The Very Big Deal About HPB Surgery

Tuesday, December 4, 2012

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HPB surgery, otherwise known as HepatoPancreaticoBiliary surgery, has been an area of special interest at Baptist for years. Recent additions in technology have added even more layers of expertise. Here’s why: High volume centers such as Baptist have shown lower morbidity and mortality in specific complex operations such as biliary reconstruction, liver resection and Whipple procedures. “We have better outcomes because my partners and I do these complicated procedures many times a year as opposed to once or twice,” says Baptist surgeon C. Randle Voyles, MD, MS, a partner with Surgical Clinic Associates in Jackson. “Baptist has a long history ofproviding tertiary care in surgical oncology. Today, we have patients in the hospital from across the state, and also from Louisiana and Alabama.”

The Whipple, or pancreaticoduodenectomy, is an open procedure primarily for cancer of the pancreatic duct, and also less common tumors such neuroendocrine tumors, which ailed the late Steve Jobs. The Whipple resection consists of removing the gall bladder, common bile duct, head of the pancreas, duodenum, proximal jejunum and regional lymph nodes. Reconstruction, the second part of the Whipple procedure, restores continuity of the digestive tract by re-attaching the pancreas, hepatic duct, and the stomach to the jejunum – in that order – to allow digestive juices and bile from the liver, to flow into the gastrointestinal tract, Voyles explains.

The mortality rate for the Whipple procedure –reportedly 3 to 5 percent in the United States – may be reduced to 1 to 2 percent in higher volume centers such as Baptist, with minimally invasive approaches playing an increased role.

“I have a 22-year survivor with a typical pancreatic duct cancer, and many patients who are four to five years out,” says Voyles, a University of Mississippi medical school graduate who completed an extensive fellowship at the Royal Postgraduate Medical School in London. “Recently, I removed 40 percent of a female patient’s pancreas through a laparoscope. She went home in 72 hours. That’s pretty impressive.”

The Baptist surgical team also routinely performs partial hepatectomies to surgically remove localized tumors from the liver. Perhaps the most common liver resection is for metastases from colon cancer and neuroendocrine cancers.

“As a result of better chemotherapy, the rules are being re-written about how we approach metastases from colon cancer,” says Voyles. “There are a number of long-term survivors after aggressive resection of colon cancers that can be removed from the liver. In addition, primary liver cancers start in either the liver cells (hepatocellular cancer or hepatoma) or bile ducts (cholangiocarcinoma). Long-term survival is possible if the cancer hasn’t spread to the nearby lymph nodesor other parts of the body, and the residual liver is functioning well.”

To perform a partial hepatectomy, the surgeon makes an abdominal incision in the patient to remove the affected part of the liver from connecting tissues, while also leaving a margin of healthy liver tissue to maintain the organ’s functions.

“The liver is unique in that regeneration occurs to restore function and actual volume to pre-resection size if the liver remnant is healthy,” says Voyles. “With a multidisciplinary team approach and carefully selected patients, the procedure offers patients a chance of longterm survival.”

The procedures for these types of surgeries are not single-surgeon driven, Voyles emphasizes.

“There are a handful of essential drivers in this kind of surgery,” he says. “Our world-class interventional radiologists provide essential staging information, but also have introduced innovative angiographic techniques treating liver tumors with embolization, as well as percutaneous techniques that introduce radiofrequency probes that ablate tumors with thermal energy. Our highly skilled gastroenterologists have incorporated newer technology such as a tiny endoscopic ultrasound probe that’s useful in staging pancreatic and rectal cancers.

“All components of the team collaborate in a well established, organized tumor conference board where we present cases and develop treatment plans. Institutional excellence has many broad overriding components, but our underlying goal is simple: uniquely personalized and highly quality care for the individual patient.”

For more information log onto http://mbhs.org/cancer or call (601) 968-1049.

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