堀口 明彦

開腹胆嚢摘出術および胆嚢癌症例におけるIncidental gallbladder cancerの頻度とその特徴について報告する。開腹胆嚢摘出術に占めるIncidental gallbladder cancerの頻度は、0.23%〜3.86%であった。報告例の集計では、開腹胆嚢摘出術を施行された14,731例中113例(0.77%)に認められ、腹腔鏡下胆嚢摘出術では、45,174例中294例(0.65%)であり、術式によりIncidental gallbladder cancerの頻度に差を認めなかった。本邦の胆嚢癌症例におけるIncidental gallbladder cancerの頻度は13.4%であり、既報告の20.8%〜65.8%より低かった。術前診断は胆嚢結石およびその併存疾患が346例(57.6%)と最多であった。腫瘍の肉眼的形態は平坦浸潤型が最多であった。組織学的検討では、胆嚢周囲進展度の低いもの、リンパ節転移のないもの、Stageが低いものが多く、1年、3年、5年生存率は、それぞれ82.8%、65.7%、59.2%であり、Nonincidental gallbladder cancerに比較し有意に予後良好であった。(著者抄録)

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.

Robotic surgery is the most advanced development in minimally invasive surgery. However, the number of reports on robot-assisted endoscopic gastrointestinal surgery is still very small. In this article, we describe total laparoscopic pancreaticoduodenectomy (PD) undertaken using the da Vinci Surgical SystemA (R) (Intutive Surgical). Three patients underwent robotic PD between November 2009 and February 2010. Following resection of the pancreatic head, duodenum, and the distal stomach, intracorporeal anastomosis was accomplished by Child's method of reconstruction, which includes a two-layered end-to-side pancreaticojejunostomy, an end-to-side choledochojejunostomy, and a side-to-side gastrojejunostomy. The time required for surgery was 703 +/- A 141 min, and blood loss was 118 +/- A 72 mL. The average hospital stay period was 26 +/- A 12 days. As a postoperative complication, pancreatic juice leak occurred in one case, but it was managed with conservative treatment. Of the three patients, one had cancer of the papilla of Vater, one had cancer of the pancreatic head, and one had a solid pseudopapillary neoplasm. In all cases, the surgical margin was negative for tumor. Robot-assisted PD required a long time, but organ removal with less bleeding was able to be safely performed owing to the high degree of freedom associated with the forceps manipulation and the magnified view. Similarly, pancreatojejunostomy could certainly be conducted. No major postoperative complications were found. Accumulation of da Vinci PD experience in the future will lead to safer and faster PD.

膵頭前後面の動脈アーケードの血管走行にはその発達程度に差があり、また胆管と膵実質への埋没形態も一定でないことはすでに報告されている。十二指腸温存膵頭切除に胆管の温存も併置する術式では、これらの解剖学的特徴を理解して手術を遂行することが肝要である。すなわち、前面の切離では前面動脈アーケードとその十二指腸枝を温存すること、背側の切離では膵実質の切離を胆管前面までにとどめ、胆管と十二指腸間に切離が及ばないように配慮し、その間を走行する後上膵十二指腸動脈とその十二指腸枝を損傷しないことが手技上の留意点である。(著者抄録)

<b>要旨：</b>膵・胆管合流異常（以下，合流異常）は，日本膵・胆管合流異常研究会の診断基準で，「解剖学的に膵管と胆管が十二指腸壁外で合流する先天性の奇形をいう．」と定義されている．合流異常には，肝外胆管形態より1）胆管拡張型，2）胆管非拡張型の2つの型がある．胆管拡張型の標準術式は拡張胆管切除，肝管腸吻合術（分流手術）である．術後の合併症として肝内胆管結石形成，遺残膵内胆管結石形成などが問題となっている．胆管非拡張型の場合は，胆嚢を摘出することは合意が得られている．しかし，肝外胆管切除について統一した見解が得られていない．共通管もしくは副膵管の拡張を認める例や複雑な合流形態の例では，膵石（蛋白栓）や膵炎を合併しやすいことから，これらに対する治療について報告されている．<br> 本稿では，先天性胆道拡張症・合流異常に対する治療について概説した．<br>

<b>要旨：</b>腹腔鏡手術は体壁破壊を最小にすることで，患者の術後QOLを大きく向上させた．一方，腹腔鏡手術は手術操作の自由度が低いこと，2次元画像であることが欠点であり，術者のストレスを増大させた．腹腔鏡支援ロボットであるda Vinci Surgical systemの利点は，3次元ハイビジョン，7自由度の関節機能，術者の動きを調整可能なscaling機能，手の震えを除去するfiltering機能，拡大視効果である．これらの機能により，繊細な手術操作もストレスなくできるようになった．しかし，開腹手術と比して手術時間が長いこと，また，通常の腹腔鏡下手術と比べると，da Vinci装着に時間を有することが今後の課題であるが，経験を積み重ね工夫することにより，克服できると考える．胆道領域におけるロボット支援腹腔鏡下手術は近い将来，standardな手技となると思われる．<br>

