志村 正博

局所進行切除不能膵癌に対してFOLFIRINOX+放射線療法を行った後,conversion surgeryを施行した1例について報告する。症例は70歳代,女性。食後の腹痛を主訴に近医を受診し,腹部造影CTを撮影したところ,膵鉤部に上腸間膜動脈,第1空腸動脈,第2空腸動脈浸潤(>180°)を伴う不整形腫瘤を認めた。画像上,UR-LA(sm),cT4N0M0,cStage IIIの膵癌と診断され,mFOLFIRINOX 5コース施行した。その後,局所制御を目的として,放射線療法50.4Gy(三次元原体照射)を追加した。CA19-9は394.1U/mLから10.5U/mLへ低下した。治療効果はRECIST:partial responseと判定した。この後,根治術可能と判断し,初回治療から8ヵ月後に亜全胃温存膵頭十二指腸切除術を施行した。腫瘍は3×2mm相当とごくわずかな範囲に認められ,pStage IA,R0,術前化学療法の治療効果判定はEvans Grade IIIであった。患者は術後5ヵ月無再発生存中である。(著者抄録)

S状結腸癌および多発肝転移に対して化学療法後,肝切除術を施行し病理結果で完全寛解を得たが,化学療法中止後肝局所再発を来したため再肝切除を行った1例を報告する。下腹部痛で当院救急外来を受診した。大腸内視鏡では全周性のII型腫瘍を認め生検にて高分化型腺癌と診断された。根治目的にて腹腔鏡下S状結腸切除+D3リンパ節郭清を施行した。術後CTにてS5,S7,S8に肝転移を認め,Bev+modified FOLFOX(mFOLFOX)を11サイクル施行した。肝転移はいずれの部位でも縮小し肝右葉切除術を施行した。切除標本からはviableな癌組織は認めず完全寛解と考えられた。術後Bev+mFOLFOXを6サイクル再開し寛解を維持していたが,化学療法を中止した3ヵ月後,肝切除後1年6ヵ月後のフォローアップCTにて肝断端の局所再発を認め,肝転移局所再発と診断し開腹肝部分切除を行った。患者は術後9ヵ月現在,無再発生存中でありmFOLFOXを再開している。(著者抄録)

We report a case of a woman in her 70s who underwent conversion surgery after FOLFIRINOX, followed by radiation therapy for initially locally advanced unresectable pancreatic cancer. She visited her local doctor with a chief complaint of upper abdominal pain. Contrast-enhanced CT scan of the abdomen revealed an irregular mass invading the superior mesenteric artery, and the first and second jejunal arteries(>180°)in the pancreatic uncinate region. Based on imaging, she was diagnosed as UR-LA(sm), cT4N0M0, cStage Ⅲ pancreatic cancer, and underwent 5 courses of modified FOLFIRINOX. Radiation therapy of 50.4 Gy was added for local control, and CA19-9 decreased from 394.1 U/mL to 10.5 U/mL. The treatment effect was judged as RECIST: partial response. The tumor was considered to be potentially curative, and a subtotal stomach preserving pancreaticoduodenectomy was performed 8 months after the initial treatment. The tumor was found to be 3× 2 mm in size, pStage ⅠA, R0, and the response to preoperative chemotherapy: Evans Grade Ⅲ. The patient is alive at 5 months postoperatively without recurrence.

We report a case of a patient with sigmoid colon cancer and multiple liver metastases who underwent hepatectomy after chemotherapy and pathological results showed complete remission. However, after chemotherapy was discontinued, the patient developed a local recurrence of the liver metastasis and underwent rehepatectomy. The patient came to our hospital with lower abdominal pain. Colonoscopy revealed a circumferential type Ⅱ, well-differentiated adenocarcinoma. Laparoscopic sigmoidectomy with lymph node dissection was performed. Postoperative CT scan showed multiple liver metastases at S5, S7, and S8. 11 cycles of bevacizumab plus modified FOLFOX(mFOLFOX)were subsequently performed. The liver metastases shrank at all sites, and the patient underwent right hepatectomy. The resected specimen was considered to be in complete remission, with no evidence of viable malignant cells. Postoperatively, bevacizumab plus mFOLFOX was resumed for 6 cycles and the patient remained in remission. However, 3 months after stopping chemotherapy and 1 year and 6 months after hepatectomy, a follow-up CT scan showed local recurrence of the liver edge, and a diagnosis of local recurrence of liver metastasis was made, and a partial hepatectomy was performed. The patient is recurrence-free and resuming modified FOLFOX 9 months after surgery.

