Annual Report 2019
Department of Hepatobiliary and Pancreatic Surgery
Minoru Esaki, Daisuke Ban, Satoshi Nara, Takeshi Takamoto, Takahiro Mizui, Jun Yoshino, Kazuaki Shimada
Introduction
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 multidisciplinary treatment in cooperation with the Department of Diagnostic Radiology and the Department of Hepatobiliary and Pancreatic (HBP) Oncology and Pathology Division.
The Team and What We Do
The Department of HBP Surgery consists of four staff surgeons. We perform more than 300 surgical procedures each year, with two chief residents and three or four residents. Occasionally, trainees from both Japan and overseas join our group.
Operations and perioperative care
One staff surgeon and one resident are in charge of each patient, and conduct the operations and provide postoperative care. The chief resident attends all the operations, supervises the residents and manages the care of all patients in the ward.
Conferences
Clinical and educational conferences on the diagnosis and treatment of HBP malignancies are held every morning. At the “Ward Conference”, the clinical conditions of perioperative patients and surgical strategies for preoperative patients are discussed in detail twice a week. At the multidisciplinary team conference, the so-called “Cherry Conference”, surgeons, physicians, endoscopists, oncologists, radiologists and medical sonographers discuss imaging studies of the patients who are scheduled for HBP surgery. An “HBP Case Conference” is held by HBP surgeons, endoscopists and oncologists to discuss the treatment strategies mainly for new patients. In a pathological conference, a so-called “Micro Conference”, instructive postoperative cases are discussed, and surgeons, physicians, radiologists, and pathologists participate.
Surgical strategies for HBP malignancies
Hepatocellular carcinoma (HCC): Surgical resection is usually indicated in patients with solitary or only a few tumors and with favorable hepatic function. Resection is also indicated for a large tumor or HCC with macroscopic vasculobiliary tumor thrombosis as long as sufficient hepatic function and remnant liver volume can be expected. Alternative treatments to hepatectomy, such as radiofrequency ablation, microwave ablation and trans-arterial chemoembolizaion, are always available in cooperation with medical oncologists and radiologists.
Pancreatic cancer: Multidisciplinary treatments with curative resection followed by adjuvant chemotherapy are the standard strategy. According to the recent advancement of systemic chemotherapy with improved response, opportunities for conversion surgical resection for initially unresectable cancer due to locally advanced disease status have been increasing.
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. Major resection including pancreatoduodenectomy or extended hemihepatectomy with extrahepatic bile duct resection with or without vascular reconstruction is frequently indicated. A safe and curative resection with careful perioperative management is mandatory.
Laparoscopic surgery: For the liver tumors located in peripheral sites, laparoscopic lateral bisegmentectomy or partial resection is considered as a first choice of treatment. Laparoscopic distal pancreatectomy and laparoscopic spleen-preserving distal pancreatectomy are also performed for patients with low-grade malignant pancreatic tumors. Based on our experience with laparoscopic surgery, we are expanding the indication to major hepatectomy, anatomical sectorectomy/segmentectomy, repeat hepatectomy and invasive ductal cancer of the distal pancreas.
The number of disease and surgical treatments is shown in Table 1 and 2. The long-term outcome after surgery in our department for pancreatic cancer, HCC, and gallbladder cancer is shown in Table 3.
Table 1. Diagnosis for surgical treatment (Between April 2019 and March 2020)
Table 2. Surgical procedures (Between April 2019 and March 2020)
Research activities
Dr. Shimada et al. are conducting two multi-institutional randomized trials. One is to evaluate the safety of drain tube free hepatectomy (ND-trial), for which the results were published in 2020. The other is to evaluate the efficacy of administrating digestive enzymes to prevent postoperative hepatic steatosis in patients who underwent pancreaticoduodenectomy (ESOP Trial), for which patients' recruitment is finished and the data is being analyzed.
We participate in an international collaboration project by EORTC (European Organization for Research and Treatment of Cancer) and JCOG (Japan Clinical Oncology Group). The project is to evaluate the accuracy of Diffusion-weighted Magnetic Resonance Imaging for the assessment of diminishing colorectal liver metastases by chemotherapy (DREAM study).
Dr. Nara is conducting a multi-institutional questionnaire study to evaluate the feasibility of preoperative CT to estimate the TNM stage of biliary cancer in order to prepare for a future phase III study of preoperative chemotherapy for advanced biliary cancer.
Each staff member attends three to four domestic or international academic meetings per year. Residents and chief residents also have opportunities to make presentations with the assistance of staff surgeons.
Clinical trials
In addition to the above-mentioned two RCTs (ND-trial and ESOP trial) and DREAM study, a single institutional clinical trial to evaluate the R0 resection rate following preoperative SIROX therapy for borderline resectable pancreatic cancer was initiated in June 2018. We are also conducting two prospective clinical studies in cooperation with several domestic companies, aiming at developing surgical imaging tools using artificial intelligence to assist liver resection (VAN-GOCH study, MARC01 study).
Education
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 skills. For each case, they learn how to decide the indication and type of procedure based on preoperative images. 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.
