shin ishihara

Purpose: The present study aimed to determine whether concomitant extrahepatic bile duct resection (EHBDR) improves the prognosis of patients with T2 gallbladder cancer (GBC). Methods: Between 2014 and 2018, 4947 patients with GBC were registered in the National Biliary Tract Cancer Registry in Japan. This included 3804 patients (76.9%) who underwent curative-intent surgical resection; 1609 of these patients had pT2 GBC with no distant metastasis. Of the 1609 patients with GBC, 520 underwent EHBDR and 1089 did not. We compared the patients' backgrounds and disease-specific survival rates between the groups. Results: The frequency of lymph node metastasis was significantly higher in the EHBDR group than in the non-EHBDR group (38.2% vs. 20.7%, p <.001). In the entire cohort, however, there was no significant difference in disease-specific survival between the two groups (76% vs. 79%, p =.410). The EHBDR group had a significantly higher incidence of postoperative complications (Clavien–Dindo classification grade = 3) (32.4% vs. 11.7%, p <.001). When we focused on the survival of only T2N1 patients who underwent gallbladder bed resection, the prognosis was significantly improved for the EHBDR group (5-year survival rate: 64% vs. 54%, p =.017). The non-EHBDR group was subcategorized into two groups: D2 dissection and D1 dissection or sampling, and survival curves were compared between these subgroups. Although the EHBDR group tended to have a favorable prognosis compared to the D2 group, this difference was not significant (p =.167). However, the EHBDR group had a significantly greater prognosis than the D1 dissection or sampling group (5 year-survival rate: 64 vs. 49%, p =.027). Conclusions: The EHBDR may improve the prognosis of patients with T2 gall bladder cancer with lymph node metastases; however, its indication should be carefully determined because of the increased risk of postoperative complications.

OBJECTIVES: The multidrug regimen with fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) is widely used for recurrent pancreatic cancer after pancreatic resection. However, there are concerns about severe toxicities and poor tolerability of FOLFIRINOX in these patients because some suffer from surgery-associated malnutrition, weight loss, and diabetes mellitus. We evaluated the toxicity and tolerability of FOLFIRINOX in these patients. METHODS: This study was conducted as a secondary analysis of the Japan Adjuvant Study Group of Pancreatic Cancer 06 study, which was a multicenter observational study of FOLFIRINOX for pancreatic cancer in Japan. The toxicity and tolerability of FOLFIRINOX in recurrent disease correlated with those of both the locally advanced and the metastatic disease group. RESULTS: The major grades 3 and 4 toxicities observed in the recurrent and locally advanced or metastatic disease groups were neutropenia (68% vs 63%), febrile neutropenia (4% vs 15%, P = 0.007), thrombocytopenia (4% vs 3%), diarrhea (4% vs 8%), and sensory neuropathy (0% vs 2%). The dose modification and relative dose intensity did not differ markedly between the groups. CONCLUSIONS: The toxicity and tolerability of FOLFIRINOX for recurrence after pancreatic resection were similar to those for locally advanced or metastatic disease with appropriate patient selection and dose modifications.

BACKGROUND: Data on FOLFIRINOX as a second-line chemotherapy for advanced pancreatic cancer are limited. In the JASPAC06 study-a nationwide, multicenter, observational study-FOLFIRINOX for patients with unresectable or recurrent pancreatic cancer as any line of treatment showed favorable efficacy and safety in Japanese clinical practice. METHODS: We performed exploratory analyses of patients with unresectable or recurrent pancreatic cancer who received FOLFIRINOX as the second-line chemotherapy in Japanese clinical settings. RESULTS: Of the 399 evaluable patients, 44 were eligible for inclusion in the analysis. The patients' characteristics were as follows: median age, 62 years; men, 26 (59%); Eastern Cooperative Oncology Group-Performance status 0/1, 30 (68%)/14 (32%); disease status, recurrent/local/metastatic: 4 (9%)/8 (18%)/32 (73%). The initial dose was reduced in 28 (64%) patients. The median time to treatment failure and number of cycles were 4.5 (range, 0.2-19.1) months and 6 cycles (range, 1-13 or more), respectively. The major grade 3/4 adverse events were neutropenia in 29 (66%), leucopenia in 17 (39%), anorexia in 7 (16%), febrile neutropenia in 5 (11%), and anemia in 5 (11%) patients. The median overall survival, progression-free survival, and 1-year survival rates were 10.3 (95% confidence interval [CI], 7.2-13.3), 4.1 (95% CI, 2.6-5.5) months, and 30%, respectively. CONCLUSION: Our findings suggest that FOLFIRINOX as a second-line chemotherapy for advanced pancreatic cancer was effective in patients with a good performance status. It displayed toxicity similar to that observed with its use as a first-line treatment.