59歳の男性で,左下腹部痛と発熱を認めたため当院を受診した.下腹部に限局した圧痛と筋性防御を認めたが,反跳痛は認めなかった.白血球数16,200/μl,CRP5.29mg/dlを認め,腹部CT検査ではS状結腸の壁肥厚を認め,周囲に遊離ガス像を認めた.S状結腸穿孔,限局性腹膜炎と診断し,手術を勧めたが患者の同意が得られず絶食と抗生剤による治療を行った.全身状態は改善したのちに精査を行いS状結腸癌と診断した.腹部CT検査で腫瘍は左骨盤壁への近接が予測され,麻酔導入後に蛍光尿管ステントを留置した.腹腔鏡下に手術を行い,術中所見で腫瘍は尿管に近接していたが,近赤外光で尿管を視認し,尿管への浸潤は認めなかった.しかし精管への癒着浸潤が疑われ,腹腔鏡下S状結腸切除術,精管合併切除術を行った.術前に尿管損傷を危惧する際において蛍光尿管ステントは術中に尿管の位置を把握するために有用であると考えられた.(著者抄録)

The natural history of intracholecystic papillary neoplasm (ICPN), especially the speed of growth from small benign to a carcinomatous lesion, is quite unrevealed. Here, we report an extremely rare case of ICPN, in which the papillary lesion was observed transforming from small and benign to malignant using abdominal ultrasound (AUS) over 2 years during routine health checks. A 44-year-old man underwent a routine health check-up. The initial AUS showed a small sessile polyp in the gallbladder, which enlarged slightly at the next AUS, a year later. In the third year, the polypoid lesion enlarged markedly, with a maximum diameter of 10 × 9 × 7 mm. Therefore, a laparoscopic cholecystectomy was performed. Microscopically, the 10 mm tumor had intracytoplasmic mucus, and a clear cytoplasm compatible with gastric-type features. Immunohistochemical analysis showed positive staining of atypical cells for MUC6 and PAS. These findings led to the diagnosis of ICPN with high-grade intraepithelial neoplasia of the gastric type. In conclusion, sessile polyps with rapid growth might be a crucial finding in the early stage of ICPN.

A 49-year-old female was underwent laparoscopic right hemicolectomy for ascending colon cancer and liver metastasis. Then, she was underwent laparoscopic hepatectomy. She received BEV plus mFOLFOX6 therapy as postoperative adjuvant chemotherapy, but she had liver recurrence. She received FOLFOXIRI therapy. Although tumor tended to progressive, it was localized, so laparoscopic hepatectomy was performed again. She received AFL plus FOLFIRI therapy. Fourteen months after hepatic resection, disseminated nodules and lung metastases were found. However, both of peritoneal dissemination, and lung metastasis were localized, so it was judged that peritoneal dissemination and lung metastasis could be resectable. Then, peritoneal dissemination resection and sigmoid colectomy were performed, and then lung resection was performed to perform R0 resection. R0 resection and multimodal therapy for simultaneous and heterotopic metastases of colorectal cancer can contribute to provide a long-term prognosis.

