ito masahiro

膵頭部領域腫瘍に対する術前診断と治療の進歩について報告した。再構成画像から早期動脈相と後期動脈相と肝実質相の3D画像を作成した。病変と主要血管を表示し、必要に応じて病変や主膵管、胆管の描出も行った。十二指腸温存膵頭切除術では、術前の3D動脈構築像による膵頭アーケードの描出が有用であった。中央区域温存膵切除術では、術前に多発する病変と膵管、動静脈を同一画面に描出し、任意の断面像にて各々の位置関係を確認することが有用であった。腹腔鏡下脾(動静脈)温存膵体尾部切除術では、術前にLaparoscopic viewにて病変と脾動静脈の位置関係を確認することで開腹手術と同様に安全性、正確性を保つことが可能であった。da Vinci用いたロボット支援による腹腔鏡下膵頭十二指腸切除術は触覚機能を有さない欠点を持つが、術者が覗き込むビューポートはハイビジョンな3D映像を提供し、その欠点を十分に補っている。

BACKGROUND/AIMS: Intraductal papillary mucinous neoplasm (IPMN) and pancreatic endocrine tumors can develop at multiple sites of the pancreas at the same time, sometimes necessitating total pancreatectomy. When low-grade pancreatic malignancy is treated surgically, preservation of function to improve long-term QOL is emphasized. For low grade malignancy tumor of the pancreatic head and tail, we performed middle- segment-preserving pancreatectomy (MSPP), with resection of the pancreatic head and tail alone, resulting in favorable QOL. METHODOLOGY: MSPP was performed for 4 patients. Intraoperative blood loss, hospital stay, postoperative complications, histopathological findings and prognosis were examined. RESULTS: Mean intraoperative blood loss was 1255 +/- 365g, mean hospital stay 61 +/- 53 days, and mortality 0%. Postoperatively, pancreatic fistula was observed in 3 patients, but subsided with conservative treatment. In one patient with diabetes preoperatively, diabetes was exacerbated postoperatively, necessitating insulin treatment. No postoperative onset of diabetes was observed. Percent change in body weight during the postoperative 6 month period from preoperative weight was 93 +/- 6.3%. One patient died of malignant lymphoma 1 year and 4 months after surgery. The other patients are alive and socially active. CONCLUSION: MSPP enables maintenance of good QOL long after surgery for malignancy affecting the head and tail of the pancreas.

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.