Dr. Ian McGilvray believes too many patients with liver cancer are being told to go home and die without being given a chance.

He is among a team of surgeons at Toronto General Hospital who are steadily working on new techniques to remove some of the toughest tumours lurking in patients’ abdomens.

They believe their experience doing liver transplants gives them an edge in carving out complex tumours enmeshed in the arteries and veins that weave in and out of the liver.

McGilvray, one of two surgeons who do both liver transplant and liver cancer surgery at Toronto General, has led the push to operate on those otherwise deemed inoperable.

So far, just a small number of people have benefited from his surgical skill.

But McGilvray says that extending the limits of care for an individual patient can help propel the whole field of medicine forward: By offering hope to what many consider a hopeless case, it will press other physicians to reconsider the traditional definition of what is incurable cancer.

Last summer, against many odds, Mark Bauer became McGilvray’s 22nd patient to undergo the experimental liver surgery. The 47-year-old could hardly believe he had a chance at being cancer-free.

It had been nine years, after all, since Bauer was told the tumour that engulfed his liver was inoperable.

While it has a remarkable ability to regenerate, operating on the liver is a nervy business that requires a careful and gentle hand.

The purplish brown triangular organ is fed by large pulsing veins and arteries that branch off into hundreds of minute vessels. Hundreds of tiny bile ducts, too, course through the organ.

For an inexperienced surgeon, the liver can seem like a big, blood-filled sponge that when torn or cut incorrectly will bleed out at an alarming rate. Each minute about 1 1/2 litres of blood swishes through the organ.

McGilvray says until as recently as 20 years ago, there was a fear among general surgeons that just touching a patient’s liver the wrong way could do irreparable harm.

And 50 years ago, when Dr. Bernard Langer started working at Toronto General in 1964, virtually no liver surgery was performed at the hospital.

“Some was being done elsewhere in the world,” he recalls, “but there was nowhere to train and those who were doing it did not train young surgeons.”

So Langer taught himself how to operate on the liver, primarily from studying techniques described in books.

In the early years, Langer says the main hazard in the operating room was not being able to see the tangle of arteries and veins underneath the liver’s smooth, shiny surface.

The advent of modern imaging techniques, including magnetic resonance imaging and CT scans, were a boon to the field because they provided detailed maps of the organ to guide surgeons in their cuts.

“As time went on, we learned — as did others out there — more about the anatomy of the liver and how to protect it during operations,” says Langer, who retired from medicine 10 years ago after pioneering many of the surgical techniques used in liver operations today.

It was while refining techniques for liver transplant, particularly live donor transplants where surgeons remove a portion of a living donor’s organ and implant it into a recipient, that the team of surgeons learned the most about the liver.

McGilvray says these complex surgeries revealed the subtleties of liver anatomy and taught surgeons both how much blood flow the organ needed to stay healthy and ways to reconstruct and reconnect its many vessels and bile ducts. They also learned how to cool the liver and preserve it during the hours-long procedures, and how to re-start it after putting it in a recipient.

And, when every step was done correctly, they found the delicate organ was surprisingly resilient.

In 2005, McGilvray and others at Toronto General — which now boasts the largest live donor liver transplant program in North America — started to investigate whether transplant techniques could have the same success for complicated cancer surgeries.

Since they had already perfected how to separate the liver from its surrounding tissue and safely split the organ in two, it was not a big leap to consider doing the same thing for cutting out an invading, bulbous tumour.

With nearly 2,000 Canadians diagnosed with primary liver cancer each year — and many thousands more with liver tumours as a secondary cancer — it was worth a try.

Around the same time, a few hospitals in the U.S. and other parts of the world were trying out extreme “ex vivo” surgeries for otherwise inoperable cancer. These involved a surgeon removing entire organ systems from a patient, surgically removing the tumour, then putting the repaired contents back in the gaping cavity.

McGilvray thought there was a better, safer way to reach the same finish line: prepare the liver as if it were to be removed for liver transplant, but slice out the cancer while the organ remained inside the patient. The procedure is quicker, he says, and is less traumatic for both the patient and the liver.

More than 20 people have now undergone the modified ex vivo liver surgery.