根治度A手術が施行された下部直腸T2癌88例(T2)の治療成績をT3またはT4a癌(T3/T4a)340例,T1癌(T1)51例と比較した。T2の全リンパ節(LN)転移率,腸管傍LN転移率,中間および主LN転移率,側方LN転移率はいずれもT1と差がなかった。T2の再発率は15.9%で,T1は差がなかった。T2はT1に比べて肺再発の頻度が有意に高率であった。T2再発例の50%は術後30ヵ月以降に認められ,T3/T4aに比して有意に高率で,T1とは差がなかった。LN転移陰性T2における多変量解析で術前血清CA19-9高値が再発危険因子であった。T2の5年生存率,再発後5年生存率はT3/T4aに比べて有意に高率で,T1と差がなかった。下部直腸T2ではT1と同様なLN郭清が適当で,術前血清CA19-9高値は再発危険因子であり,術後30ヵ月以降の肺再発に配慮したフォローアップが必要と考えられた。(著者抄録)

The outcomes of 88 patients with lower rectal T2 cancer who underwent radical A surgery(T2)were compared with those of 340 patients with T3 or T4a cancer(T3/T4a)and 51 patients with T1 cancer(T1). The rates of all lymph node(LN) metastasis, paraintestinal LN metastasis, intermediate and main LN metastasis, and lateral LN metastasis in T2 were all significantly lower than in T3/T4a and not different from those in T1. The recurrence rate of T2 was 15.9%, significantly lower than that of T3/T4a and not different from that of T1. Fifty percent of T2 recurrences were observed after 30 months postoperatively, significantly higher than that of T3/T4a and not different from that of T1. The 5-year survival rate of T2 was significantly higher than that of T3/T4a and did not differ from that of T1. In lower rectal T2, cancer LN dissection similar to that in T1 is appropriate, and high preoperative serum CA19-9 level is a risk factor for recurrence, suggesting the need for follow-up after 30 months postoperatively to take recurrence into consideration.

AIM: This study aimed to compare the incidence of postoperative nonalcoholic fatty liver disease (NAFLD), postoperative cholangitis, and fibrosis-4 (FIB)-4 index in patients who underwent duodenum-preserving pancreatic head resection (DPPHR) and pancreaticoduodenectomy (PD) for low-grade malignant tumors and verify the usefulness of DPPHR in preventing the occurrence of these disorders. METHODS: This retrospective study included 70 patients who underwent PD (n = 39) and DPPHR (n = 31) between 2006 and 2018 for benign or low-grade malignant tumors. The present study compared the preoperative background, cumulative incidence of postoperative NAFLD and cholangitis, and other biochemical markers, including the FIB-4 index. Subanalysis by propensity score matching (PSM) analysis was conducted to minimize treatment selection bias. RESULTS: In terms of the cumulative incidence of NAFLD, the 5-y incidence was significantly lower in the DPPHR group than in the PD group both before (10% vs 38%, P = .002) and after (13% vs 38%, P = .008) matching. Multivariate analyses identified DPPHR as the only independent preventive factor for postoperative NAFLD (hazard ratio: 0.160, 95% confidence intervals: 0.034-0.76, P = .021). The 5-y cumulative incidence of postoperative cholangitis was significantly higher in the PD group than in the DPPHR group before (51% vs 3%, P < .001) and after (49% vs 4%, P < .001) matching. The FIB-4 index at 12 mo postoperatively was significantly better in the DPPHR group than in the PD group (1.45 vs 2.35, P = .006) before matching. CONCLUSION: Preservation of the duodenum and bile duct may contribute to preventing long-term postoperative NAFLD and cholangitis, and liver fibrosis for benign or low-grade malignant pancreatic head tumors.

Herein, we report an extremely rare case of intraductal tubulopapillary carcinoma (ITPC) that was detected due to the pancreatic duct dilatation newly appeared on CT after surgery for gallbladder cancer associated with pancreaticobiliary maljunction. Present case: a 77-year-old female. Extended cholecystectomy, extra-bile duct resection, and hepaticojejunostomy was performed and resected specimen showed that this gallbladder tumor was papillary adenocarcinoma, pT2(ss), pN0, pDM0, pHM0, pEM0. Thereafter, the follow-up CT scan 2 years after surgery detected the dilatation of main pancreatic duct (MPD) and the elevation of carcinoembryonic antigen (CEA) level was pointed out (4.9 to 5.9 ng/ml). Moreover, pancreatic juice cytology revealed adenocarcinoma cells. Thus, distal pancreatectomy was performed based on the diagnosis of pancreatic adenocarcinoma associated with pancreaticobiliary maljunction (PBM). Histologically, proliferation of highly columnar atypical cells in the dilated main pancreatic duct with marked papillary and irregular tubular structures is seen. No mucus production is observed. Based on immunohistochemistry, Mucin (MUC) 1, 2 and 5AC were focal weak positive, negative and negative, respectively. Taken together of these findings, we could diagnose this tumor with ITPC without invasive component. The patient is alive without any recurrence for 36 months after a second surgery. In conclusion, it is essential to be fully aware that PBM is a disease in which there is still a possibility that pancreatic or biliary tract cancer may occur in the future, and that careful routine follow-up for a long period after diversion surgery may lead to early detection of complicated cancers.

