P R O C E D U R E P R O F I L E

Hepatobiliary and
Pancreas Surger y

LIVER DISEASE Surgical Capabilities Among the surgical procedures we offer

include:
MANAGEMENT & New diagnostic and surgical capabilities
have enabled California Pacific’s hepato-
TRANSPLANT biliary team to better treat hepatobiliary Biliary Tumors and
and pancreatic carcinoma as well as other Injuries
PROGRAM diseases affecting these organs. Our skilled
Biliary surgery is most frequently performed
hepatobiliary team—comprised of surgeons,
for stones, strictures and tumors. Among the
interventional endoscopists, radiologists and
treatment options available at California
hepatologists—works together to provide
At California Pacific Pacific include:
surgical treatment for the following
Medical Center we are problems:
• Resection of primary biliary
committed to bringing
Biliary neoplasms (cholangiocarcinoma)
new and advanced Treatment of bile duct cancer usually
• Carcinoma of the gallbladder
diagnostic tools, • Malignant tumors of the bile duct requires removal of the bile duct and
medical treatments and • Bile duct injuries and strictures possibly portions of the liver, gallbladder,
surgical options to the • Choledochal cysts pancreas and small intestine. After resect-
• Recurrent pyogenic cholangitis ing the neoplasms—either through open
physicians and patients surgery or laparoscopically—the surgeon
we serve. Through this reconnects the bile ducts to the small
Pancreas
procedure profile, our • Pancreatitis intestine for proper biliary drainage (see
physicians illustrate • Pancreatic pseudocyst illustration).
surgical capabilities • Malignant neoplasms of the pancreas
• Cystic neoplasms of the pancreas
and techniques that
• Pancreatic islet cell tumors
provide you with a
window into their
Liver
practice of diagnosis, Hepaticojejunostomy
• Hepatic trauma (Bile ducts drain into
treatment and patient • Metastatic neoplasms of the liver small intestine)

follow-up. • Benign tumors and cysts of the liver Removed bile duct
• Portal hyptertension (portasystemic and gallbladder

shunts)
Jejunal-Jejunostomy
With the use of laparoscopy and endoscopic
ultrasound (EUS), all patients with malignan-
cies are staged pre-operatively. Following Roux-en-Y Hepaticojejunostomy Procedure performed for
staging, our hepatobiliary team works in injuries and cancer of the bile duct.

conjunction with the referring physician to

• Biliary Drainage Procedures
determine the best treatment for the patient’s
Biliary drainage procedures are performed
condition. Because choosing a treatment plan
when the bile duct becomes blocked,
is an important decision, we review all
narrowed or injured. During surgery,
options with patients and family members as
continuity of the biliary tree is usually
well as their referring physician, explaining
For patient referrals: re-established via a hepaticojejunostomy
the benefits and disadvantages of each
(888) 637–2762 option.
(see illustration).

www.cpmc.org/liver
Diseases of the Pancreas— • Distal Pancreatectomy (laparoscopic or open)
Surgical Options
Tumor removed from
Upon referral of a suspected pancreatic pathology, California body of pancreas

Pacific’s hepatobiliary team initiates a pre-operative work up

which usually includes an evaluation of the pancreas via
EUS. This evaluation helps to determine the location of the
pathology in the head, neck, body or tail of the pancreas.

pancreatic duct
Spleen-preserving Distal Pancreatectomy

Head Neck Body Tail Indicated for tumors in the body and tail of the pancreas, a
Pancreas sections used in defining tumor(s) location. distal pancreatectomy involves the removal of neoplasms
either laparoscopically or with open surgery. With both
laparoscopic and open distal pancreatectomy procedures,
Subsequent treatment options include:
surgeons attempt to preserve the spleen. (see illustration)

• Pancreaticoduodenectomy (Whipple Procedure)

• Drainage Procedures
A pancreaticoduodenectomy, also known as a Whipple
With chronic pancreatitis, a dilated pancreatic duct usually
procedure, involves the removal of the pancreas head due
reflects obstruction. Procedures to improve ductal drainage
to a tumor in the pancreas or bile duct, or pancreatitis.
include:
If a tumor exists in Figure 1
– Longitudinal Pancreaticojejunostomy (Puestow Procedure)
the head of the
The pancreatic duct is opened from the tail to the head of
pancreas, it is
the pancreas and attached to the small bowel.
usually necessary
to remove the Cut bile duct

pancreas head, Pylorus – Distal Pancreaticojejunostomy (Du Val Procedure)

preserved
duodenum, gall- The pancreas is divided transversely at the neck, and the
bladder and a body and tail are drained via attachment to the small
Cut edge of
portion of the bile pancreas bowel.
duct (Figure 1).
Jejunum (small
Sometimes, part of Resected pancreas and
intestine) – Sphincteroplasty
removed organs
the stomach is also When endoscopic sphincterotomy is unsuccessful,
removed. The end surgical sphincteroplasty may be required of the minor
of a patient’s bile Figure 2 or major papilla.
duct and the remain-
ing pancreas are then
connected to the • Pancreas Transplantation
small bowel
Choledochojejunostomy A pancreas transplant is indicated for patients with
(Figure 2) to ensure insulin-dependent diabetes.
flow of bile and
enzymes into the Pancreaticojejunostomy

intestines. Gastrojejunostomy

Whipple Procedure
Liver Cancer – Surgical Options
When determining treatment options for tumors of the liver,
the hepatobiliary team reviews the results of one’s pre-opera- Cryoprobe or Radiofrequency Probe
tive evaluation and overall health to recommend appropriate
treatment options. Treatments offered at California Pacific for
Ultrasound
tumors of the liver include: Tumor