BACKGROUND: Lymph node metastasis is an important prognostic factor for distal bile duct cancer. The number of lymph node metastases was adopted for nodal classification. However, different cutoff values have been proposed, ranging from two to five. METHODS: A total of 1748 cases who underwent curative surgery with pancreatoduodenectomy for distal bile duct cancer registered in the nationwide biliary tract cancer registry in Japan from 2008 to 2013 were included. Univariate Cox regression was performed to assess the effect of prognostic lymph node metastasis counts on mortality and to determine cutoff values. RESULTS: The overall survival rate after resection was 47.4% at 5 years. Univariate and multivariate analysis found prognostic factors to include lymph node metastasis. The cutoff point was set to two lymph node metastases using the Cox model. There were significant differences in pairwise comparisons between three groups by the number of metastatic lymph node (P < .001 for 0 vs 1-2 and P = .003 for 1-2 vs ≥3). CONCLUSION: Our data suggest lymph node classification as N0 (patients without lymph node metastases), N1 (metastasis in 1-2 regional lymph nodes), and N2 (metastases in ≥3 regional lymph nodes).

BACKGROUND: We present a case of pancreatic and splenic metastases following alveolar soft part sarcoma (ASPS), which was successfully treated by surgery. CASE PRESENTATION: A 41-year-old male was referred to our hospital in 2012. Computed tomography (CT) showed the presence of a pancreatic tumor. In 2002, the patient had undergone surgical resection of an ASPS of the anal region. In 2009, during follow-up, CT revealed lung metastases, which prompted surgical resection of the lung, followed by resection of the head skin in 2011. Abdominal ultrasonography (US) revealed the presence of isodense masses sized 34 mm in the pancreatic head and 60 mm within the spleen. The contrast-enhanced US revealed a solitary lesion with enhancement. Contrast-enhanced CT revealed solitary lesions with enhancement within the pancreatic head, spleen, and liver. The patient underwent metastasectomies from the pancreas, spleen, and liver. The patient was discharged on postoperative day 22 without recurrence for 18 months after metastasectomy. Twelve years after primary resection and 2 years after metastasectomy, the patient died as a consequence of multiple metastases. CONCLUSIONS: We have presented a rare case of pancreatic and spleen metastases from ASPS. Resection by radical metastasectomy was successful without morbidity. Thus, for improved survival of patients with multiple metastases from ASPS, metastasectomy may be indicated. If multiple metastases are resectable, surgical approaches may be the preferred treatment.

＜文献概要＞早期胆嚢癌(early gallbladder cancer)の定義はたいへん難しい.なぜなら,何をもって早期とするのかは,個々人の感覚により左右されるからである.そこで,ここでは局所進展度(contiguous extent)がT1の胆嚢癌を早期と定義した.日本の胆道癌登録の成績ではT1aの5年生存率は92.5%,T1bは87.2%であった.T1でリンパ節転移のないStageIの5年生存率(5 year survivalrate)は91.1%であった.領域リンパ節(regional lymph node)に転移を認める症例は,5年生存率が28.5%であった.リンパ節転移がある症例を早期とするか否かは議論が残るところである.T1a胆嚢癌の治療法は,全層胆嚢摘出術(simplecholecystectomy)でコンセンサスがある.T1b胆嚢癌では,切除範囲やリンパ節郭清の有無につきコンセンサスがない.腹腔鏡下胆嚢摘出術(laparoscopic cholecystectomy)に関しては,大規模研究の結果が待たれる.今後,早期の定義については,専門家集団による議論が必要である.

上行結腸憩室出血に対して術中内視鏡を併施し腹腔鏡下手術を施行した2例を経験した。2例とも造影CT検査を行い、腸管内への造影剤の漏出が確認できた。症例1は一時緊急下部消化管内視鏡検査を行い止血したが、貧血進行し、造影CT検査で腸管内への造影剤の再漏出が確認され、下部消化管内視鏡検査を再度行うも憩室が多発しており出血部位の同定は困難であったため手術を施行した。症例2は造影CT検査で腸管内への造影剤の漏出が確認でき、IVRにより止血したが再出血のため手術を行った。術中内視鏡を併施することで残存予定腸管に出血点およびその原因となり得る病変がないことの確認ができ、切除範囲決定に有用であった。IVRが常時行えない施設では術中内視鏡を併施することで腹腔鏡下手術でも切除範囲を決定できる可能性があり、憩室出血に対して有効な治療法の1つになりうる。(著者抄録)

