堀口 明彦

<p>膵粘液性嚢胞腫瘍（MCN）の外科的治療を中心に概説した．MCNは嚢胞径の大きなもの，壁在結節を認めるなど悪性が疑われる場合，切除の適応である．一方，嚢胞径が小さいもの，壁在結節がなく悪性でないものは詳細な経過観察が可能との論文も散見される．自然史が解明されていないこと，非手術的管理は高額な画像診断を長期に行う必要があること，浸潤癌を確実に同定することができないことなどから，現時点では基本的にはMCNの診断がつけば手術適応である．浸潤癌が疑われた症例は，ductal cancerと同様，リンパ節郭清を伴う膵切除術の適応となる．しかし，悪性が疑われない症例では，術後遠隔時のQOLを考慮した臓器温存術式の適応となる．手術適応と判断された場合，優れた経験を有する膵臓外科医のいるハイボリュームセンターで行うことが推奨される．本稿では臓器温存術式を中心にMCNの外科治療について述べる．</p>

© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

腎細胞癌の転移臓器として膵臓は比較的稀であるが、転移性膵腫瘍の原発巣は腎臓の頻度が高いと言われている。また、再発までの期間も10年以上の報告例が多く長期にわたる経過観察が必要である。当科では2008年から2015年の間に5例の腎細胞癌膵転移の切除例を経験した。転移までの期間は最長16年であった。5例中3例が多発症例であった。3例の多発症例では、多発病変が造影CTの早期動脈相にて強濃染される腫瘍として明瞭に描出された。全例に根治切除が施行され、多発例のうち2例は可能な限り膵を温存する術式を選択し、1例は胃全摘を合併した膵全摘となった。多発する転移性膵腫瘍の術式は様々であり、膵全摘を推奨する報告と機能温存術式を推奨する報告が散見される。根治性と機能温存の両面から慎重に術式を決定することが必須である。(著者抄録)

腎細胞癌の転移臓器として膵臓は比較的稀であるが、転移性膵腫瘍の原発巣は腎臓の頻度が高いと言われている。また、再発までの期間も10年以上の報告例が多く長期にわたる経過観察が必要である。当科では2008年から2015年の間に5例の腎細胞癌膵転移の切除例を経験した。転移までの期間は最長16年であった。5例中3例が多発症例であった。3例の多発症例では、多発病変が造影CTの早期動脈相にて強濃染される腫瘍として明瞭に描出された。全例に根治切除が施行され、多発例のうち2例は可能な限り膵を温存する術式を選択し、1例は胃全摘を合併した膵全摘となった。多発する転移性膵腫瘍の術式は様々であり、膵全摘を推奨する報告と機能温存術式を推奨する報告が散見される。根治性と機能温存の両面から慎重に術式を決定することが必須である。(著者抄録)

A case of colouterine fistula caused by colonic diverticulitis that was successfully treated laparoscopically is presented. A 74-year-old woman visited us with lower abdominal discomfort and vaginal excretion with minor fecal contamination. Mild tenderness was observed in her lower abdomen. Blood examinations revealed elevated white blood cell count and C-reactive protein. Sigmoid colon diverticulitis was revealed on CT, and her condition was diagnosed as colouterine fistula. Hinchey classification was stage I. After 2 weeks of conservative therapy, her symptoms were reduced, and the white blood cell count and C-reactive protein level decreased. However, fecal contaminated vaginal excretion continued. The patient underwent laparoscopic sigmoidectomy combined with uterus excision, and she has been in good health for the 3 years since the operation. Although colouterine fistula is usually treated with open surgery, patients with controlled and well-localized inflammation may be good candidates for a laparoscopic approach.

