© 2007 Foundation for Promotion of Cancer Research
Tips and Tricks Learnt by a Sasakawa Foundation Scholar in an HPB Unit in Japan
Specialist Surgical Registrar, Frimley Park Hospital
Frimley, Surrey, UK
E-mail: aamirzkhan{at}yahoo.com
Recently I was fortunate to visit one of the leading centres in Japan as a scholarship recipient for training in Hepatobiliary and Pancreatic Surgery at the University of Tokyo Hospital. The Unit is headed by Professor Masatoshi Makuuchi who leads an inspired and motivated team that offer a state of the art HPB and liver transplant service. During my time on the team, I learned lot of tips and tricks from my Japanese colleagues, which are outlined below. For purposes of this manuscript, these are limited to liver surgery.
PRE-OPERATIVE EVALUATION AND ONCOSURGICAL PLANNING
Most patients are admitted for surgery two days prior to operation. A minority are kept as inpatients pre-operatively in order to control diabetes or poorly managed obstructive jaundice. Patients are staged and worked up quite thoroughly including indocyanine green retention rate (ICGR) alongside high quality CT and MRI scanning.
Individualized treatment plans are drawn up for patients in light of the ICGR, type and extent of hepatic resection required, size and function of the future liver remnant (FLR). Evaluation of the need for either percutaneous biliary drainage for patients with obstructed biliary systems or portal vein embolization for those at risk of insufficiency are assessed and instituted as appropriate. The unit was the first to devise and implement PVE as an adjunct to surgery and have a huge experience in this field.
Either a J-shaped incision is made (or an inverted T-shaped incision for donor hepatectomy). For right sided hepatic resections, the thoracic cavity is universally opened and the diaphragm divided to afford better access to the hepatocaval confluence. This is different from surgical practice in England and thoracotomy for hepatic resection is rare.
Intra-operative ultrasonography (IOUS) described by Makuuchi et al. (1) is standard practice, allowing direct contact sonography to be performed and gives high quality definition of the location of the lesions within the liver and there relation to the portal and hepatic vein tributaries. IOUS allows meticulous systematic anatomical segmentectomy and sub-segmentectomy to be performed.
The preferred method for hepatic parenchymal transection is a hybrid technique using the crushing clamp technique alongside the ligasure® device. This technique seems to work well for hard hepatitic livers which account for the vast majority of hepatic resections in Japan.
ANAESTHETIC TECHNIQUE, PERI-OPERATIVE MANAGEMENT AND POST-OPERATIVE CARE
A low CVP anaesthetic is used and tidal volume reduced just before commencing parenchymal transection in order to reduce back bleeding from the hepatic venous system. Intra-operative steroids are used routinely during hepatic resection and continued in the early post-operative period in order to dampen the acute phase response (2). This is thought to reduce the incidence of small for size syndrome after extended resections and also contributes towards dampening the ischemia-reperfusion injury that occurs after prolonged operations where the hepatic pedicle is clamped. Early enteral nutrition is encouraged mainly consisting of carbohydrates. Blood transfusions are used only if the hematocrit level falls below 20%. Packed cells are used routinely when required following major hepatic resections. This, in contrast to transfusion of whole blood does not seem to be associated with adverse outcomes following hepatic resection for malignancy (3). FFP is used quite often following surgery and the sodium level is kept just below normal in order to optimize hepatocyte function in the immediate post-operative phase.
LIVING DONOR LIVER TRANSPLANTATION (LDLT)
LDLT is the jewel in the crown for the unit in Tokyo. The unit had performed 385 LDLT without a single mortality and is really one of the world's leading centres in this regard (4). The high success rate for this operation in the unit offers hope of long-term survivorship to a large subset of patients who are poor candidates for resection based on inadequate hepatic reserve.
The practice of hepatic surgery is well established in Japan. Thorough pre-operative assessment and access to high quality state of the art imaging allows better and more careful patient selection and oncosurgical planning. In contrast to surgical practice in England, some patients may be investigated as inpatients. Most surgeons and surgical trainees are competent at performing diagnostic and therapeutic ultrasonography of the biliary tract, probably due to different upbringing during surgical training and entirely different working patterns. Most hepatic resections are done for hepatocellular carcinoma on diseased livers and Japanese knowledge and practice of anatomical liver resection is of the highest standard.
Finally I am unequivocally grateful to the Great Britain Sasakawa Foundation for there support, help and grant towards my fellowship to Japan.
References
1 Torzilli G, Takayama T, Hui AM, Kubota K, Harihara Y, Makuuchi M. A new technical aspect of ultrasound-guided liver surgery. Am J Surg (1999) 178:341–3.[CrossRef][Web of Science][Medline]
2 Chiappa AC, Makuuchi M, Zbar AP, Biella F, Vezzoni A, Torzilli G, et al. Protective effect of methylprednisolone and of intermittent hepatic pedicle clamping during liver vascular inflow occlusion in the rat. Hepatogastroenterology (2004) 51:1439–44.[Medline]
3 Martin RC, 2nd, Jarnagin WR, Fong Y, Biernacki P, Blumgart LH, DeMatteo RP. The use of fresh frozen plasma after major hepatic resection for colorectal metastasis: is there a standard for transfusion? J Am Coll Surg (2003) 196:402–9.[CrossRef][Web of Science][Medline]
4 Sugawara Y, Makuuchi M. Living donor liver transplantation: present status and recent advances. Br Med Bull (2006) 75–76:15–28.
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