膵体尾部の病変に対する術式において注意すべき外科解剖につき概説した。膵体部は頭側が胃膵間膜、尾部が横行結腸間膜前葉に連続する膜に包まれた組織内に位置する。また、膵腹側は膵前筋膜、背側は膵後筋膜からなっている。膵後面と腎全面の膜はGerota筋膜と称され、膵後筋膜とこのGerota筋膜の間にはToldtの癒合筋膜(Toldt&#039;s fusion fascia)が存在する。MDCTによるDPAの分岐形態の検討では、脾動脈から分岐するタイプが40%、総肝動脈から分岐するタイプが25.7%、上腸間膜動脈から分岐するタイプが20.0%であった。膵体尾部の静脈は膵実質から脾静脈へ直接流入する数本の細い静脈とcentro-inferior pancreatic veinが重要である。centro-inferior pancreatic veinは膵体部下縁実質から脾静脈あるいは上腸間膜静脈へ流入する静脈であり、横行膵静脈と吻合枝を形成する症例もある。また、下腸間膜静脈が脾静脈へ流入する頻度は34%、脾静脈と上腸間膜静脈の合流部に流入する頻度は24%、上腸間膜静脈へ流入する頻度は42%と報告されている。(著者抄録)

1）To learn the techniques required immediately after the start of clinical practice, new residents were introduced to the skills laboratory during their orientation period.<br>2）We attempted to establish the Yanegawara style, which is an overlapping teaching style in which the second–year residents plan the entire training schedule and simultaneously teach the first–year residents while being supported in their teaching by more senior physicians.<br>3）Training with the new system resulted in greater rapport among all residents as well as a greater feeling of security among first–year residents.

The ideal surgical procedure for treating pancreatic cancer achieves radical excision in a minimally invasive manner and allows rapid transition to adjuvant chemotherapy. If the afferent artery to the pancreatic head is not ligated until the latter half of the surgery, congestion of the pancreaticoduodenal vein may occur, leading to phleborrhagia and increased intraoperative hemorrhage. Ligation of the afferent artery, i.e., the inferior pancreaticoduodenal artery (IPDA), in the first half of the surgery may prevent the occurrence of hemorrhage due to congestion. Early ligation of the IPDA is also useful in ensuring the success of radical dissection of the plexus around the superior mesenteric artery or the no. 14 lymph node. We have been performing pancreaticoduodenectomies with antecedent IPDA ligation since 2005 and have found that the percentage of R0 versus R1 and R2 has increased compared with that when standard pancreaticoduodenectomies were performed. Preemptive ligation of the IPDA early in pancreaticoduodenectomy for invasive pancreatic cancer is a useful method for reducing blood loss and achieving R0 resection in a thorough yet efficient manner.

Xanthogranulomatous cholecystitis (XGC) is comparatively rare and difficult to distinguish from advanced gallbladder cancer (GBC) by imaging studies. It is important to accurately diagnose XGC preop-eratively, because patients undergo unnecessarily extensive surgery, such as liver resection, if GBC is diagnosed. We selected 3 cases of XGC diagnosed by post-operative pathological examination, between April 2007 and March 2009. Multi Detector-row CT (MD-CT) was useful for preoperative diagnosis of XGC, because it could detect an enhanced continuous mucosal line and intramural hypoattenuated nodule that are distinctive of XGC. Furthermore, measurement of gallbladder wall blood flow (GWBF) and both resistance index (RI) and pulsatility index (PI), indicating vascular resistance by color Doppler US, were also useful for making a differential diagnosis between XGC and GBC. However, it is still difficult to precisely diagnose XGC preoperatively despite progress in imaging studies, and because a higher percentage of XGC coexists with GBC. Therefore intraoperative pathological examination plays an important role in selecting the most suitable surgical procedure. © 2011 The Japanese Society of Gastroenterological Surgery.