安定同位体を用いた呼気試験を行い、各術式別に脂肪吸収能を比較し、臓器温存術式の有用性を検討した。解析はWagner-Nelson法(WN法)を用いて胃排出速度の影響を受けない消化吸収能を表す指標であるAaを算出し、膵頭切除術前後における術式別脂肪消化吸収能を比較検討し、機能温存術式の有用性について検討した。健常人と十二指腸温存膵頭切除術(duodenum-preserving pancreatic head resection: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(pylorus-preserving pancreaticoduodenectomy:PPPD)、亜全胃温存膵頭十二指腸切除術(subtotal stomach-preserving pancreaticoduodenectomy:SSPPD)、膵頭十二指腸切除術(pancreaticoduo-denectomy:PD)との比較では、いずれも有意に吸収能は低下した。DPPHRはPD、PPPD、SSPPDに比べて有意に良好な吸収能を認めた。術前後における消化吸収能の比較ではDPPHRは術前後で差を認めなかったが、PPPD、SSPPD、PDは術後有意に消化吸収能の低下を認めた。13Cトリオクタノイン呼気試験は、簡便かつ非侵襲的でリアルタイムに評価することができる膵外分泌機能検査法である。(著者抄録)

患者は71歳,女性.下部直腸癌に対して腹腔鏡下腹会陰式直腸切断術を施行した.術後会陰部の創感染と尿路感染を認めたが,保存的治療にて軽快した.術後8ヵ月目に会陰部の膨隆を自覚した.立位で会陰部に手拳大の膨隆を認め,腹臥位で還納された.腹部CT検査では骨盤底部から会陰部に脱出する小腸を認めた.続発性会陰ヘルニアと診断した.腹腔鏡下にて腹腔内を観察すると,骨盤底に4×4cmのヘルニア門を認めた.VENTRIOTM Hernia Patchを用いて修復術を行った.術後1年経過するも明らかな再発は認めていない.続発性会陰ヘルニアに対する腹腔鏡下ヘルニア修復術は,有用な治療のオプションになりうると考えられた.(著者抄録)

膵頭十二指腸切除術(PD)を施行した62例(男性39例、女性23例、平均67.9歳)を対象とした。手術で得られた摘出標本の膵切離断端線維化の程度によりI群0〜10%、II群10〜30%、III群30〜50%、IV群50〜100%に分類した。膵瘻なし群45例、膵瘻あり群17例であった。膵癌は、膵瘻なし群29例、膵瘻あり群3例で、膵瘻あり群は、なし群に比し膵癌症例の比率が有意に低かった。平均Velocity of shear wave(Vs値)は、膵瘻なし群3.01、膵瘻あり群2.25で、膵瘻あり群は、なし群に比べ有意に低かった。Vs値は、I群2.12±0.56、II群2.38±0.83、III群3.15±1.22、IV群3.21±1.24で、I群とII群間、III群とIV群間に有意差は認めなかったが、I群とIII、IV群間、II群とIII、IV群間では有意にIII、IV群の方が高値であった。

IPDAを先行切離することにより、膵頭部切除に伴う静脈性出血を防止し、出血量を減少させ、安全に膵頭十二指腸切除術を施行することができる。MD-CTを用いた動脈構築像によるIPDAの分岐形態を、3タイプに分類できる。第一空腸動脈と共通幹を形成しているタイプがもっとも多く72.2%に認めた。また、このタイプは上腸間膜動脈(superior mesenteric artery:SMA)の背側から左側に共通幹が分岐し、その後、第一空腸動脈とIPDAに分かれる。IPDAは右側にむかい膵鉤部に流入する。SMAから直接分岐するタイプは18.8%に認め、このタイプはSMAの背側からすぐ右側にむかい、膵鉤部に流入する。また、前下膵十二指腸動脈(anterior inferior pancreatoduodenal artery:AIPDA)と後下膵十二指腸動脈(posterior inferior pancreatoduodenal artery:PIPDA)がそれぞれ別々に分岐するタイプは9%に認め、このタイプは、PIPDA、AIPDAは多彩な分岐形態をとることが多い。術前MD-CTによるIPDAの確認は安全に膵頭十二指腸切除術を行ううえで有用である。(著者抄録)