Future prospects
HBP malignancy often requires technically-demanding and invasive surgical procedures, but the long-term prognosis is not satisfactory yet. Our most important mission is establishing safer and more feasible surgical techniques including perioperative patient management, and to promote survival outcomes by multidisciplinary approaches. Due to the recent advances in 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.
On the other hand, minimal invasive surgical treatments with laparoscopic surgery are established for selected patients with low-malignant distal pancreatic tumors or primary/metastatic liver cancers which are located peripherally. We started to expand the indication of laparoscopic surgery for patients with more aggressive disease and undergoing repeat surgery.
We will continue to strive to create new skills and treatment strategies. In addition, clinical trials to explore unclarified clinical questions are expected.
List of papers published in 2019
Journal
1. Ishida T, Nara S, Akahoshi K, Takamoto T, Kishi Y, Esaki M, Hiraoka N, Shimada K. Left hepatic trisectionectomy for perihilar cholangiocarcinoma with a right-sided round ligament: A case report. World J Gastrointest Surg, 12:68-76, 2020
2. Iwasaki T, Nara S, Kishi Y, Esaki M, Takamoto T, Shimada K. Proposal of a Clinically Useful Criterion for Early Drain Removal After Pancreaticoduodenectomy. J Gastrointest Surg, 2020
3. Yonemaru J, Takahashi M, Nara S, Ichikawa H, Ishigamori R, Imai T, Hiraoka N. A yolk sac tumor of the pancreas and derived xenograft model effectively responded to VIP chemotherapy. Pancreatology, 20:551-557, 2020
4. Takamoto T, Hashimoto T, Miyata A, Shimada K, Maruyama Y, Makuuchi M. Repeat Hepatectomy After Major Hepatectomy for Colorectal Liver Metastases. J Gastrointest Surg, 24:380-387, 2020
5. Nakamura A, Esaki M, Nakagawa K, Asakura K, Kishi Y, Nara S, Shimada K, Watanabe SI. Three risk factors for pulmonary metastasectomy in patients with hepatocellular carcinoma. Gen Thorac Cardiovasc Surg, 67:782-787, 2019
6. Sugawara S, Arai Y, Sone M, Nara S, Kishi Y, Esaki M, Shimada K, Katai H. Retrospective Comparative Study of Absolute Ethanol with N-Butyl-2-Cyanoacrylate in Percutaneous Portal Vein Embolization. J Vasc Interv Radiol, 30:1215-1222, 2019
7. Hiraoka N, Toue S, Okamoto C, Kikuchi S, Ino Y, Yamazaki-Itoh R, Esaki M, Nara S, Kishi Y, Imaizumi A, Ono N, Shimada K. Tissue amino acid profiles are characteristic of tumor type, malignant phenotype, and tumor progression in pancreatic tumors. Sci Rep, 9:9816, 2019
8. Kishi Y, Nara S, Esaki M, Hiraoka N, Shimada K. Feasibility of resecting the portal vein only when necessary during pancreatoduodenectomy for pancreatic cancer. BJS Open, 3:327-335, 2019
9. Iwasaki T, Hiraoka N, Ino Y, Nakajima K, Kishi Y, Nara S, Esaki M, Shimada K, Katai H. Reduction of intrapancreatic neural density in cancer tissue predicts poorer outcome in pancreatic ductal carcinoma. Cancer Sci, 110:1491-1502, 2019
10. Wada S, Inoguchi H, Sadahiro R, Matsuoka YJ, Uchitomi Y, Sato T, Shimada K, Yoshimoto S, Daiko H, Shimizu K. Preoperative Anxiety as a Predictor of Delirium in Cancer Patients: A Prospective Observational Cohort Study. World J Surg, 43:134-142, 2019
11. Kishi Y, Nara S, Esaki M, Shimada K. Feasibility of “Watch-and-Wait” Management before Repeat Hepatectomy for Colorectal Liver Metastases. Dig Surg, 36:233-240, 2019
12. Sekiguchi M, Igarashi A, Sakamoto T, Saito Y, Esaki M, Matsuda T. Cost-effectiveness analysis of postpolypectomy colonoscopy surveillance using Japanese data. Dig Endosc, 31:40-50, 2019
13. Asano D, Nara S, Kishi Y, Esaki M, Hiraoka N, Tanabe M, Shimada K. A Single-Institution Validation Study of Lymph Node Staging By the AJCC 8th Edition for Patients with Pancreatic Head Cancer: A Proposal to Subdivide the N2 Category. Ann Surg Oncol, 26:2112-2120, 2019
14. Asano D, Nara S, Shimada K. ASO Author Reflections: Clinical Significance of Further Subdivision of N Staging in Pancreatic Cancer. Ann Surg Oncol, 26:766-767, 2019
15. Takamoto T, Makuuchi M. Precision surgery for primary liver cancer. Cancer Biol Med, 16:475-485, 2019
16. Awano N, Takamoto T, Kawakami J, Genda A, Ninomiya A, Ikeda M, Matsuno F, Izumo T, Kunitoh H. Issues associated with medical tourism for cancer care in Japan. Jpn J Clin Oncol, 49:708-713, 2019