Department of Hepatobiliary and Pancreatic Surgery
Kazuaki Shimada, Minoru Esaki, Satoshi Nara, Yoji Kishi, Yoichi Miyata
The Department of Hepatobiliary and Pancreatic (HBP) Surgery deals with malignant neoplasms arising from the liver, biliary tract including the gallbladder and pancreas. We conduct aggressive surgical treatment and also multidisciplinary treatment in cooperation with the Department of Diagnostic Radiology, Department of Hepatobiliary and Pancreatic (HBP) Oncology and Division of Pathology.
The HBP Surgery Department consists of four staff surgeons and we perform around 300 surgeries each year, along with one chief resident and three or four residents. Occasionally, trainees from both Japan and overseas join our group.
Operation and perioperative care
Five to seven major operations for hepatobiliary and pancreatic malignancies are performed every week. One staff surgeon and one resident are in charge of each patient, and conduct the operation and provide postoperative care. The chief resident attends all the operations, supervises the residents and manages the care of all inpatients.
We have several clinical or educational conferences on the treatment of HBP malignancies. At the “Ward Conference”, the clinical conditions of the perioperative patients and surgical strategies for preoperative cases are discussed. At the “Cherry Conference,” surgeons and radiologists discuss imaging studies of mainly the patients scheduled for surgery. An “HBP Case Conference” is held by surgeons and medical oncologists to discuss the clinical course of both surgical and medical patients as well as common issues among HBP malignancies. The “Micro Conference” is a pathological conference on postoperative cases, where surgeons, radiologists, and pathologists participate in the discussion. In the “Research conference”, which is held every three months, the progress of academic studies including clinical research and paper writing are evaluated.
Surgical strategies for HBP malignancies
Hepatocellular carcinoma (HCC): Surgical treatment for HCC is always determined based on the balance between tumor condition and hepatic functional reserve. Surgical resection is usually indicated in patients with solitary or only a few tumors and with favorable hepatic function. A huge tumor or HCC with macroscopic vasculobiliary tumor thrombosis are also indicated for resection as long as sufficient hepatic function and remnant liver volume is expected. Alternative treatments other than hepatectomy are performed in cooperation with medical oncologists and radiologists.
Pancreatic cancer: The prognosis of patients with invasive ductal carcinoma is poor even with aggressive surgical resection. Multidisciplinary treatments with curative resection followed by adjuvant chemotherapy is the standard strategy for this potentially noncurative disease. Resection of borderline malignancies, such as pancreatic cystic neoplasms, neuroendocrine tumors (NETs) is performed aggressively, since a favorable prognosis can be expected with surgical resection.
Biliary cancer – cholangiocarcinoma and gall bladder cancer: Based on careful imaging evaluations of cancer extension, a wide variety of surgical resections can be applied to biliary cancer. Pancreatoduodenectomy is conducted for middle to distal bile duct cancer. Extended hemihepatectomy with extrahepatic bile duct resection is considered as the first-line procedure for perihilar cholangiocarcinoma. When necessary, portal vein and/or hepatic artery resection and reconstruction is performed to achieve curative resection.
Laparoscopic surgery: For the liver tumors located in the peripheral site, laparoscopic lateral bisegmentectomy or partial resection is considered as a choice of treatment. Laparoscopic distal pancreatectomy is considered for slowly growing malignant tumors.
Dr. Shimada et al. conducts one prospective randomized trial to evaluate the safety of drain tube free hepatectomy (the safety of liver surgery with No-Drain policy: a multicenter randomized controlled trial, ND-trial) and plans another multi-institutional trials to evaluate the efficacy of administrating digestive enzymes to prevent postoperative hepatic steatosis in the patients who underwent pancreat icoduodenectomy (comparison of Berizym and Pancrelipase for the effect to suppress onset of Hepatic Steatosis after Pancreaticoduodenectomy, ESOP Trial). Dr. Kishi attends an international collaboration project by EORTC (European Organisation for Research and Treatment of Cancer) and JCOG (Japan Clinical Oncology Group) as a Japanese side manager. The project is to evaluate the accuracy of Diffusionweighted Magnetic Resonance Imaging for the assessment of diminishing colorectal liver metastases by chemotherapy, which is named “Diffusion-weighted Magnetic REsonance Imaging Assessment of Liver Metastasis, DREAM study”. This trial is to be started in August 2016.
Each staff attend three to four domestic or international academic meetings per year. Residents and Chief residents also have opportunities to make a presentation with the assistance of staff surgeons.
In addition to the abovementioned two RCTs (ND-trial and ESOP trial) and DREAM study, we attend a JCOG1202 phase III trial that evaluates the efficacy of adjuvant S-1 treatment in the patients who underwent curative surgical resection for biliary tract cancer (a phase III trial of S-1 vs. observation in patients with resected biliary tract cancer, ASCOT trial).
During three to six months of the trainee period, every week, each resident attends one to two major HBP surgeries mainly as a first assistant. They also have the chance to be an operator depending on their skill. For each case, they learn how to decide the indication and type of procedure. In the operation room, the residents learn not only each step of HBP surgery, but also tips on how to help safely proceed with the surgery. The chief resident trains them in a two-year program. In the first year, they devote themselves to the management of all inpatients and attend basically every surgery. Depending on the development of their skills, they have the opportunity to be an operating surgeon for major HBP surgery. In the second year, the chief resident works on research studies and publishes several English papers. Motivated residents also have the opportunity to make presentations in academic meetings and write English papers.
