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 resections which preserve organ function, is indicated for patients with benign or borderline malignancies. However, some diseases such as invasive pancreatic cancer, gallbladder cancer, hilar and intrahepatic cholangio-carcinoma are still associated with dismal long-term prognosis. Therefore, both medical and surgical oncology groups as an integrated clinical activity collectively treat the hepatobiliary and pancreatic tumors. As a result, our treatment regimens have developed in close co-operation with medical oncologists and radiologists.

Routine Activities 
This division includes five attending surgeons, two chief residents, and three to four residents. The out patients 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 imaging diagnosis on every Tuesday in co-operation with radiologists and medical oncologists, and a monthly pathologic conference with pathologists.
Treatment strategy for HCC is based on number of lesions, tumor size and liver function. Surgical treatment is feasible in patients with relatively good liver function (Child-Pugh: A or B). When the number of tumors is 3 or less and each tumor is smaller than 30 mm in size, the efficacy of surgical treatment is similar to that of percutaneous ablation therapy. We started a multi-institutional prospective randomized study comparing the therapeutic efficacy between surgery and ablation therapy in such cases. Nevertheless, in those having tumor over 31 mm, we believe that hepatectomy is the most effective for achieving local control, if the liver function tolerates the hepatic resection. 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 intraoperative ablation therapy or transcatheter arterial embolization following the operation. In the patients treated with such a debulking surgery, 2-year survival rate was 43%.
Pancreatic cancer is a devastating disease. More than 80% of the pancreatic cancer patients undergoing curative resection die within 5 years of surgery, and standard therapeutic strategy is not yet established. Two multi-institutional prospective randomized studies are now underway. First trial is a comparative study between extended radical and standard techniques of pancreaticoduodenectomy. Second is a study evaluated the efficacy of intraoperative radiation therapy (IORT). On the other hand, we have been trying to develop 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 (intraductal papillary-mucinous neoplasm, 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 cholangio-carcinoma. 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. In those with disease requiring more than a right hepatectomy, transileocecal portal embolization is performed before the surgery.
Since the opening of our hospital, we have aggressively performed hepatic resection for liver matastasis from colorectal cancer. Extended lobectomy plus partial resection is considered as the upper limit of hepatectomy. Overall 5-year survival rates after initial hepatectomy was 53%.


New Developments in 2002
Prospective randomized trial of intraoperative radiation therapy for pancreatic cancer
The prognosis for patients with pancreatic cancer is dismal. Although surgical resection offers the only hope of long-term survival, it is clear that additional therapy is needed. In order to improve the treatment results, IORT had been indicated to the patients in addition to the surgical resection, but efficacy of IORT is still controversial. Therefore, we conducted a multi-institutional prospective randomized trial, comparing therapeutic efficacy between surgery alone and that with IORT. The patients with resectable pancreatic cancer are preoperatively randomized into the IORT group or surgery alone group. The former group received 25 Gy IORT to the tumor bed after curative resection.

M. KONISHI

Table of Contents