Most major hepatobiliary-pancreatic surgeries including hilar bile duct cancer and liver transplantations are difficult to perform and take a long time to establish. Furthermore, since the introduction of laparoscopy, all kinds of procedures were tried and settled down successfully by laparoscopic approach. This has been another challenge to HBP surgeons. As a junior surgeon, I was put in the division of HBP surgery in the medium-volume center in the developing era to perform these kinds of difficult surgeries without enough training in advanced high-volume centers. However, I had a dream to establish every kind of HBP surgery including liver transplantation.
The first step to achieve this goal was safe hepatectomy. At the beginning of HBP surgery in the early 1990’s, there was still a lot of transfusion after profuse bleeding followed by pretty high rates of postoperative mortality after hepatectomies. After observing clinical hepatectomies and doing experimental research at the advanced medical centers both domestically and abroad, I could achieve acceptable surgical outcome, and the number of hepatectomies increased year by year. For the safe hepatectomy, learning the concept of ischemia/reperfusion injury and low central venous pressure with hepatic transection and limited amount of bleeding was crucial. I gained a lot of ideas and practice through clinical and experimental research work at Duke University Medical Center where I was supervised by professor PA Clavien during his last year in the USA. Furthermore, observing the Asan Medical Center’s team perform surgeries for several weeks was also valuable. I also learned from the presentations as they included video clips that showed the work of many distinguished surgeons in the academic conference including domestic surgeons and those from abroad; there were particularly a lot of leading surgeons from Japan. After stabilization of safe hepatectomy, I tried various kinds of anatomical resection. One of the most attractive procedures was systematic segmentectomy by the dye injection method into the segmental portal venous branch guided by ultrasonogram, also known as Makuuchi’s procedure. As surgical skills and laparoscopic instruments developed, advanced laparoscopic surgeries, including laparoscopic major hepatectomy and anatomical resection, were performed successfully and established progressively.
Another issue was safe PPPD with minimizing the postoperative pancreatic fistula(POPF). Is there a knack or mystique to reduce pancreatic fistula? That was one of my central questions in the developing era. After observing several cases of the PPPD performed by Dr. JL Cameron & Dr. CJ Yeo at Johns Hopkins University, I applied the concepts I acquired from them to my patients. The key concepts I learned included the idea that enough mobilization of the remnant pancreatic stump and enough covering over the anastomotic line of pancreatico-jejunostomy with jejunum, like a jejunal patch, keeps minimal tension in the entire row of stitches for the anastomosis. An additional procedure that I developed for safety was temporary external diversion of the pancreatic juice through a polyethylene tube that was inserted transhepatically for the patients who had normal pancreatic parenchyma and was maintained until 2-3 weeks after surgery. Because of the application of this technique, the POPF rate dramatically decreased and resulted in a low rate of postoperative mortality. As the number of hepatectomy and PPPD increased year by year, surgery of the hilar bile duct cancer also stabilized despite the several failures during the early trial periods.
The final goal was to perform successful liver transplantations with a living donor as well as a deceased donor. A liver transplantation requires more in depth preparation, because it involves not only collaboration with good surgeons for stable surgeries for both the donor and the recipient, but also close collaboration between anesthesiologists and nurses. Because initial success was very important, we invited a leading surgeon from the high volume center and finished the first LDLT successfully. Although the annual number of liver transplantations was limited, sometimes failed, the number increased steadily. Ten years after the first LDLT, we adopted a young surgeon who was well trained in the high-volume liver transplant center. Afterwards, the liver transplant program was stabilized much more, and the number of LDLT as well as the number of DDLT increased, and the result has been nearly a one hundred percent rate of success so far.
In conclusion, my initial dream to do establish difficult HBP surgeries such as hepatectomy, PPPD, surgery of the Klatskin tumor, advanced laparoscopic hepatectomy and liver transplantation with acceptable complication rate and long-term survivals, was accomplished by persistent endeavor. Of course, there have been trials and errors followed by tears and cheer for the establishment of each kind of surgery. In the future, we should prepare for the era where all kinds of surgery are minimal invasive surgeries, not just laparoscopy, but also robotic surgery, which is already established by leading surgeons. Additionally, we should look forward to the progression of the translational and experimental research backed by not only nationwide database that has been built by KHBPA but also international database with a network.