A 50-year-old woman was hospitalized for fainting caused by hypoglycemia. Her blood glucose level was low (40 mg/dL), immunoreactive insulin was 16.9 μU/mL, and C-peptide level was high (4.8 ng/mL). Computed tomography and magnetic resonance imaging revealed a 7-mm tumor in the uncinate process of the pancreas. A selective arterial calcium injection test indicated an increase in the superior mesenteric artery. Insulinoma of the uncinate process of the pancreas was diagnosed, and tumor enucleation was planned using an artificial pancreas for intraoperative and postoperative blood glucose control. Hypoglycemia (blood glucose, 38 mg/dL) was observed from the onset of surgery. An artificial pancreas cannot be used if the blood glucose level is ≤ 70 mg/dL; thus, continuous glucose infusion was administered. The sudden rise in blood glucose prompted insulin infusion from the device, causing hypoglycemia. Controlling blood glucose levels is challenging when introducing the artificial pancreas. However, altering the device’s blood glucose control algorithm controlled the fluctuating blood glucose level, and, intraoperative average blood glucose was raised to 94.8 ± 21.1 mg/dL, thereby avoiding hypoglycemia, that is, a blood glucose level of ≤ 70 mg/dL. We report a case in which an artificial pancreas was used for glycemic control during surgery for an insulinoma.

In this report, we describe a case of highly advanced hepatocellular carcinoma with tumor thrombosis extending into the main portal vein of the pancreas that was successfully treated with adjuvant lenvatinib after right hepatic resection with thrombectomy. A 70-year-old woman was referred from the clinic because of elevated hepatobiliary enzymes. The patient was positive for the hepatitis B virus antigen at our hospital. The tumor markers were highly elevated with alpha-fetoprotein (14.5 U/mL) and protein induced by vitamin K absence (PIVKAII) (1545 ng/mL), suggesting hepatocellular carcinoma. Dynamic abdominal computed tomography showed an early enhanced tumor approximately 6 cm in size and portal vein tumor thrombosis filling the main portal vein, but not extending into the splenic or superior mesenteric vein (SMV). On magnetic resonance imaging 1 week after CT, portal vein tumor thrombosis had extended to the confluence of the splenic vein with the SMV, indicating rapid tumor growth. Thus, we performed emergent right hepatectomy with tumor thrombectomy. Postoperatively, we treated the patient with lenvatinib for a tumor reduction surgery. Fortunately, the patient was alive 2 years postoperatively without recurrence. This case report suggests that a favorable outcome may be achieved with multidisciplinary treatment including resection and postoperative treatment with lenvatinib.

BACKGROUND: The association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the 13C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF. METHOD: A total of 80 patients who underwent 13C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between 13C-trioctanoin absorption and PF incidence. RESULTS: Among 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the 13C-trioctanoin breath test value (Aa% dose/h) increased (odd's ratio: 1.082, 95% confidence interval: 1.007-1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53). CONCLUSIONS: Favorable preoperative fat absorption evaluated using the 13C-trioctanoin breath test is a feasible and objective predictor of PF after PD.