Often they have colorectal cancer that has spread to the liver. Others have had primary liver tumours wrapped around the main artery feeding the organ. Almost all were told by other cancer specialists they had no chance of being cured.

At 38, he was broad-shouldered and bullishly strong.

The only signs anything might be out of the ordinary that summer were waves of unexplained fatigue and repeated bouts of gout. So it came as a shock when his doctor said that he had cancer — even more so when surgeons in St. John’s shook their heads and stated it was inoperable.

“The doctors told him: ‘If you have life insurance cash it in because you have three to six months to live,’ ” recalls Bauer’s wife, Ann. “It was as blunt as that.”

The Bauers, however, were not ready to give up. Their son, Cody, was just 9 and there were so many things the family still wanted to do together.

They sought second opinions, but each time they were told the same thing: it was too dangerous to operate because the tumour was too big and wound too tightly around the main artery leading into the liver.

“It was pretty hard to argue with them when they point out the problems on the CT scan,” Bauer says. “Still, it wasn’t easy to keep hearing that you’re terminal.”

In 2003, Bauer flew to Edmonton for experimental chemotherapy treatment in the hope it would shrink the tumour enough to make surgery safe.

At the time, chemoembolization — sending concentrated doses of chemotherapy into a tumour after choking off its main blood supply — was a relatively new treatment.

For each of the eight procedures, Bauer had to sign a form waiving the hospital of any liability in case he died on the table.

“They gave us a long line of risks,” he says. “If it leaks out, you are dead. If the injection misses, you are dead. They told me I could go into cardiac arrest at any time.”

Ann said the chemoembolization, for which her husband flew to Edmonton every six weeks, was scarier than the cancer itself.

“I never knew if he was going to get off the plane and come home again.”

That year, the tumour did not shrink. But neither did it grow.

In desperation, the Bauers turned to naturopathy. They believed it was their only hope since traditional medicine had failed.

After months of research, Ann created a special diet for her husband based on raw foods, including raw meat, fish and eggs, and featuring apricot seeds, which some naturopathic doctors claim can kill cancer cells.

By 2007, Bauer’s tumour had shrunk. No doctor could say whether it was from residual chemotherapy, the naturopathic diet or something else.

And though Bauer was alive years longer than any doctor had predicted, the expectation of his death continued to cling to the family. They were never sure what the next week — or day — might bring.

Then, in late 2008, the Bauers moved to Brampton so Ann could upgrade her dental hygiene credentials.

After some time, Bauer found a new family physician, triggering another chain of referrals to gastric specialists, oncologists and other doctors. At least one told him — yet again — that he had just months to live. But another specialist, a gastroenterologist, suggested he meet with surgeons at Toronto General Hospital. There was some hope Bauer could be a candidate for a liver transplant.

Bauer says he almost did not go to the initial appointment at Toronto General. He did not want to listen to yet another death sentence.

But at the last minute, he changed his mind. Neither he nor Ann can say what triggered his change of heart.

As it turned out, Bauer did not meet the criteria for a transplant. But McGilvray saw his chart and believed he could offer something better: he could cut the tumour right out.

McGilvray warned Bauer there was a 10 to 20 per cent chance he would die during surgery. (To date, the mortality rate for this surgery at Toronto General is 8 per cent.)

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The big man, who had already been through so much, just laughed: “I said I got that much risk getting killed on the 401 heading back to Brampton.

“I had complete confidence. To me, a 10 to 20 per cent chance is a lot better than anything else I had gotten.”

Until then, the only certainty Bauer had heard from doctors were assurances he would die of cancer.

They were the first family in the large glass waiting room at Toronto General. As it turned out, they would also be the last to leave that day.

McGilvray was prepared for an eight-hour surgery. As he does for every case, the surgeon had studied Bauer’s liver, devised a plan to remove the tumour and wrote out a multi-page script outlining each step of the process. All the members of the surgical team had a copy.

Because Bauer is such a big man, McGilvray had to make a big incision. He started at the bottom of the rib cage, where Bauer’s ribs meet, then sliced down to the bellybutton before making horizontal cuts out to each side; an inverted T-shape incision, 28 inches in total length.

