Yukio Asano

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.

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.

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.

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.

A 62-year-old male with hyperamylasemia was diagnosed as locally advanced pancreatic head cancer with extrapancreatic nerve plexus invasion by abdominal CT and ERCP. He underwent a course of chemoradiotherapy with a total 50Gy and systemic infusion of 600mg/m<sup>2</sup> gemcitabine(GEM) and then intravenous administration of 800mg/m<sup>2</sup> GEM was instituted after chemoradiotherapy. After 2 courses of chemotherapy, the tumor dramatically shrank and the invasion of the extra-pancreatic nerve plexuses improved. Serum CA19-9 was also decreased to standard value. The patient successfully underwent pancreatoduodenectomy with no residual tumor, and showed no sign of recurrence 18 months after first visiting our hospital. In conclusion, chemoradiotherapy followed by systemic administration of GEM was effective for unresectable pancreatic cancer, and it may allow us to curatively resect the advanced pancreatic cancer.<br>

Patients with intraductal papillary mucinous tumor (IPMT) have a good prognosis after surgical treatments. One of the recent advances in pancreatic surgery is organ preserving operation. Although local resection can preserve pancreatic function, morbidity still occurs frequently, especialy pancreatic fistula for the main pancreatic duct injury. We performed pancreatic tube guided inferior pancreatic head resection for branch typed IPMT.<br> A 69-year-old man was admitted to the hospital because of epigastric pain. MRCP showed a cystic tumor about 3.5cm in diameter in the pancreatic head. Multiplanar reconstruction CT revealed the cystic tumor in the pancreatic uncus.<br> Endoscopic retrograde pancreatography demonstrated the cystic tumor in the inferior pancreatic duct region. An endoscopic naso-pancreatic drainage (ENPD) tube was inserted in the main pancreatic duct on the preoperative day one. The resection line near the main pancreatic duct was decided by touching the ENPD tube. The patients, postoperative course was uneventful without postoperative complications.<br> This procedure is considered to be appropriate for treating benign tumors and non-invasive malignant tumors involving the uncinate process.

Patients with intraductal papillary mucinous tumor (IPMT) have a good prognosis after surgical treatments. One of the recent advances in pancreatic surgery is organ preserving operation. Although local resection can preserve pancreatic function, morbidity still occurs frequently, especialy pancreatic fistula for the main pancreatic duct injury. We performed pancreatic tube guided inferior pancreatic head resection for branch typed IPMT.&lt;br&gt; A 69-year-old man was admitted to the hospital because of epigastric pain. MRCP showed a cystic tumor about 3.5cm in diameter in the pancreatic head. Multiplanar reconstruction CT revealed the cystic tumor in the pancreatic uncus.&lt;br&gt; Endoscopic retrograde pancreatography demonstrated the cystic tumor in the inferior pancreatic duct region. An endoscopic naso-pancreatic drainage (ENPD) tube was inserted in the main pancreatic duct on the preoperative day one. The resection line near the main pancreatic duct was decided by touching the ENPD tube. The patients, postoperative course was uneventful without postoperative complications.&lt;br&gt; This procedure is considered to be appropriate for treating benign tumors and non-invasive malignant tumors involving the uncinate process.

A 43-year-old man was seen at the hospital because of right lower abdominal pain. Abdominal CT scan showed mild swelling of the appendix and air in the vicinity of the appendix. With the most likely diagnosis of penetration of acute appendicitis into appendiceal mesentery or diverticulitis of the appendix, surgery was performed on the same day. During surgery, purulent ascites around the appendix and the slightly swollen appendix were noted. And redness and hypertrophy of the appendiceal mesentery were seen. Appendectomy was carried out. On the resected material, fecalith was identified near the root of appendix, and deverticulum was present on the mesentery side of the appendix. Histopathologically the appendiceal diverticulum was true diverticulum in which the proper muscular layer was kept intact. Perforation was identified in a part of the diverticulum, with abscess formation around it, so that diverticulitis of the appendix was definitely diagnosed.&lt;br&gt;Diverticulosis of the appendix is a relatively uncommon entity. Clinically it can perforate in a high frequency, and it poses the problem of indicating surgery if the disease is detected in asymptomatic subjects. If perforation once occurs to develop inflammation, serious complications are often associated. Strict care must be exercised for asymptomatic patients as well as those who are suspected to have inflammation.

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