The two patterns of pathogenesis for pancreatic colloid carcinoma are reported; (1) progression from ordinary ductal adenocarcinoma, a subtype of invasive pancreatic ductal carcinoma, and (2) progression from papillary adenocarcinoma derived from intraductal papillary mucinous neoplasm (IPMN) or mucinous cystic neoplasm (MCN). Whether these two conditions are the same disease remains controversial. Case Report 1. An 81-year-old woman was evaluated for an increased carbohydrate antigen 19-9 (CA19-9) value (130 U/mL) detected at 4-year follow-up after distal pancreatectomy for IPMN. Based on the image findings, a local recurrence of IPMN was diagnosed, and the patient underwent a remnant total pancreatectomy. Histopathologic findings showed marked mucus production from the tumor, also noteworthy because mucous nodule formation occurs in more than 80% of tumor. Fibrosis around the mucous cavity was noted, and a low papillary lesion was found in part of the cyst wall, which was contiguous to a flat, basal area; its nucleus was enlarged and heterogeneous in size, which is considered to be a component of intraductal papillary mucinous (IPMC). Therefore, the patient was diagnosed with pancreatic colloid carcinoma derived from IPMN. Case report 2 a 71-year-old man was evaluated for jaundice. Based on the image findings, a diagnosis of pancreatic head cancer was made, and a substomach preserving pancreaticoduodenectomy was performed. Histologically, marked mucus production and floating cuboidal masses of atypical cells without mucinous nodules were seen. Mucinous nodule formation is observed in more than 80% of tumor, but there was no IPMN component, which led to the diagnosis of pancreatic colloid carcinoma. In conclusion, there might be two types of colloid carcinoma of the pancreas, and further study is needed to determine whether these diseases are truly the same or not.

BACKGROUND: Performing major hepatectomy for patients with marginal hepatic function is challenging. In some cases, the procedure is contraindicated owing to the threat of postoperative liver failure. In this case report, we present the first case of marginal liver function (indocyanine green clearance retention rate at 15 min [ICGR15]: 28%) successfully treated with right hepatectomy, resulting in total caudate lobe preservation. CASE PRESENTATION: A 71-year-old man was diagnosed with sigmoid colon cancer with three liver metastases (S5, S7, and S8). All of metastatic lesions shrunk after chemotherapy, but his ICGR15 and indocyanine green clearance rate (ICGK) were 21% and 0.12, respectively. Moreover, the remnant liver volume was only 39%. Therefore, portal venous embolism (PVE) of the right portal vein was suggested. Portography showed divergence of the considerably preserved right caudate lobe branch (PV1R) from the root of the right portal vein. The liver function was reevaluated 18 days after PVE was suggested. During this time, the ICGR15 (21-28%) and ICGK rate (0.12-0.10) deteriorated. The right caudate lobe was significantly enlarged; thus, a total caudate lobe-preserving hepatectomy (TCPRx) was performed. Patients eligible for TCPRx included those with (1) hepatocellular carcinoma or metastatic liver cancer, (2) no tumor in the caudate lobe, (3) marginal liver function (ICG Krem greater than 0.05 if TCPRx was adapted; otherwise, less than 0.05) and Child-Pugh classification category A, and (4) preserved PV1R and right caudate bile duct branch. The procedure was performed through (A) precise estimation of the remnant liver volume preoperatively, (B) repeated intraoperative cholangiography to confirm the biliary branch of the right caudate lobe (B1R) conservation, and (C) stapler division of posterior and anterior Glisson's pedicles laterally to avoid injuries to the PV1R and B1R. CONCLUSIONS: Right hepatectomy with total caudate lobe preservation, following PVE, was a safe and viable surgical technique for patients with marginal liver function.

