伊東 昌広

During a pancreatoduodenectomy (PD) it is important that the anatomy of the arcade of blood vessels in the head of the pancreas is fully understood before the surgery in order to reduce intraoperative bleeding. In most of the patients our group has treated, the inferior pancreaticoduodenal artery (IPDA), one of the efferent arteries of the head of the pancreas, has formed a short common trunk with the first jejunal artery (FJA). Thus, by first locating the origin of the FJA, it was easier to locate the IPDA. There are two ways to locate the IPDA: (1) by measuring the distance between the origin of the superior mesenteric artery (SMA) and that of the FJA; (2) by measuring the distance between the origin of the middle colic artery (MCA) and that of the FJA. Here, we report our measurements of both distances using three-dimensional (3D) models of arteries constructed with multidetector-row computed tomography (MD-CT) images and discuss which is the better measurement to determine the location of the IPDA during PD. A total of 140 patients underwent 64-MD-CT imaging to acquire early and late arterial phase scans. The distance between the origin of the SMA and that of the FJA and the distance between the origin of the MCA and that of the FJA origin were measured. In patients whose IPDA formed either a common trunk with the FJA or arose directly from the SMA, the IPDA or the common truck was located in parallel with the SMA at a very short distance of approximately 18 mm from the MCA origin towards the center. The distance between the SMA origin and the IPDA was significantly longer (approximately 36 mm). Therefore, locating the MCA origin during PD helped determine the location of the IPDA. However, in patients whose anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) arose separately, the distance between the AIPDA origin and the MCA origin was approximately 18 mm, the distance between the AIPDA origin and the PIPDA origin was approximately 19 mm, and the distance between the PIPDA origin and the SMA origin was 19 mm. Thus, locating the SMA helped determine the location of the IPDA during PD in these patients. Based on our findings that the distance between the IPDA origin and the MCA origin was short, we have shown that it is effective to locate the MCA origin in order to determine the location of the IPDA.

The current literature contains little information about laparoscopic surgery for pancreatic disease. We performed spleen-preserving distal pancreatectomy on 7 cases during the period from 2005 to 2008 at our university hospital, including 2 laparoscopic operations. Case 2: A 54-year-old woman was found to have a hypoechoic 4x4 cm lesion in the tail of the pancreas, adjacent to and impinging on the spleen. On careful assessment we suspected a mucoid cystic tumor (MCT), and performed a laparoscopic spleen-preserving distal pancreatectomy. Blood loss was 380 g, and operating time was 310min. Case 1: A 27-year-old woman was found to have a hypoechoic 2x2 cm mass on ultrasound examination of the body of the pancreas. We performed laparoscopic spleen-preserving distal pancreatectomy for solid pseudopapillary tumour (SPT) of the pancreas. Blood loss was minimal, and operating time was 182 min. The other 5 cases were operated upon using the open method. All were female, with an average age of 54.8 years. The average blood loss was 387g. Operating time was 321 min. Laparoscopic pancreatic surgery is generally thought to be difficult owing to the need for lymph node resection, and because nerve plexus invasion occurs with malignant tumors such as pancreatic cancer. The present case series was reported to demonstrate the techniques that have evolved the safety of the operation and its future potential related to the minimally invasive nature of the surgery.