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.

症例は72歳、男性。2009年より慢性膵炎にて薬物治療中、腹部USにて膵管拡張を指摘され当院紹介となった。採血上、腫瘍マーカーは正常範囲内であった。造影CTでは、膵体部に尾側膵管の拡張を伴う直径30mmの乏血性腫瘍を認めた。同腫瘍は総肝動脈・脾動脈・腹腔動脈に浸潤が疑われた。EUSでは直径29×24mmの低エコー腫瘍を認めた。ERCPでは膵体部主膵管の途絶を認め、膵液細胞診では腺癌を疑う結果であった。局所進行切除不能膵体部癌と診断し、GnPを施行した。GnP6コース施行後のCTにて腫瘍は縮小傾向を認めた。PET-CTでは、同腫瘍にSUVの軽度集積亢進を認めるも、血管周囲には集積を認めなかった。以上より、根治切除可能と判断し手術を施行した。手術は腫瘍周囲の軟部組織の迅速病理検査を行い、悪性所見のないことを確認した上で脾臓合併膵体尾部切除術を行った。病理組織学的にtubular adenocarcinomaの所見で、腫瘍は全体の約30%程度の残存で、組織学的効果判定はGrade2であった。(著者抄録)

今回、術前から肝動脈分岐形態と膵頭部領域腫瘍との位置関係に留意しながら肝動脈合併切除(非再建)PDを施行し、根治術が可能であった2症例を報告する。症例1:患者は73歳、男性。黄疸を主訴に来院し、術前精査にて遠位胆管癌と診断された。術前造影CTにて右肝動脈は通常どおり胆管後面を走行しており、胆管腫瘍と周囲リンパ節内を貫通しており浸潤が示唆された。左肝動脈は肝十二指腸間膜左縁を走行しておりintactであった。術中所見では右肝動脈は腫瘍と周囲リンパ節に一塊となって巻き込まれており、右肝動脈温存は不可能であった。右肝動脈をクランプ後、エコーにて肝右葉内の動脈血流が左肝動脈から肝門板を介して流入していることを確認し、右肝動脈合併切除非再建PDを施行した。術後、肝動脈血流に問題なく、また病理組織からもR0切除可能であった。症例2:患者は65歳、男性。黄疸を主訴に来院し、術前精査で総肝動脈にencasementを認める膵頭部癌(BR)と診断された。自験例では右肝動脈はSMAから、左肝動脈は左胃動脈から分岐しており、総肝動脈を切離しても肝動脈血流は十分保持されると判断し、総肝動脈門脈合併亜全胃温存膵頭十二指腸切除術(SSPPD)を施行した。術中所見では総肝動脈、胃十二指腸動脈をテストクランプ後も肝動脈血流は問題なく総肝動脈は非再建とした。術後肝酵素の上昇や肝梗塞は認めず、病理学的にもR0切除が可能であった。(著者抄録)

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.