PURPOSE: The aim of this study was to elucidate the association between pancreatic fistula (PF) and the sequential changes in the perioperative exocrine function after pancreatectomy. METHODS: The subjects were 96 patients who underwent a 13C-trioctanoin breath test before and 1 month after pancreatectomy, between 2006 and 2018. We retrospectively compared the pre- and postoperative fat absorption levels between patients with PF (PF group; n = 17) and without PF (non-PF group; n = 79) using the breath test. RESULTS: The preoperative level of 13C-trioctanoin absorption (%dose/h) was comparable between the non-PF and PF groups (36.5 vs. 36.9). In the non-PF group, 13C-trioctanoin absorption was significantly decreased after surgery in comparison to the preoperative setting (post-operative 28.5; pre-operative 36.5; p < 0.0001), whereas these values were comparable (post-operative 36.9; pre-operative 34.5; p = 0.129) in the PF group. Moreover, postoperative absorption in the PF group was significantly better than that in the non-PF group (34.5 vs. 28.5%, p = 0.0003). The maximum drain amylase level was significantly higher in patients with a 13C-trioctanoin absorption level (%dose/h) of ≥ 30 in comparison to patients with levels of < 30 (2502 vs. 398 U/L, p = 0.001). CONCLUSION: PF did not exacerbate the pancreatic exocrine function in the early postoperative period, and the acceleration or preservation of the exocrine function after surgery may be an important cause of PF.

The spread of the new coronavirus (COVID-19) infection in 2020 has had a significant impact on the treatment of cancer worldwide. During the COVID-19 pandemic, the biggest challenge for pancreatic surgeons is the difficulty in providing oncological care. In this review article, from the standpoint of surgeons, we explain the concept of triaging of patients with pancreatic tumors under the COVID-19 pandemic, and the actual impact of COVID-19 on the treatment of patients with pancreatic tumors. The most vital points in selecting the best therapeutic approach for patients with pancreatic tumors during this pandemic are (1) Oncologists need to tailor the treatment plan based on the COVID-19 phase, tumor malignant potential, and patients' comorbidities; and (2) Optimal treatment for pancreatic cancer should be planned according to the condition of each patient and tumor resectability based on national comprehensive cancer network resectability criteria. To choose the best therapeutic approach for patients with pancreatic tumors during this pandemic, we need to tailor the treatment plan based on elective surgery acuity scale (ESAS). Newly established ESAS for pancreatic tumor and flowchart indicating the treatment strategy of pancreatic cancer, are feasible to overcome this situation.

81歳男性.発熱,黄疸の精査のため紹介となり,造影CTで遠位胆管に狭窄を認めた.ERC時に行った腫瘍生検で遠位胆管癌と診断し,膵頭十二指腸切除術を施行した.病理標本では腫瘍部位に腺癌の他,浸潤部位の免疫染色ではchromogranin A,synaptophysin及びCD56が陽性,MIB-1 index 80%と神経内分泌癌も認め,混在した腺癌成分と神経内分泌癌成分とが各々30%以上を占めており,Mixed neuroendocrine-non-neuroendocrine neoplasm(MiNEN)と診断した.その後肝転移を認め,化学療法を開始したがその20ヵ月後に死亡した.胆管原発MiNENの術前診断は,画像診断や胆管生検では困難であり,その治療方針は手術療法だけでなく術前化学療法など集学的治療も考慮されているが,未だ確立されていない.今回稀な胆管MiNENを経験したため報告する.(著者抄録)

We present the case of a 66-year-old female diagnosed with gallbladder cancer that was initially discovered with contrast enhanced computed tomography. The primary gall bladder tumor displayed heterogeneous enhancement. The patient underwent cholecystectomy with full-thickness excision of the gallbladder cancer. After 3 rounds of adjuvant chemotherapy with the oral fluoropyrimidine derivative, S-1(administered for 4 weeks at 120 mg/day and then stopped for 2 weeks), a metastasis measuring 15 mm in diameter emerged within hepatic segment 5. The chemotherapy regimen was altered to include 6 months of combination therapy with gemcitabine(1,000 mg/m2)and cisplatin(25 mg/m2)given once every week for 2 weeks and then stopped for 1 week. The hepatic metastasis decreased in size to 8 mm in diameter, and a partial liver resection was performed. After hepatectomy, the patient remains alive and without disease recurrence.

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.

