintentional weight loss, loss of appetite, pain in the abdomen that can go through to the back, or newly diagnosed diabetes, or an unexplained rise in insulin requirements in someone who already has diabetes. These are the most common presenting symptoms.

What are the treatments that you're able to offer your patients?

I aim to provide a full and fast service, supported by a multidisciplinary team (MDT). When I see a patient in clinic and think they need a scan, the HCA team are very good at facilitating that. In most cases the patient can walk to the radiology department and have the scan on the same day, unless it is a specialised scan that needs a specialist radiologist. So patients get the clinic assessment and all the necessary investigations very quickly.

I provide the surgical part of the treatment and collaborate with colleagues who help with the rest. The anaesthetists I work with are specialist cardiac or specialist liver anaesthetists, with a lot of expertise in the anaesthetic care that complex liver and pancreas cases require. HCA also has a very good set-up, including an ICU, so we can offer complex surgery.

Patient care is more than the operation. Collaboration with oncologists, gastroenterologists and hepatologists is essential, and we have a good network we work with. We have a private MDT, so every private patient is discussed before a decision is made, and it does not rest on me or any one person to decide the best treatment. Specialist dietitians also help patients on their journey, before and after treatment. All the radiologists who review my patients' scans are HPB radiologists, not general radiologists, and even when a patient has had a scan elsewhere it is re-reviewed by specialist radiologists and goes through the MDT.

As an example, a patient in his 40s came to me recently with a large splenic cyst that looked entirely benign. He had been recommended surgery on the NHS but wanted it done faster privately. I took him through the same process and the MDT, and the specialist radiologist identified a pancreatic cyst that had been missed in the initial report. It is unlikely to affect his management and is a benign incidental finding, but certain types of pancreatic cyst carry a low lifetime risk of conversion to malignancy, so it still matters. That is the level of care, and the depth of specialist expertise, that the whole team provides, right through to the surgical care.

What are your areas of sub-specialist interest?

My subspecialty interest is complex cancer surgery. Since 2008, at least for pancreatic cancer, surgery has been centralised in HPB cancer services. Until then every hospital could operate on HPB cancer cases, but evidence showed that the more you do, the better you become, as in any technical profession, and the team around you also gets better at looking after patients. That is how centralisation came about.

Even so, specialist centres offer a variety of treatment options, and some are stronger in one area than another. For example, another centre may be better at minimally invasive approaches. My interest is in what we call locally advanced or locally extended cancer, where the tumour involves major vascular structures or other organs. These patients need a very specific, structured and timely approach to reach a good outcome. It should never be a case of doing something and seeing what happens: there has to be a plan, and the plan has to be delivered in a particular way.

My fellowship training was based on this. With training in both HPB and transplant surgery, I have the expertise and skills to perform a lot of vascular resections and reconstructions. When I came back to the UK, I established the programme at the Queen Elizabeth Hospital Birmingham. There is no other programme in the UK to compare it with, and we benchmark ourselves only against huge centres around the world. With HCA coming to Birmingham, I had the opportunity and the facilities to bring this to the private sector. Cases that are deemed inoperable or palliative can still have a chance of longer-term survival if they go down this pathway, either in the NHS in Birmingham or in the private sector if they wish.