In navigation surgery, preoperatively acquired image data are used so that surgical instruments can be guided inside the body while their location is displayed on a computer monitor. It is used in cranial nerve and spinal surgery. In the field of abdominal surgery, however, surgical manipulations in the target area cause major changes in the displayed images compared with those obtained preoperatively, and therefore, with the exception of certain organs, navigation surgery is difficult to apply. In general, this type of surgery aims to use intraoperative image information to improve surgical precision, carry out the preoperative plan accurately, and avoid dangerous areas. Three-dimensional images of the vascular architecture obtained with multislice computed tomography (MS-CT) make it possible to visualize arteries, the portal vein, bile duct, and even the pancreatic duct from any angle, which cannot be done with conventional angiography. Accurate positional relationships in the affected region can be determined preoperatively by manipulating multiplanar reconstruction images at a work station. MS-CT is extremely useful in navigation for safe performance of all types of pancreatectomy.

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.

BACKGROUND/PURPOSE: When a pancreatoduodenectomy is to be conducted, preoperative understanding of the vascular anatomy of the pancreatic head is important in order to reduce intraoperative bleeding. Using multislice computed tomography (MS-CT), we investigated the depiction rate and branching of the inferior pancreaticoduodenal artery (IPDA) and dorsal pancreatic artery (DPA), afferent arteries to the pancreatic head. METHODS: In 109 patients (68 with pancreatic cancer, 21 with biliary tract cancer, 15 with intraductal papillary mucinous tumor of the pancreas, and 5 others), images were taken, using 64-row MS-CT, in the early and late arterial phases. RESULTS: The depiction rates were 98.2% for the IPDA and 96.3% for the DPA. Branching of the IPDA was categorized into three types: a type in which the IPDA formed a common vessel with the first jejunal branch (72.0%), a type in which the IPDA branched directly from the superior mesenteric artery (18.7%), and a type in which the anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) branched separately (9.3%). DPA branching was categorized into five types, in which the DPA branched from the splenic artery (40.0%), from the common hepatic artery (25.7%), from the superior mesenteric artery (20.0%), and from the celiac artery (8.6%), and a type in which the DPA branching did not follow any of the above patterns (5.7%). CONCLUSIONS: MS-CT images of vascular architecture enable evaluation from any angle, which is not possible with conventional angiography, making MS-CT a useful diagnostic imaging technique for understanding the vascular anatomy of the pancreatic head prior to conducting pancreatoduodenectomy for diseases of the pancreatic head region.

At the Fujita Health University School of Medicine, about 30% of medical students are admitted on the basis of recommendations.To evaluate the performance of these students after admission, a placement test was given to all new students just after the entrance ceremony to examine basic academic abilities.The scores were compared with the number of absences from lectures and with examination results for the first and second years.<BR>1) The 398 students admitted from 2002 through 2005 were classified into three populations: 126 recommended students, 137 students who scored in the top half on the entrance examination, and 135 students who scored in the bottom half.<BR>2) Scores on the placement test were highest for the top-half students, intermediate for the bottom-half students, and lowest for the recommended students.Scores on examinations in the first and second years were highest for the top-half students, intermediate for the recommended students, and lowest for the bottom-half students.<BR>3) The average number of absences from lectures in the first and second years tended to be lower for recommended students than for the top-half or bottom-half students.<BR>4) The examination scores in the second year were correlated with scores in the first year, and the average number of absences in the second year correlated with those in the first year.<BR>5) These results indicate that the motivation of students in each classification to study in the 1st year is, in addition to their basic academic abilities obtained in high school, an important factor affecting their performance in the second year and beyond.

Complete surgical resection of biliary tract carcinoma remains the best treatment. The Japanese Society of Biliary Surgery has organized a registry project and established a classification of biliary tract carcinoma. We report here the status of biliary surgery in Japan. For hilar bile duct carcinoma, major hepatectomy is needed to increase the resection rate, and total caudate lobectomy is required for curative resection. The 5-year survival rate was 39.1%. Middle and distal bile duct carcinomas were treated with pancreatoduodenectomy ( PD) or pylorus-preserving PD ( PPPD) or bile duct resection alone. The 5-year survival rate was 44.0%. The treatment of gallbladder carcinoma with pT1 lesions is cholecystectomy. The treatment of pT2 lesions is extended cholecystectomy or various hepatectomy with or without extrahepatic bile duct resection along with lymphadenectomy. Treatment of pT3 and pT4 lesions includes hepatectomy with or without bile duct resection, combined with vascular resection, extended lymphadenectomy, and autonomic nerve dissection. Several groups in Japan have performed hepatopancreatoduodenectomy. The 5-year survival rate of pT1, pT2, pT3, and pT4 were 93.7, 65.1, 27.3, and 13.8%. PD or PPPD is the standard operation for carcinoma of the papilla of Vater. The 5-year survival rate was 57.5%. Copyright (C) 2007 S. Karger AG, Basel.

