Hepatobiliary and Pancreatic Surgery
Introduction
The main targets of the Hepatobiliary and Pancreatic Surgery Division are true malignant tumors. In recent years, it has been possible to diagnose many borderline malignancies and benign tumors, including a wide variety of adenomas and hyperplasia, as distinguished from true malignancies. Curative resection is indicated for patients with true hepatobiliary pancreatic malignancies. However, limited resection is indicated for patients with benign or borderline malignancies which were, recently, markedly increasing. The hepatobiliary and pancreatic tumors are collectively treated by both medical and surgical oncology groups as an integrated clinical activity. Staff meetings are held 3 times a week and the treatment strategies are discussed from medical and surgical viewpoints. As a result, our treatment regimens have been developed in close co-operation with medical oncologists and radiologists.
Routine Activities
The Division includes four consultant surgeons, several residents, and unpaid volunteer-trainee doctors. The outpatient clinic is open 4 days a week. In 1998, we performed hepatectomy in 92 patients, including 42 patients with hepatocellular carcinoma (HCC), 30 with liver metastasis, and 16 with biliary tract cancer. Pancreatectomy was performed in 17 patients with pancreatic cancer and in 4 patients with bile duct cancer. Bypass operation combined with intraoperative radiotherapy was performed in 9 patients with locally advanced pancreatic cancer. To determine the exact extent of the cancer before surgery, we conducted CT cholangiography, MR cholangiography, endoscopic retrograde pancreatography (ERP)-CT, cholangioscopy, and pancreatoscopy.
We performed hepatectomy in 205 patients with HCC over the last 6 years. The 5-year survival rate for 205 patients who underwent resection was 48%. However, the 5-year survival rate for 110 patients who underwent percutaneous ethanol injection (PEI) was also 48%.
We compared survival after resection, PEI, and transcatheter arterial embolization (TAE) in patients with similar prognostic factors. In patients with HCC having three or fewer tumors 30 mm or smaller in size, the 5-year survival rates for 31 patients who underwent resection and patients who underwent PEI were significantly better (70% and 50%, respectively) than that of patients who underwent TAE alone (30%). In patients with HCC having a tumor size of 31-50 mm, the 5-year survival after resection (58%) was significantly better than that after TAE (34%). In HCC patients with a tumor size of 51 mm or larger, the 5-year survival rate after resection (32%) was significantly better than that after TAE (9%). Our results suggest that resection is, consistently, the most effective method of treatment for HCC.
In patients with liver metastasis originating from colorectal cancer, the 5-year survival rate after resection was 66%. The 5-year survival rate of patients with synchronous metastatic cancer was 58% and that of patients with metachronous liver metastasis was 88%.
The survival of patients with ductal invasive pancreatic cancer and biliary tract cancer remained very poor. In ductal invasive pancreatic cancer, only 44 of 124 patients (24.6%) were resected and the 5-year survival rate after resection was 16%. In bile duct cancer, 73 of 161 patients (45.3%) were resected and the 5-year survival rate after resection was 23%. In gallbladder cancer, 24 of 84 patients (28.6%) were resected and the 5-year survival rate after resection was 48%. The patients with only papilla vater cancer had a relatively high 5-year survival rate (62%).
An increase has been found in the incidence of malignant tumors other than ductal invasive cancer of pancreas and also benign tumors. The 5-year survival rate of 23 patients with benign pancreatic tumor (100%) was significantly better than that of 44 patients with malignancy other than ductal invasive cancer (78%). In view of our results, we think safe and function-preserving limited resection should be done in patients with benign tumor or low-grade malignancies in the pancreas.
New Developments
1. Operative Microwave Coagulation Therapy
PEI has become one of the most effective treatment modalities for patients with HCC. However, PEI has some limitations, because alcohol diffusion is often incomplete and residual viable neoplastic tissue can persist along the periphery of the nodule or in portions isolated by septa. To overcome this problem, we have performed microwave coagulation therapy (MCT) during surgery. Operative MCT was conducted for three patients who had inadequate liver function for hepatic resection or multiple malignant lesions. The liver cancers were completely coagulated by MCT under intraoperative ultrasonic guidance. Post operative course was uneventful and all patients are alive without recurrence. We expect that MCT will be an effective therapy for liver cancer.
2. TAE of the Collateral Vessels to the Liver One Day before Hepatic Resection
One of the major risks in hepatic surgery is a large amount of blood loss. Thus, there are compelling reasons to minimize blood loss during hepatic resections by developing a safe and reproducible method, especially in patients with huge tumors and with marked collateral vessels. For this purpose, we have been performing TAE of collateral vessels such as the phrenic artery, just one day before resection. We performed this procedure in 4 patients and we could perform hepatic resection without any serious blood loss from the collateral vessels. These results suggest that TAE of collateral vessels such as the phrenic artery, just one day before resection, is safe and effective for patients with marked collateral vessels to the liver.
Statistics
| Disease | No. of pts | No.of operated pts | in hospital mortality |
| HCC | 44 | 42 | 1 |
| CCC | 7 | 6 | 1 |
| Liver metastasis | 32 | 30 | 0 |
| Biliary tract | 29 | 19 | 1 |
| Pancreas | 26 | 17 | 1 |
| Others | 34 | 34 | 0 |
| Total | 172 | 4 (2.3%) |
| Disease | No. of pts | 5-yr survival rate (%) |
| HCC | 205 | 48 |
| Metastatic liver cancer | 98 | 66 |
| Bile duct cancer | 73 | 23 |
| Gallbladder cancer | 24 | 48 |
| Papilla Vater cancer | 16 | 62 |
| Ductal invasion pancreatic cancer | 44 | 16 |
| Other pancreatic malignancies | 44 | 78 |
| Benign tumor of the pancreas | 23 | 100 |
(M. Ryu)