• Surgical Resection (Tumor Removal)—Open or

Laparoscopic
Typically, surgeons can Portal Vein Embolization
Liver
safely remove up to 70%
of the liver (if there is no Ablation Procedure
fibrosis) and expect full
regeneration. During • Ablation (Radiofrequency or Cryoablation)
resection, the surgeon Tumor Patients who are not candidates for resection or transplan-
first uses ultrasound to tation due to inadequate liver reserve, large or multiple
determine the tumor(s) lesions in multiple lobes, fibrosis or cirrhosis can benefit
1. Catheter delivers micro- from treatments such as CT-guided, laparoscopic or open
proximity to hepatic
spheres to embolize the right
structures and then portal vein. radiofrequency or cryoablation. With new radiofrequency
removes it with as little (RF) ablation technology, liver tumors up to 7 cm in
liver as possible, while diameter can be treated. The ideal patient for RFA
ensuring a margin free of generally has no more than three lesions that are no greater
tumor. For patients who than 5 cm in size. RF ablation delivers radiofrequency
Left Lobe
may not have enough liver Right Lobe energy to the tumor, heating it to temperatures above
reserve, portal vein 113º F and thereby destroying the lesion. During cryoabla-
embolization is used pre- tion, argon gas is delivered through probes inserted into
operatively (see illustration). the liver, creating an ice ball that freezes the tumor and
This technique, which destroys its cells (see illustration).
involves the insertion of 2. Left lobe of liver enlarges due to
tiny microspheres into the increased blood supply.
• Percutaneous Ethanol Injection Therapy (PEIT)
portal vein, blocks blood Another option for patients who are not surgical candi-
flow to the portion of the dates, PEIT involves the injection of alcohol into the tumor,
liver containing tumor(s), causing immediate dehydration of the cytoplasm with
and results in the enlarge- consequent coagulation, necrosis and fibrous reaction.
ment of the remaining PEIT results in complete ablation in up to 75% of selected
liver segments on which patients with hepatocellular carcinoma.
the patient will depend 3. Right lobe (with tumor) is
resected and patient relies
after resection. on left lobe for liver func-
tion.
• Hepatic Arterial Pumps
Indicated for patients with metastatic colon cancer, hepatic
• Liver Transplantation arterial pumps deliver chemotherapy to the liver through a
While a liver transplant represents the best cure for most catheter placed in the hepatic artery. The catheter is typi-
patients with non-metastic liver cancer, the limited organ cally inserted via laparoscopic or open surgery and a
supply may make this option unattainable. The eligibility pump, which delivers the chemotherapy, is implanted
criteria for transplantation is the presence of a single subcutaneously. The pump is generally filled with
hepatoma 5 cm or less in diameter, or three or fewer tumor chemotherapy once a month.
nodules, each 3 cm or less in diameter. Both living-related
and cadaveric liver transplants are options for patients at
California Pacific.
 Hepatobiliar y and Pancreas Surger y

For more information

Why Choose Us?
California Pacific’s Center for Complex Digestive Disease For surgical information, contact
offers comprehensive specialty care for diseases of the liver,
pancreas and bile duct. We emphasize ongoing communica- Robert Osorio, M.D.
tion with referring physicians and incorporate them in the Surgical Director
decision process of their patient’s medical management. Center for Complex Digestive Disease
Following treatment, we follow up our care with an organ- California Pacific Medical Center
ized discharge report to the referring physician. 2340 Clay Street, 4th Floor
San Francisco, California 94115
For patients requiring hospitalization, we have a dedicated
hepatobiliary critical care unit, a heptobiliary hospitalist, (415) 600–1010 tel
physician assistants, on-call anesthesia staff and a specialized (415) 600–1012 fax
O.R. nursing team. At California Pacific, our focus is on
providing experienced, personalized care for all patients.
www.cpmc.org/liver

With the use of advanced technology and surgical methods,

patients now have more options than ever for the treatment For referrals, contact
of hepatobiliary disease. Our physicians are actively California Pacific Specialty Referral Program
involved in clinical research and offer multiple studies in 1 (888) 637–2762 tel
areas such as hepatocellular carcinoma, gastroenterology and 1 (415) 923–6595 fax
viral hepatitis. Additionally, our hepatobiliary team offers
outreach clinics in local communities throughout Northern
California and Nevada, providing pre- and post-operative
hepatobiliary care close to home.

We welcome your inquiries regarding treatment options,

research, outreach locations or referrals.