Visitors from both domestic and foreign institutions are welcome anytime.
HBP malignancy often requires technically demanding surgical procedures, whereas the longterm prognosis so far is not satisfactory. Our most important mission is to establish more safe and feasible surgical techniques including perioperative patient management, and to promote survival outcomes by multidisciplinary approaches. Due to the recent advances of chemotherapy, we have experienced a few patients who achieved curative surgical resection for initially unresectable pancreatic cancer due to local advancement. So the feasibility of conversion therapy should be assessed prospectively. We continue making efforts to create new skills and treatment strategies.
List of papers published in 2015
- Oguro S, Esaki M, Kishi Y, Nara S, Shimada K, Ojima H, Kosuge T. Optimal indications for additional resection of the invasive cancer-positive proximal bile duct margin in cases of advanced perihilar cholangiocarcinoma. Ann Surg Oncol, 22:1915-1924, 2015
- Kinoshita T, Kinoshita T, Saiura A, Esaki M, Sakamoto H, Yamanaka T. Multicentre analysis of long-term outcome after surgical resection for gastric cancer liver metastases. Br J Surg, 102 (1):102-107, 2015
- Shirota T, Ojima H, Hiraoka N, Shimada K, Rokutan H, Arai Y, Kanai Y, Miyagawa S, Shibata T. Heat shock protein 90 is a potential therapeutic target in cholangiocarcinoma. Mol Cancer Ther, 14 (9):1985-1993, 2015
- Nakamura M, Wakabayashi G, Miyasaka Y, Tanaka M, Morikawa T, Unno M, Tajima H, Kumamoto Y, Satoi S, Kwon M, Toyama H, Ku Y, Yoshitomi H, Nara S, Shimada K, Yokoyama T, Miyagawa S, Toyama Y, Yanaga K, Fujii T, Kodera Y, Study Group of JHBPS, JSEPS, Tomiyama Y, Miyata H, Takahara T, Beppu T, Yamaue H, Miyazaki M, Takada T. Multicenter comparative study of laparoscopic and open distal pancreatectomy using propensity score-matching. J Hepatobiliary Pancreat Sci, 22:731-736, 2015
- Gotohda N, Yamanaka T, Saiura A, Uesaka K, Hashimoto M, Konishi M, Shimada K. What are the True Advantages of Devices for Hepatic Parenchymal Transection in Open Surgery? Reply. World J Surg, 39:3030-3031, 2015
- Kishi Y, Shimada K, Nara S, Esaki M, Kosuge T. Administration of Pancrelipase as Effective Treatment for Hepatic Steatosis After Pancreatectomy. Pancreas, 44 (6):983-987, 2015
- Hiraoka N, Ino Y, Yamazaki-Itoh R, Kanai Y, Kosuge T, Shimada K. Intratumoral tertiary lymphoid organ is a favourable prognosticator in patients with pancreatic cancer. Br J Cancer, 112 (11):1782-1790, 2015
- Nakamura H, Arai Y, Totoki Y, Shirota T, Elzawahry A, Kato M, Hama N, Hosoda F, Urushidate T, Ohashi S, Hiraoka N, Ojima H, Shimada K, Okusaka T, Kosuge T, Miyagawa S, Shibata T. Genomic spectra of biliary tract cancer. Nat Genet, 47 (9):1003-1010, 2015
- Fukutake N, Ueno M, Hiraoka N, Shimada K, Shiraishi K, Saruki N, Ito T, Yamakado M, Ono N, Imaizumi A, Kikuchi S, Yamamoto H, Katayama K. A Novel Multivariate Index for Pancreatic Cancer Detection Based On the Plasma Free Amino Acid Profile. PLoS One (7), 10:e0132223, 2015
- Gotohda N, Yamanaka T, Saiura A, Uesaka K, Hashimoto M, Konishi M, Shimada K. Impact of energy devices during liver parenchymal transection: a multicenter randomized controlled trial. World J Surg, 39:1543-1549, 2015
- Miyazaki M, Yoshitomi H, Miyakawa S, Uesaka K, Unno M, Endo I, Ota T, Ohtsuka M, Kinoshita H, Shimada K, Shimizu H, Tabata M, Chijiiwa K, Nagino M, Hirano S, Wakai T, Wada K, Isayama H, Iasayama H, Okusaka T, Tsuyuguchi T, Fujita N, Furuse J, Yamao K, Murakami K, Yamazaki H, Kijima H, Nakanuma Y, Yoshida M, Takayashiki T, Takada T. Clinical practice guidelines for the management of biliary tract cancers 2015: the 2nd English edition. J Hepatobiliary Pancreat Sci, 22 (4):249-273, 2015
- Utsumi H, Honma Y, Nagashima K, Iwasa S, Takashima A, Kato K, Hamaguchi T, Yamada Y, Shimada Y, Kishi Y, Nara S, Esaki M, Shimada K. Bevacizumab and postoperative wound complications in patients with liver metastases of colorectal cancer. Anticancer Res, 35:2255-2261, 2015
- Morita S, Onaya H, Kishi Y, Hiraoka N, Arai Y. Multiple Intraglandular Metastases in a Patient with Invasive Ductal Carcinoma of the Pancreas. Intern Med, 54:1753-1756, 2015