林 千紘

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.

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.

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.

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.

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.

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)

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)

胆道癌取扱い規約第6版より、胆嚢癌の局所進展度はT1aとT1bに分類された。T1aは粘膜固有層への浸潤、T1bは固有筋層への浸潤を認めるものである。T1aの治療方針は、通常リンパ管侵襲、血管侵襲、リンパ節転移を認めないため胆嚢摘出術で問題ない。T1bの治療方針は、2017年に報告された2編のmeta解析の結果では、肝切除を伴った拡大胆嚢摘出術をすべきであるとの報告と胆嚢摘出術でよいとの報告がある。リンパ節郭清については、連続切片で検討した、2編の報告ではリンパ節転移を認めず、胆道癌取扱い規約第6版で規定された所属リンパ節郭清は必要はない。T1胆嚢癌に対する腹腔鏡手術は、現時点では推奨されず、原則として開腹胆嚢摘出術を行うべきである。腹腔鏡手術に対する質の担保された研究が、近年、少数ではあるが報告されてきており、今後の大規模な研究が待たれるところである。(著者抄録)

＜文献概要＞【ポイント】 ◆膵頭十二指腸切除術の際,はじめに流入動脈である後下膵十二指腸動脈を結紮することで術中出血量は減少する.◆後下膵十二指腸動脈へのアプローチは前方アプローチ,Treitz靱帯アプローチ,右側アプローチがある.◆背側膵動脈は脾動脈からの分岐がもっとも多い.

前立腺癌に対する、ロボット支援手術の保険収載により、爆発的にロボットの導入が増え、現在世界第2位のロボット保有国となった。しかし、本邦では消化器領域でのロボット支援による内視鏡手術の報告は依然少ない。しかし、将来的には消化器領域におけるロボット支援手術が普及し、腹腔鏡下手術がさらに安全に遂行されると考える。本稿では、ロボットの機能がもっとも発揮できる膵切除術における胆管空腸吻合、膵管空腸吻合について概説する。(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)

BackgroundHepatocyte transplantation (HTx) has yielded significant improvements in liver function and survival in experimentally induced acute liver failure and liver-based metabolic disease. However, transplantation is inefficient, and it is thought that transplanted hepatocytes have a shortened lifespan because of inflammation involving excess nitric oxide (NO). The present study aimed to clarify whether edaravone, a free radical scavenger used to treat ischemic stroke, could reduce ischemic changes in hepatocyte-transplanted livers. MethodsEdaravone (3mg/kg) was administered intravenously 24h before HTx to Nagase analbuminemic rats (NARs). Hepatocytes were isolated, and 30 x 10(6) cells were injected in a 1.0-ml volume directly into the spleens of NARs. All experimental groups studied received FK506 to control rejection. Animals in Group A received medium-only; Group B received HTx only; and Group C received HTx and edaravone. Forty-eight hours after transplantation, the hepatocytes from animals were isolated and analyzed for staining with propidium iodide- and annexin-V using flow cytometry. Liver sections were also studied by immunostaining for albumin, and TUNEL. Peripheral blood serum albumin levels were measured on post-transplant days 0, 3, 5, 7, 10 and 14 using ELISA. ResultsThe edaravone-treated animals demonstrated an increased number of engrafted donor hepatocytes in the liver. The edaravone-treated liver sections also contained fewer TUNEL-positive cells and animals that received edaravone had higher serum albumin levels post-transplantation. Hepatocytes were also found to have increased in numbers 2 weeks following treatment with edaravone. ConclusionsEdaravone administration during HTx can suppress apoptosis near the transplanted cells, increasing engraftment. These studies indicate its potential usefulness for future clinical application.

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。(著者抄録)

膵頭十二指腸切除術(PD)12例、幽門輪温存膵頭十二指腸切除術(PPPD)20例、亜全胃温存膵頭十二指腸切除術(SSPPD)45例、十二指腸温存膵頭切除術(DPPHR)10例を対象に、術後普通食摂取可能な時期に13C-Trioctanoinを100mg添加した液状試験食を経口投与し、試験食摂取前から摂取後4時間まで経時的に呼気を採取した。赤外分光分析装置にて呼気中13CO2存在比の変化を測定し、薬物動態学上の吸収量(Aa)を算出した結果、健常人10例との比較にて、DPPHRは有意差を認めず、PPPD・SSPPD・PDはいずれも有意に減少した。次に、摘出した標本の非癌部の組織学的所見により膵線維化の絶対量をGrade0〜Grade2の3段階に分類し、線維化程度別の各術式間におけるAaを比較した結果、Grade0においてDPPHRはPPPD・PDに比し有意に良好な消化吸収能を示した。線維化の少ない正常膵ではDPPHRが最も優れた術式であると思われた。

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>