BACKGROUND/PURPOSE: Pancreatoduodenectomy (PD) is one of the most difficult operations in gastrointestinal surgery. Standard PD ligates and cuts superior mesenteric vein (SMV) branches after the removal of the pancreas head, which leads to congestion and bleeding of these veins. METHODS: In this study, we modified the standard PD and first ligated the efferent vessels (arteries); namely, the gastroduodenal artery and inferior pancreatoduodenal artery (IPDA), before ligating and cutting the corresponding afferent vessels (veins) of the pancreas head. By doing this, congestion of these veins was relieved and bleeding from the resected surface was substantially prevented. Thirty-six patients (18 underwent standard PD and 18 had modified PD) formed the study population. RESULTS: The amount of bleeding in the modified PD group was significantly lower than that in the standard PD group. (678 +/- 329 g vs 1225 +/- 375 g, respectively; P < 0.05) However, no difference in operation time was found between the two groups. CONCLUSIONS: We believe this modified PD procedure is valuable to enable the safe performance of PD.

Background/Aims: When an Appleby operation is performed for pancreatic by and tail carcinoma, it is necessary for prevention of hepatic circulation after resection of the celiac artery, the common hepatic artery and the portal vein. We studied the hepatic circulation by monitoring the ShvO(2) (hepatic venous hemoglobin oxygen saturation) during an Appleby operation. Methodology: We performed an Appleby operation on 8 patients with pancreatic cancer. In 6 of 8 patients, a 7-Fr fiberoptic flow direct catheter was inserted in right hepatic vein. The ShvO(2) values were monitored continuously during surgery. Results: The ShvO(2) value was 76+/-3.5% just after laparotomy, and reduced to 61+/-13.2% after clamping the common hepatic artery. The values of the ShvO(2) returned to 70.8+/-10.9% one hour after clamping. But, one patient underwent reconstruction of the common hepatic artery, because the ShvO(2) value still stood at 50%. Combined resection of the portal vein was performed in 5 out of 8 patients. Two patients underwent resection of the portal vein without reconstruction due to the development of the collateral vein, one patient; resection of the portal vein with reconstruction, and two patients; wedge resection. In all 5 patients, the ShvO(2) was stable during resection of the portal; vein. Conclusions: Monitoring the ShvO(2) is a useful method top evaluate at real time the hepatic circulation during the Appleby operation, and to decide if reconstruction of the common hepatic artery or the portal vein is needed or not.

標記術後患者15例に対して経皮的胃電図検査とアセトアミノフェン法検査を行い,胃運動能・排出能の術後回復過程を検討した.その結果,胃運動能は術後21日目に回復し,胃排出能は術後28日目に回復することが明らかになった

幽門輪温存膵頭十二指腸切除術(PpPD)を受けた2例と,胃切除を伴う膵頭十二指腸切除術を受けた4例の術後膵外分泌機能を便中キモトリプシンテスト(FCT)と,従来より行われているpancreatic function diagnostant testで検討した.その結果,いずれのtestにおいても膵外分泌機能はPpPD群の方が有意に良好であり,PpPDの再建術式別では,Billroth-II法に比べてBillroth-I法が良好であった.FCTは術後膵外分泌機能を評価する手段として簡便かつ有用な方法であると考えられた

47歳女.眼球黄染を主訴とした.血液生化学所見,US,CT,ERCP,PTBD,EUS所見等により,嚢胞性病変を伴う膵頭部癌と診断し,切除術を施行した.胃幽門部は,膵頭部の嚢胞の圧排により膨瘤しており,膵頭部の腫瘍は横行結腸間膜後面と上腸間膜静脈に浸潤していた為,膵頭十二指腸切除,門脈合併切除,2群リンパ切郭清を行った.膵頭部上方に認めた大きな嚢胞の大部分は乳頭腺腫で乳頭状隆起の部分は乳頭腺癌であった.乳頭状隆起の部分から膵実質内では管状腺癌となり,浸潤性に発育して総胆管,主膵管に浸潤していた.膵鉤部には小さい嚢胞があり,乳頭腺腫であった.管状癌と小さい嚢胞間では,小さい嚢胞の周囲へ管状腺癌の浸潤を認めた.これらにより膵頭部に発生した膵管内乳頭腫の一部が癌化し,乳頭腺癌から管状腺癌へと変化,浸潤性に発育していったと考えられた.症例は6ヵ月後に再発,癌死した