Hepatocellular adenoma (HCA) is a benign hepatocyte-derived epithelial tumor. HCA is associated with oral contraceptive use among Caucasian populations. We report a case of hepatocellular adenoma with a pedunculated protuberance and high protein induced by vitamin K absence or antagonist-II (PIVKA-II) levels, which made diagnosis challenging. The patient was a 22-year-old woman. In a medical check-up, a high γ-GTP level was detected and a 115-mm solid mass was found in her lower abdomen via abdominal ultrasonography. A blood test showed a high PIVKA-II level. Abdominal CT showed a tumor in the lower abdomen. Contrast-enhanced CT showed a blood vessel thought to be the left hepatic artery connecting to the mass, and a blood vessel thought to be the left hepatic vein returning from the mass to the inferior vena cava. In EOB-MRI, uneven enhancement was observed after contrast imaging, but washout in the equilibrium phase was unclear. Parenchymal hepatocyte phases showed a pale, non-uniform, high signal. These findings indicated that the tumor was derived from the left lobe of the liver and was suggestive of HCC. Surgical resection was then performed. A pathological examination led to a diagnosis of HCA, corresponding to unclassified HCA. The WHO classification of tumors of the digestive system based on an immunohistological examination includes HNF1α-inactivated HCA, β-catenin-activated HCA, inflammatory HCA, and unclassified HCA. In summary, our patient had a large HCA with pedunculated protrusion into the extrahepatic pelvic cavity. This case was challenging to diagnose because of abnormally high PIVKA-II levels, and it was resected laparoscopically.

＜文献概要＞ポイント ◆可能な限り,早い段階で脾動脈確保を安全に施行することが,出血コントロールで重要である.◆膵切離では,切離前に膵圧挫用クリップでしっかり圧挫し,自動縫合器にてゆっくり切離する.◆出血したら,まずガーゼ圧迫と脾動脈テープを牽引する.脾動脈の枝からの出血ならクリップ,脾動脈本幹からの出血なら縫合閉鎖する.

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)

13C-Trioctanoin呼気試験を用い、膵頭切除術の術後脂肪消化吸収能を測定し、臓器温存術式の有用性について検討した。術式別検討で健常人と十二指腸温存膵頭切除術(DPPHR)の間には有意差を認めなかった。また、健常人と幽門輪温存膵頭十二指腸切除術(PPPD)、亜全胃温存膵頭十二指腸切除術(SSPPD)、胃切除を伴う膵頭十二指腸切除術(PD)との比較では、いずれも有意に吸収能の低下を認めた。術式別の手術前後における吸収能の検討で、DPPHRは手術前後で有意差を認めなかった。PPPD、SSPPD、PDは術後有意に減少した。DPPHRは胆管、乳頭、全十二指腸が温存されるため術後良好な脂肪消化吸収能を示したと考えられ、長期QOLを考慮した有用な術式である。13C-Trioctanoinによる呼気試験は、膵頭切除術後の膵外分泌機能を把握するうえで有用な検査法である。(著者抄録)

症例は、40歳男性。腹痛を主訴に前医受診。上部消化管内視鏡で胃噴門部癌と、CTで膵前面に腫瘤を指摘され当院紹介受診となった。当院初診時のCTで、膵前面に急速に増大する巨大腫瘤を指摘された。CTガイド下生検を行い、病理組織診断はneuroendocrine tumor G3(neuroendocrine carcinoma:NEC)であった。巨大膵神経内分泌癌(pancreatic neuroendocrine carcinoma:P-NEC)、胃噴門部癌と診断し手術を施行した。術式は、高度に周辺臓器への浸潤を認めたため、肝左葉切除+胃全摘+膵体尾部切除を含む巨大腫瘍摘出術を施行した。術後1ヵ月のCTで多発肝転移、腹膜播種結節が出現。化学療法として、ソマトスタチンアナログ(サンドスタチンLAR)とCPT11+CDDP併用療法を選択した。2クール終了後の評価CTで、転移巣の縮小が認められPRと判断した。(著者抄録)

胆嚢癌は壁深達度が重要な予後因子で、pT2症例は予後不良なpT3、pT4症例と比較して、外科切除療法によって、唯一根治性が期待できる胆嚢癌である。一方、T2胆嚢癌に対する至適肝切除範囲、あるいは胆管切除付加の意義についてのエビデンスは乏しい。日本胆道癌登録全国集計分析によるpT2胆嚢癌に対する肝切除範囲の検討ではS4a+5切除と胆嚢床切除の差を認めず、また、胆管切除の有無も差を認めなかった。現時点では予防的系統的肝切除、予防的胆管切除の意義は不明瞭であるが、R0手術を行うことが重要と考える。今後、多施設共同randomized control studyが望まれる。(著者抄録)

