Hepatobiliary and Pancreatic Surgery

Introduction
In hepatobiliary and pancreatic surgery division, we manage quite a few diseases, because the recent development of various diagnostic techniques has increased the number of borderline malignancies and benign tumors in these days. Limited resection which preserve organ function comes to be indicated for the patients with benign or borderline malignancies. However, some diseases such as invasive pancreatic cancers, gallbladder cancers, hilar and intrahepatic cholangiocarcinomas are still associated with dismal long-term prognosis. Therefore, we combine both medical and surgical oncology groups to be an integrated clinical activity in order to treat the hepato-biliary and pancreatic tumors collectively. Actually our treatment regimens have developed in close co-operation with medical oncologists and radiologists.

Routine Activities　
This division includes six consultant surgeons, two chief residents, and two to three residents. The outpatient clinic is open 5 days a week. We have staff meetings 3 times a week, and discuss the treatment strategies from medical and surgical points of view. We have a case conference of image diag-nosis on every Tuesday in co-operation with radiologists and medical oncologists, and a monthly pathologic conference with pathologists.
Treatment procedures indicated to HCC are actually different by number of lesions, tumor size and liver function. Surgical treatment is feasible only in the patients with relatively good liver function (Child-Pugh: A or B), and in those with tumor of which size is ranged 21-30 mm, the choice of treatment depends on the patientis will (hepatectomy or believe that hepatectomy is the most effective for achieving local control. Even for the cases of which main tumor size is over 70 mm, or those having intrahepatic metastases in the contralateral lobe, aggressive surgery is available. In addition, when residual tumors are observed in the remnant liver, we can treat the patients with additional surgical abrasion therapy or transcatheter arterial embolization during the operation. In the patients treated with such a debulking surgery, 2-year survival rate was 43%.
Pancreaticoduodenectomy is commonly indicated to an invasive ductal pancreatic cancer. However, more than 80% of the patients who underwent curative resection die within 5 years after surgery. In order to improve the treatment results, intraoperative radiation therapy (IORT) had been indicated to the patients in addition to the surgical resection, but efficacy of IORT is still controversial. Therefore, we are planning to conduct a multiinstitutional prospective randomized trial, comparing the therapeutic efficacy between the surgery alone and that with IORT. On the other hand, we have been trying to progress limited surgery, such as duodenum- preserving pancreas head resection, local resection of inferior head of the pancreas and partial pancreatic resection, for the patients with borderline malignancies and benign tumors (mucin-producing tumor, solid cystic tumor and neuroendocrine tumor).
In biliary tract cancer, we perform surgical therapy for the patients without distant metastases. We think that extended hepatic resection is necessary for the patients with gallbladder cancer and hilar cholangiocarcinoma. In the patients with advanced gallbladder cancer, we perform systematic S4a+5 hepatectomy or extended right hepatectomy. In those with hilar cholangiocarcinoma, we perform right or left hepatectomy with resection of the caudate lobe, and in those with disease requiring more than a right hepatectomy, portal embolization is performed before the surgery.

New Developments
New technique for the right hepatectomy
Liver surgery will not fall into disuse, considering the current widespread of the minimal invasive surgery. We developed a new and simple technique of the right hepatectomy with an upper midline incision carried out with the liver-hanging maneuver that had been invented by Belghiti. In this technique, we divide and cut the cystic duct, right hepatic artery, right portal vein and right hepatic duct, respectively. And, we perform the complete hepatic division at the Rex-Cantlieis line exposing the middle hepatic vein under Pringle maneuver using liver-hanging maneuver. Then, we divide and cut the short hepatic veins, Makuuchiis inferior right hepatic vein, and finally the right hepatic vein. The final surgical step is the dissection of the right round and triangle ligaments. This approach is feasible and reproducible.

M. KONISHI

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