石原 慎

BACKGROUND/AIMS: The aim of this study was to determine whether Billroth I pancreaticogastrostomy (PG-I) or Billroth II pancreaticojejunostomy (PJ-II) after pylorus-preserving pancreatoduodenectomy is associated with better postoperative fat absorption, based on residual pancreatic exocrine function. Several reconstructive operations have been employed after pylorus-preserving pancreatoduodenectomy to maximize postoperative nutrition. However, no single-institution study has been published comparing the reconstructive procedures with respect to digestion and absorption of fat. METHODOLOGY: Fat absorption was studied using the C-13-trioctanoin breath test in patients who were grouped according to the degree of fibrosis of the pancreatic remnant, which was determined by histologic examination of the resection specimen. The fibrosis was graded: grade 0, <10% fibrosis; grade 1, 10-30% fibrosis; and grade 2, >30% fibrosis. There were 22 patients in the PG-I group and 22 patients in the PJ-II group. RESULTS: There were no significant differences between the PG-I and PJ-II groups in the cumulative excretion of labeled carbon dioxide in the patients with grade 0 pancreatic fibrosis. The cumulative excretion in the PG-I group was better than in the PJ-II group in the patients with grade 1 and grade 2 pancreatic fibrosis. CONCLUSIONS: Fat absorption after PG-I is superior to that; after PJ-II in patients with disordered exocrine function of the pancreatic remnant. Billroth I pancreaticogastrostomy allows more effective utilization of the exocrine enzymes of the pancreatic remnant due to elimination of the blind loop characteristic of the Billroth II pancreaticojejunostomy.

The prognosis of pancreatic body carcinoma has been poor due to cancerous invasion of major vessels. Resection of the involved vessels may improve resectability and prognosis. We report a patient who had a pancreatic body carcinoma with cavernous transformation of the portal vein, in whom the portal vein was resected without reconstruction during an Appleby operation. A 67 year-old man was admitted for evaluation of back pain. Enhanced computed tomography showed no main trunk of the portal vein but a developed collateral circulation. Celiac angiography revealed encasement of the common hepatic, splenic and celiac artery,venous angiography revealed obstruction of the portal and splenic veins with cavernous transformation surrounding these veins. Pre-operative diagnosis was carcinoma in the. pancreatic body, which invaded the portal vein, the celiac and common hepatic arteries. The Appleby operation combined with resection of the portal vein without reconstruction could be performed, by preserving collateral vessels and monitoring hepatic venous oxygen saturation (ShvO(2)) to prevent hepatic ischemia caused by occlusion of the portal vein. The post-operative course was uneventful.

肝虚血時,肝組織中NO値の上昇に伴い血中ヒアルロン酸は上昇し,血中alanine aminotransferaseには有意な変化を認めず,更に再灌流により大量のNOが放出され,肝類洞内皮細胞障害を増強させており,NOと類洞内皮細胞障害との強い関連が示唆された

We report a 66-year-old man who had a cystic intraductal papillary adenocarcinoma containing a papillary adenoma, in the head of the pancreas and a coexistent invasive, well differentiated solid tubular adenocarcinoma in the tail of the pancreas. He was hospitalized with acute epigastralgia. Computed tomography demonstrated a multilocular cystic mass in the head of the pancreas and a solid tumor in the tail. Endoscopic retrograde pancreatography showed mucin secretion from an enlarged papilla of Vater, marked dilatation of the main pancreatic duct in the head and body, cystic dilatation of the uncinate branch, and irregular narrowing of the main pancreatic duct in the tail. Total pancreatectomy was performed. Between the cystic tumor and the solid tumor there was a distance of 4.8 cm of normal pancreatic parenchyma and duct, recognized both grossly and microscopically. The patient died 35 months after the operation. At autopsy, peritonitis carcinomatosa was found in the abdominal cavity. Microscopically, disseminated nodules were also well differentiated tubular adenocarcinoma. The apparent anatomic separation of these two tumors within the pancreas is extremely unusual.

