Table of Contents
Routine Activities
The surgery group includes four consultant surgeons, several residents, and doctors involved with voluntary training. The outpatient clinic is open 4 days a week. In 1997, we performed surgery for 224 patients including 41 with hepatocellular carcinoma (HCC), 16 with metastatic liver tumors, 24 with biliary tract cancers, 24 with pancreatic cancers, and 119 with gastric and other malignancies. We also performed transhepatic bile drainage, abscess drainage, and postoperative fistulography every 3 days in a week. To ascertain the precise extent of cancer preoperatively, we conducted CT cholangiography, MR cholangiography, cholangioscopy and pancreatoscopy.
Aggressive but function-preserving surgery, using multimodality treatments, is indicated for patients with hepatobiliary pancreatic cancer.
We have performed hepatectomy for 129 patients with previously untreated HCC over the last 5 years. We found that in those without macroscopic tumor embolus in the main portal trunk [Vp(-)], the mean blood loss (MBL) was 681 ml in the 44 patients receiving a partial hepatic resection, 895 ml in 16 with subsegmentectomy, 1323 ml in 21 with segmentectomy, 1035 ml in 26 with bisegmentectomy, and 1980 ml in 5 with trisegmentectomy. In the 17 patients with macroscopic portal tumor embolus in the main portal trunk [Vp(+)], however, MBL was 2555 ml, i.e. significantly greater than those observed in Vp(-) cases. The mean operative times for patients who underwent partial resection, subsegmentectomy, segmentectomy, bisegmentectomy and trisegmentectomy among the Vp(-) cases, were 3h 44m, 4h 30m, 3h 48m, 4h 20m, and 5h, respectively. In the 17 Vp(+) patients, it was 4h 48m, i.e. not significantly different from that observed in the Vp(-) group patients. The overall 5-year survival rate was 52% and that of the Vp(-) group (n=112) (65%) was significantly better than the 23% of the vp(+) group (n=17). we have four 2-year survivors in the vp(+) group. in view of these four patients, we feel that, as long as a safe surgical method is available, aggressive resection is warranted, in an attempt to improve survival.
New Developments
1. Remote after loading system with 192-Iridium (RALS): In 8 patients who underwent palliative bile duct resection, the residual cancers at the resected margin were irradiated for this treatment modality. Six of the 8 patients are currently alive without recurrence and only one has had recurrence with jaundice. We expect that RALS will be an effective adjuvant therapy for advanced bile duct cancer after palliative resection.
2. Stomach-preserving gastric bypass (SPGB): We have been performing SPGB for unresectable pancreatic cancer. To date, it has been carried out for 25 patients and other types of bypass for 5. Although the mean operative time for SPGB was longer than that for the other types of bypass, the mean intraoperative blood loss was similar. In the patients undergoing SPGB, the incidence of delayed gastric emptying was 25%, but the comfort index (ratio of good palliative duration to survival duration) exceeded 50% when metastases were either regional or systemic but limited. The comfort index of patients undergoing other types of bypass was less than 40%. These results suggested that SPGB is safe and effective for patients with either regional metastases or limited systemic metastases.
Statistics
| Disease | No. of pts | No. of surgical pts |
| HCC | 41 | 35 |
| Liver Meta. | 16 | 16 |
| Biliary Tract | 24 | 24 |
| Pancreas | 24 | 15 |
| No. of pts | 5-yr survival rate | |
| Vp(+) group | 17 | 23% |
| Vp(-) group | 112 | 65% |
| Total | 129 | 52% |
| Surgical procedure | No. of pts | 3-yr survival rate |
| Vp(-) group | ||
| Partial resection | 44 | 67 % |
| Subsegmentectomy | 16 | 100 % |
| Segmentectomy | 21 | 49 % |
| Bi-segmentectomy(Hr2) | 26 | 72 % |
| Tri-segmentectomy | 5 | 20 % |
| Vp(+) group | ||
| HR2 or ext.HR2 | 17 | 24 % |
| Total | 129 | 52 % |
| Surgical procedure | No. of pts | Mean blood loss (ml) | Mean operative time |
| Vp(-) group | |||
| Partial resection | 44 | 681 | 3h 44m |
| Subsegmentectomy | 16 | 895 | 4h 30m |
| Segmentectomy | 21 | 1,323 | 3h 48m |
| Bi-segmentectomy (Hr2) | 26 | 1,035 | 4h 20m |
| Tri-segmentectomy | 5 | 1,980 | 5h |
| Vp(+) group | |||
| HR2 or ext.HR2 | 17 | 2,555 | 4h 48m |
| Total | 129 | ||
| Surgical procedure | No. of pts | No. of pts who received BTF |
| Vp(-) group | ||
| Partial resection | 44 | 11 (25%) |
| Subsegmentectomy | 16 | 2 (25%) |
| Segmentectomy | 21 | 8 (38%) |
| Bisegmentectomy (Hr2) | 26 | 11 (42%) |
| Trisegmentectomy | 5 | 3 (60%) |
| Vp(+) Group | ||
| Hr2 or ext.HR2 | 17 | 11 (65%) |
| Total | 129 | 48 (37%) |
(M. Ryu)