Hepatobiliary and Pancreatic Surgery Division

Introduction
The Hepatobiliary and Pancreatic (HBP) Surgery Division deals almost exclusively with malignant neoplasms arising from the liver, biliary duct system, and pancreas. Those include tumors that are potentially malignant such as cystoadenomas of the liver, endocrine tumors, or mucinous cystic tumors of the pancreas. We also manage patients with secondary hepatic neoplasms from any primary site. In this field of diseases, a complete cure by surgical therapy can be achieved in only selected patients. Thus, we treat patients in close cooperation with medical oncologists and radiologists experienced in this area.

Routine Activities
The HBP Surgery Division has four attending surgeons. Our division also includes one chief resident, three or four residents, and several trainees from Japan and from overseas.
Our outpatient service is open on weekdays, and about 300 new patients are accepted annually. Subteams compromised of two attending physicians and a resident conduct the hospital care. A chief resident supervises residents and trainees and manages the care of all hospital patients. The surgical team makes daily brief inpatient rounds, and there are weekly inpatient rounds made jointly with medical oncologists. On average, 5-6 major surgeries are carried out every week.
Three weekly conferences are held: (1) an HBP case conference with surgeons and medical oncologist, (2) an imaging diagnostic case conference in co-operation with radiologists and medical oncologists, and (3) a surgico-anesthesiologic conference with the anesthesiology division. Biweekly surgico-pathologic conferences are held with pathologists. The latest papers dealing with current subjects in biliary and pancreatic diseases are introduced at the Journal Club of Pancreatology held biweekly.

Treatment Strategy
Hepatocellular carcinoma (HCC): Aggressive surgical intervention is plagued by compromised hepatic functional reserve because of frequently associated chronic liver disease. Non-cirrhotic or cirrhotic patients with Child-Pugh grade A or B liver function, who do not have distant metastases, are candidates for local therapy, including surgical resection, percutaneous ethanol enjection (PEI) or radiofrequency themal ablation therapy (RFA). The indications for resection include HCCs of TNM stages I, II, IIIA, IIIB, and part of IVA, if liver function permits. The remaining patients with local desease but without sufficient hepatic functional reserve for surgery undergo PEI or RFA, and those with advanced widespread diseases are treated by trans-arterial chemoembolization (TAE). Bile duct carcinoma, gall bladder carcinoma, and pancreatic carcinoma: A patient with a locally resectable tumor, who has no distant metastases or peritoneal dissemination is a candidate for resection therapy. When the disease is diagnosed as un-resectable from pre- or intraoperative findings, chemoradiation therapy is a treatment option. In cases of curatively resected pancreatic duct cell carcinoma, postoperative adjuvant chemotherapy is performed according to the protocol study program. Preoperative biliary decompression is performed when a patient has obstructive jaundice due to biliary or pancreatic tumors. Trans-ileocolic portal venous branch embolization is performed to enhance the safety of surgery for patients with diseases requiring major hepatic resection (more than a right lobectomy) to achieve compensated hypertrophy of the future remaining liver. This procedure is used in patients with hilar cholangiocarcinomas, gall bladder carcinomas, HCCs and metastatic liver tumors.

Research Activities
Our division is involved in the following studies and reviews:
1. This study is a histological analysis of 90 new lesions detected by intraoperative ultrasound (IOUS) in 79 liver resections for hepatocellular carcinoma. IOUS should be mandatory in liver resection for HCC because it is useful for finding new lesions and might contribute to prediction of the histologic features (Takigawa Y et al).
2. This study revealed that the factors that influenced the patient s prognosis in hepatic resection for metastatic liver tumors from colorectal cancer were different between the synchronous and metachronous groups. It may be useful to develop a staging system that considers this difference (Sugawara Y et al).
3. This is an analytical study of preoperative and postoperative variables in 60 patients who underwent hepatectomy for mass-forming intrahepatic cholangiocarcinoma with curative intent. A proposal of a new staging system for mass-forming intrahepatic cholangiocarcinoma (Okabayashi T et al). This comparative study was conducted to clarify the efficacy of percutaneous ethanol injection (PEI) and surgical resection in the treatment of small hepatocellular carcinomas (HCC). Cumulative 1-, 3-, and 5-year tumor-free survival rates in the PEI group were 63.4%, 30.3%, and 9.7 %, whereas those in the surgery group were 75.5%, 44.7%, and 25.7%, respectively (P =. 10). our overall findings show that local therapy can achieve an actual 5-year survival rate of around 60% for patients with small HCC with the proper selection of treatment. A prospective randomized comparative trial is required to settle this longstanding issue (Yamamoto J et al).

Clinical Trials
Two clinical trials are ongoing. One is a multi-nstitutional prospective randomized trial designed to evaluate postoperative adjuvant chemotherapy for pancreatic ductal adenocarcinoma. Another is a multiinstitutional prospective randomized study comparing surgical resection and percutaneous ethanol injection for small hepatocellular carcinoma. In both trials, the collection of cases will be started in April 2002.

K. SHIMADA

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