Using helical computed tomography (CT), we evaluated cystic pancreatic lesions in 11 patients and compared the imaging and the histopathologic findings. Helical CT allowed us to assess the tumor vasculature. Contrast-enhanced images showed satisfactory details of the cysts, cyst walls, and intracystic structures. Helical CT is extremely useful for the evaluation of cystic pancreatic lesions. © Springer-Verlag 1996.

A 21-year old man was transferred to our hospital after a traffic accident. He had a chief complaint of right upper abdominal pain. Abdominal computed tomography scan at admission showed fluid collection in the abdominal cavity and linear low density area in the hepatic hilus including segment V of the liver. Operative findings revealed a hepatic laceration extending from the boundary between segment IV and segment V to the hepatic hilus, and a completely transection of the left hepatic duct near the caudate lobe without ischemic change and contusion. The bile duct of the caudate lobe communicated with the left hepatic bile duct at the distal portion of the torn wedge, and was not injured. The transected bile duct was primarily repaired with an interrupted end-to-end anastomosis using a retrograde transhepatic bile duct tube (RTBD tube) as stent. Intra- and postoperative cholangiography via the tube revealed no leakage or narrowing. He is in good health of 60 months after surgery. The case illustrates the condition of the transectional wedges for end-to-end anastomosis, and the usefulness of RTBD tube for the anastomosis stent and the diagnosis of the bile leakage after anastomosis.

The aim of this study was to determine if fat absorption is better after pylorus-preserving pancreatoduodenectomy (PPPD) or duodenum-preserving pancreatic head resection (DPPHR) compared with that following pancreatoduodenectomy with gastrectomy (SPD), provided the patients have similar pancreatic exocrine function. Fat absorption was studied using the 13C-trioctanoin breath test in patients who were grouped according to the degree of fibrosis of the pancreatic remnant. The latter was judged by histologically measuring the fibrosis in a transectional wedge of resected pancreas. We evaluated 11 SPD cases, 25 PPPD cases, and 9 DPPHR eases. The 13C excretion rates and cumulative excretion values following DPPHR or PPPD were significantly better than those following SPD. The 13C excretion rates and cumulative values for the patients with &gt 30% fibrosis of the pancreas were lower than those in patients with &lt 30% pancreatic fibrosis, regardless of the surgical procedure. The cumulative value in the SPD group, however, was lower than that in the PPPD or DPPHR patients with &lt 30% pancreatic fibrosis. The results suggested that fat absorption following PPPD or DPPHR is superior to that after SPD in patients with the same fibrotic area of the pancreatic remnant and depends on the degree of fibrosis in the pancreatic remnant.

A 71 year old woman was admitted with jaundice and found to have a tumor originating from the cystic and common, hepatic ducts, which infiltrated the origins of the right bile duct and duct of Spiegel. The tumor was also shown to encase the right hepatic artery. A central bisegmentectomy with concurrent caudate lobectomy was performed using the right gastroepiploic artery for reconstruction of the posterior segmental branch of the right hepatic artery. Celiac angiography conducted 3 weeks postoperatively confirmed the patency of the hepatic segmental arterial anastomosis. The patient had an uneventful recovery with no evidence of fiver failure, and was discharged home thirty-two days. Tumors infiltrating the right hepatic artery, which have traditionally been treated with extensive liver resection, can be managed with hepatic segmentectomy and reconstruction of the segmental hepatic artery.

A 76-year-old woman underwent combined resection of the gallbladder plus partial hepatectomy for early gallbladder cancer. From the pathology results, the surgical treatment was deemed to have been curative. However, 3 years later, the patient was readmitted to the hospital with an elevated carbohydrate antigen (CA) 19-9 level. Percutaneous transhepatic cholangiography demonstrated irregularity of the common hepatic duct and the left intrahepatic bile duct, and percutaneous transhepatic cholangioscopy revealed two separate papillary tumors at these sites. A diagnosis of multiple carcinomas of the bile duct was made and left hepatic lobectomy and resection of the extrahepatic bile duct was performed reconstruction was carried out with a right hepatico-jejunostomy with Roux-en-Y anastomosis. Microscopic study revealed that both of the lesions were papillary adenocarcinomas, and normal biliary mucosa was confirmed to exist between them. © 1994 Springer-Verlag.