To get at the liver, which is tucked under the ribs, the surgical team used special retractors to lift Bauer’s ribcage up, then out.

Next, McGilvray worked to release the liver from the ligaments attaching it to the diaphragm and stomach. For such surgeries, it is important to be able to move and manipulate the liver as easily as if you were kneading a loaf of bread.

With the liver free, McGilvray started the meticulous process of teasing the organ away from the main veins and arteries that feed and drain the purplish tissue. His careful hands then turned to the branching bile ducts.

Later, McGilvray would say: “All three hepatic veins were involved, which is why he (Bauer) was repeatedly told an operation wasn’t possible. Even though the tumour was not invading the bile ducts, it was close enough to be a problem.”

Hours later, the liver was ready to be shut down — just as if it were going to be removed from a living donor and made ready for transplant.

First, McGilvray clamped the upper and lower parts of the major arteries and veins leading in and out of the liver, stopping all blood flow. Then, when everything was perfect, he cut the left hepatic vein — the most critical part of the surgery.

Moments later, cold perfusion solution was pumped into the liver to drain it of all blood and to force the organ to almost freezing temperature. The surgical team then packed ice around the liver. Both the solution and the ice are critical to preserve organ function; without a source of blood, the organ will die.

“It’s exactly what we do in liver transplant, except that the liver stays inside the patient,” says McGilvray. “It’s now shut down. You now have 1 ½ hours to do whatever you want — that’s your window.”

By treating this kind of cancer surgery as if it were a transplant operation, it allows McGilvray to take on patients other doctors consider inoperable.

“Before, the liver would die and so would the patient,” McGilvray says. “Now we can shut it down and bring it back alive.”

In the waiting room, Ann and Cody started to get worried after eight hours had passed. By 8 p.m. — 14 hours after Bauer had been wheeled into the surgical suite — Ann was frantic, convinced her husband had died during the operation.

“I cried when he found out he had cancer and I cried on that night. That was the hardest day out of all of this.”

At midnight, Ann and Cody were allowed to see Bauer in the recovery room. They were told the procedure took longer than expected because McGilvray had found more cancer and wanted to be sure all of it was gone.

It also took him hours to rebuild some of the organ’s structures and to carefully piece the remainder of the liver back in place.

A few days later, McGilvray was able to tell Bauer something remarkable: The pathology tests had confirmed he was cancer-free. It was a special moment for both patient and surgeon.

It has been six months and Bauer can still hardly put his feelings into words. There is relief, of course, and a sense the future has opened up too.

Bauer used to pray that he would live to see Cody graduate from high school — something he will do in June. Now, he is looking forward to his son receiving a graduate degree.

“It’s almost like a great big bruise has been cut away from my life . . . that feeling hanging over me is gone now.”

Joanna DiPetta, 52, was McGilvray’s 13th patient. She came to him after her colon cancer — which initially was deemed to be curable in 2008 — had spread to her liver.

McGilvray was the only surgeon who believed he could carve out the tumour and give her another chance at life, which he did during a lengthy surgery in April 2010.

By the following winter, DiPetta was cancer-free. She had five months to enjoy “the miracle,” then her cancer returned.

It’s not clear what is next for DiPetta. But according to McGilvray, it is clear that without the surgery she would almost certainly have died months ago.

“We operate with the intent of “curing” the disease, but realistically achieving that — especially for some very aggressive cancers — is impossible,” he says. “But controlling it for long periods of time is very possible, and offering people life for a significant period of time is often achievable.”

“I don’t want to raise false hope,” he adds. “The techniques are not available to the majority of patients because bad cancers are bad cancers. But there is a significant subset of patients who will benefit.”

DiPetta has no regrets. The surgery offered her and her family something to believe in when there was little around to inspire faith.

“You do whatever is possible,” she says. “You have to. You have to try, because if you don’t nothing would ever advance.”

McGilvray agrees. For him, the surgeries taking place at Toronto General do more than help individual patients. They encourage others in the medical community to try new treatments, be they a surgical technique or novel drug. With each success, he says, more and more cancer patients who would once be given a death sentence are instead offered a new chance.