The Hepatobiliary and Pancreatic Surgery (HPB) Program provides state-of-the-art treatment for patients with primary and metastatic cancers of the liver, gallbladder, bile duct and pancreas. The program also treats benign disease including cysts, biliary strictures and bile duct injuries.
Rather than isolated silos of care, we have a highly integrated team approach. Based on the successful model of the UCSF liver and kidney transplant programs, the HPB Program combines the expertise of hepatobiliary and transplant surgeons, diagnostic radiologists, interventional radiologists, medical oncologists, hepatologists, gastroenterologists and anesthesiologists.
When one looks at a broad spectrum of hepatobiliary and pancreatic disease, there are often competing therapies for which a patient might be a good candidate. We believe its best to have all the people in the room so everyone can give their perspective about which therapy is best for that particular patient.
The HPB program has established standard protocols for both outpatient and inpatient care. Patients are housed together in one ward and they receive pre- and post-operative care from a team which specializes in treating hepatobiliary surgical patients. There is continuity of care, and we have built redundancy into the system, so there is always a continuum of individuals who can perform these operations and take care of these complex patients.
Advanced Laparoscopic Liver Procedures
UCSF is one the few centers nationally that performs a large number of advanced laparoscopic liver procedures. While some large tumors still require open surgery, many liver procedures can be done laparoscopically. In addition to shorter hospitalization and recovery times, minimally invasive approaches reduce the likelihood of wound complications, particularly since the liver is the source of many proteins important for wound healing. This approach also allows many patients with significant comorbidities to receive surgical treatment.
Laparoscopic Intraoperative Ultrasound
With the help of our diagnostic radiologist, we use laparoscopic intraoperative ultrasound to detect liver tumors that are not always visible with preoperative imaging. Tumors identified interoperatively can then be resected, or if not amendable to surgery, treated with ablative techniques to destroy the tumor in place. By combining minimally invasive surgery with therapies targeted only at the liver such as ablative therapies, chemoembolization and radioembolization has broadened the number of patients eligible for palliative or curative treatments. In the past, these patients would all die within a period of months. With these newer treatments, we have converted the liver cancer of some patients into a chronic disease.
The HPB Program offers a full range of treatment options for patients with liver cancers. Some patients with tumors on both sides of the liver may require staged operations to address all of their disease burden. For example, if the right liver has more tumor volume than the left liver, surgeons plan to remove the entire right lobe. They precondition the "future remnant" liver by resecting or ablating tumors on the left side. They then deliberately block part of the blood supply (portal vein) to the right liver for several weeks, promoting growth of the future remnant prior to resecting the right liver. This approach provides extra time for the left liver to regenerate, and helps reduce risk of liver failure resulting from a major resection that leaves an insufficient amount of remnant liver.
Some patients are appropriate candidates for treatments by radiologists such as Transarterial Chemoembolization (TACE) that may allow for treatment prior to surgery, or enable avoiding surgery all together. Because primary liver tumors thrive on highly oxygenated blood, blocking the artery feeding the tumor may kill the tumor.
There are new experimental treatments in which interventional radiologists may inject a slurry of chemotherapy-eluting beads into the small branches of the hepatic artery. These beads, about 50 μ in diameter, have been incubated with an agent such as doxorubicin, which releases into the liver over time. The beads not only clog the branches of the hepatic artery, cutting off the oxygen supply to the tumors, but also deliver targeted chemotherapy. Recent studies show that only about 5 percent of the chemotherapy circulates in the bloodstream, resulting in fewer side effects than systemic chemotherapy. Similarly, beads containing yttrium-90 that release radiation may be used in a targeted, well-tolerated manner.
The HPB Program also treats patients with metastatic tumors affecting the liver, including those with breast, colon, renal cell, stomach and esophageal cancer. The program also specializes in the treatment of patients with bile duct cancers, which are rare, often lethal, and only curable through surgery. These include gallbladder cancer and hilar cholangiocarcinoma (also known as Klatskin tumors).
For liver, gallbladder and bile duct cancer cases requiring major resections, transplant surgeons apply their expertise from living donor liver transplantation to perform complex reconstruction of the hepatic artery, portal vein or bile duct. This allows the HPB team to resect cancers involving major blood vessels which may be deemed inoperable at other centers.
The HPB Program has also adopted a patient-centered approach for nonsurgical preparation and perioperative care. In the past, all patients were required to make a preoperative visit to draw labs and assess risk of surgery. We saw a lot of healthy patients who were fit for surgery, who had to come in for unnecessary trips and get repeated labs. It was a huge burden for the patient, particularly if they held down a job and lived four hours away.
Now, once a surgeon determines that a patient is a surgical candidate, patients can submit their medical health history online. One of our anesthesiologists reviews the medical history and diagnostic tests that were already recently performed. Subsequently they contact the patient to discuss the perioperative plan and obtain additional information, if needed. If required, they obtain test results from outside doctors and medical centers, and can sometime arrange for additional tests to be performed close to a patient's home.
Liver Anesthesiologists Play Leading Role
Because our anesthesiologists are experienced in the care of liver transplant patients, they know which risk factors may increase their likelihood of surgical complications,and which tests are necessary to proceed with surgery. If they have any specific questions or concerns, they can refer a patient to be pre-evaluated by a specialist at UCSF, such as a cardiologist, who is familiar with the physiologic stresses of complex operations. That is something that cannot be done at most hospitals. By reviewing medical histories and existing diagnostics and talking with patients, the HPB program has been able to approve approximately half of patients for surgery without requiring an additional trip to UCSF for the perioperative consultation.
The anesthesiologists also provide their e-mail addresses and pager numbers, and are available to answer any questions that arise. They try to establish a relationship early on during the evaluation process, so the patient feels comfortable calling us. Patient feedback has been extremely positive.
Carlos U. Corvera, M.D.
Associate Professor of Surgery
Chief, Hepatobiliary and Pancreas Surgery
Division of General Surgery