遠位胆管癌に対する、ロボット支援膵頭十二指腸について概説する。ロボットは、通常の腹腔鏡手術にはみられない、特性を備えている。すなわち、六つの自由度をもつ関節機能、手振れ防止機能ハイビジョン3D画像である。これらの機能は、外科医のストレスを確実に軽減させる。一方、欠点として、開腹手術と比較し、手術時間が長いこと、洗練されたpatient cart側のアシスタントが必要であり、コストパフォーマンスが悪いことである。当院でも症例数はまだ少ないが、膵頭十二指腸切除術後の膵管空腸吻合、胆管空腸吻合、に関しては、ロボット支援手術は通常の腹腔鏡下手術と比して術者のストレスを軽減し、正確な剥離、吻合操作が可能となり、有用と思われた。今後、次世代のda Vinciの開発、made in Japanのロボット開発により、肝胆膵外科領域でも報告例が増えると思われるが、最も重要なことは安全に遂行すること、すなわち、解剖を含め膵臓外科および内視鏡外科を熟知したうえで執刀することである。(著者抄録)

＜最近の知見と重要ポイント＞低悪性腫瘍の多くは,膵頭部癌と異なり,soft pancreasの症例が多い.膵液瘻が懸念された場合,早急に洗浄ドレナージを施行する.ドレナージ不良が疑われる場合,迷わず再ドレナージを施行する.(著者抄録)

膵・胆管合流異常の診断基準は、2013年9月に改訂された。その診断基準に、画像診断として、EUSまたはmultidetector-row CT(MD-CT)のmulti-planar reconstruction (MPR)像などで、膵管と胆管が十二指腸壁外で合流することを確認する項目が新設された。MD-CTは、造影剤アレルギーがある場合、腎機能が不良の場合は施行できない欠点はあるが、EUSのごとく術者の技量に左右されないことや同時に癌の精査が行える利点がある。自験例27例の検討では、MD-CTにて全例で膵・胆管合流異常の診断が可能であった。既報告では、その診断率は小児例では19.6%、成人例では58.3〜100.0%であり、成人例では診断率は満足できる報告もある。MD-CTにて膵・胆管合流異常の診断は可能であるが、日本膵・胆管合流異常研究会による合流形式分類のc型のように、複雑な合流形式をとるものには、術式の立案のためERCPを追加で行う必要がある。(著者抄録)

膵がんはがん遺残のない外科切除（R0切除）が唯一長期生存を得ることができる治療法であるが，その長期成績は十分とはいえない．しかし近年，術後補助化学療法の組み合わせにより徐々に成績が向上してきており，R0切除後に早期に補助療法に移行する戦略は膵がんの予後を向上させるとの方向性が示された．また近年，ロボット支援を含めた腹腔鏡下膵切除術の導入で，術後早期のQOLを向上させ，早期に補助療法を行う戦略も報告されている．一方，初診時に切除不能な膵がんに対してはadjuvant surgeryを念頭に治療を行うことが重要である．浸潤性膵管がんに対する外科治療の現状と展望について概説する．<br>

膵がんはがん遺残のない外科切除(R0切除)が唯一長期生存を得ることができる治療法であるが、その長期成績は十分とはいえない。しかし近年、術後補助化学療法の組み合わせにより徐々に成績が向上してきており、R0切除後に早期に補助療法に移行する戦略は膵がんの予後を向上させるとの方向性が示された。また近年、ロボット支援を含めた腹腔鏡下膵切除術の導入で、術後早期のQOLを向上させ、早期に補助療法を行う戦略も報告されている。一方、初診時に切除不能な膵がんに対してはadjuvant surgeryを念頭に治療を行うことが重要である。浸潤性膵管がんに対する外科治療の現状と展望について概説する。(著者抄録)