New concepts and techniques of hepato-pancreato-biliary surgery

Abstract

Surgery is the most effective and preferred treatment for hepato-pancreato-biliary (HPB) tumors. The improvement of HPB surgery technique mainly focus on reducing the amount of bleeding, improving the safety of operation, simplifying the operation, reducing the complications and mortality all the time. As one of the largest HPB centers in China, hepatic center of Tongji hospital has set up a series of new concepts and new techniques of HPB surgery since 1980s. We proposed a new classification standard of hepatocellular carcinoma (HCC) to guide the surgical procedures and evaluation of prognosis. According to this method, HCCs lager than 5 cm were defined as lager (>5 cm and ³ 10 cm). Traditionally, the large/huge HCC patients were thought can’t tolerate hepatectomy because of the insufficient residual liver volume. However, we confirmed the feasibility and safety of the resection of large/huge HCC and applied it in clinic concurrently in 1990s, which greatly extended the inclusion criteria for operation. Serious intraoperative bleeding is another constraint for resection of large/huge HCC. In order to reduce the intraoperative bleeding and increase the safety of major hepatectomies, three new bleeding control techniques for hepatectomy were established: Infrahepatic inferior vena cava clamping combine with occlusion of the portal triad; tying up of inflow and outflow vessels without dissecting the hilus of the liver; and implementation of the liver double-hanging maneuver through the retrohepatic avascular tunnel on the right side of the inferior vena cava. According to the AASLD and the EASL guidelines for HCC management, patients with portal vein tumor thrombosis (PVTT) are excluded from either surgical treatment or TACE, and only palliative therapies are recommended. However, our studies confirmed treating PVTT patient by indicated surgical protocol according to the location and extension of PVTT is safety and effective. Based on the guideline set by western countries, liver resection is contraindicated in patients with portal hypertension. But in China, 85%–90% patients with HCC showed various degrees of liver cirrhosis, and a large proportion of these patients presented clinical signs of portal hypertension. Thus, we set up a surgical treatment strategy (limited liver resection plus splenectomy with or without devascularization of gastroesophageal varices) for HCC combined with portal hypertension. There are still controversies on the optimal extent of hepaticresection to achieve a high percentage of R0 resection for hilarcholangiocarcinoma. We proposed a new concept that treats hilar cholangiocarcinoma using minor liver resection which showed lower operative morbidity and good prognosis. We also created new surgical procedures such as new intrahepatic cholangiojujunostomy for multiple intrahepatic biliary ductal openings and the inserting bilio- jejunostomy for iatrogenic bile duct injury were all invented and proved to be available in clinic. In order to diminish pancreatic leakage, we established Chen’s U-suture technique for end-to-end invaginated pancreaticojejunostomy following pancreaticoduodenectomy. Many end-stage liver disease patients died due to severe shortage of organ donors. To address the shortage, we are the first to establish auxiliary partial orthotopic liver transplantation technique in the world and applied it in clinic successfully.