消化器外科領域における腹腔鏡下手術の発展は目覚ましい。近年、ロボット支援による腹腔鏡下手術の報告が散見されるようになった。da Vinci Surgical Systemのメリットは、(1)3次元ハイビジョン映像であり、従来の腹腔鏡と比して安全である。(2)6つの自由度とグリップ機能をもつ高性能な関節機能を有すること。術者の手の動きと鉗子の動きを2:1、3:1、5:1に調整することができるscaling機能と執刀医の手の震えを除去するfiltering機能がついている。また拡大視効果は約15倍まで可能であり、この三つの機能により、膵管空腸粘膜吻合などの詳細な手術操作を必要とするとき、とくに威力を発する。ロボット支援腹腔鏡下膵切除の歴史は浅く、今後、さらに多くの施設でトレーニング、臨床経験を重ねることにより、膵切除術において、きわめて有用な手技になると考える。(著者抄録)

To apply duodenum-preserving pancreatic head resection (DPPHR) as radical procedure for benign or low-grade malignant tumors, it needs the reconciliation of complete pancreatic head resection and preservation of the bile duct and peripancreatic vessels. Several modifications have been introduced and applied to remove these lesions, however, the techniques have not been made clear in the management of the peripancreatic vessels and the bile duct. The long-term outcomes of the DPPHR have been reported as extremely rare in comparison with pylorus preserving pancreatoduodenectomy (PPPD) in these pancreatic head tumors. The angiograms by multi-detector row CT (MD-CT) can be reconstructed more physiologically than selective angiography. The anterior arcade is predominant in 43% of 64 patients. Therefore, we modified the DPPHR to include a complete resection of the pancreatic head and the preservation of both anterior and posterior arterial arcades. The bile duct is covered by the pancreatic parenchyma in various ways. The techniques of the preservation of the bile duct are also introduced. We performed 21 DPPHRs and 19 PPPDs in the patients with benign or low-grade malignant pancreatic head tumor. There was no significant difference in operative factors. The postoperative death was one patient in PPPD, but none in DPPHR. The postoperative complications of PPPD were more often than that of DPPHR. There is no postoperative recurrence in DPPHR in the follow-up period from 2 to 216 months. Both exocrine and endocrine function and the long-term results following DPPHR were superior to those following PPPD. The DPPHR should be favored over the PPPD in benign or low-grade malignant tumors of the head of the pancreas if there is no compromise with oncologic radicality.

Introduction Single-incision laparoscopic surgery (SILS) offers the potential advantages of reduced postoperative pain and a lower incidence of port-site complications. Moreover, careful attention to closure can reduce the scarring after surgery. Consequently, this method is a promising technique for reducing postoperative pain, decreasing complications, and improving cosmesis. We have performed cholecystectomy in eight patients by SILS. The umbilicus was the point of entry to the abdomen in all patients. Methods Between May 2009 and October 2009, 31 patients underwent cholecystectomy at our hospital. The umbilicus was the point of entry to the abdomen in all patients. Three SILSs were performed using a new SILS port, and five SILSs were performed by the conventional method in which three ports are inserted into the umbilicus; the remaining ten patients underwent multiple-incision laparoscopic cholecystectomy (standard cholecystectomy). The results for the patients who underwent standard cholecystectomy, conventional SILS, and SILS using the new port were compared using the Mann-Whitney U test. The data are expressed as mean +/- standard deviation. Result Of the eight cholecystectomies carried out, three were performed by SILS using the new port. No complications or mortalities were associated with this technique. The mean operating times for conventional SILS, SILS with the new port, and standard cholecystectomy were 154 +/- 57, 120 +/- 11, and 100 +/- 51 min, respectively; these inter-group differences are not significant. The blood loss in conventional SILS, SILS with the new port, and standard cholecystectomy was 9 +/- 16, 1, and 6.1 +/- 11 g, respectively; these inter-group differences are not significant. All umbilical incisions were concealed within the umbilicus. Conclusion Cholecystectomy performed using SILS with the new port is a safe and feasible approach with reasonable operation times.

During a pancreatoduodenectomy (PD) it is important that the anatomy of the arcade of blood vessels in the head of the pancreas is fully understood before the surgery in order to reduce intraoperative bleeding. In most of the patients our group has treated, the inferior pancreaticoduodenal artery (IPDA), one of the efferent arteries of the head of the pancreas, has formed a short common trunk with the first jejunal artery (FJA). Thus, by first locating the origin of the FJA, it was easier to locate the IPDA. There are two ways to locate the IPDA: (1) by measuring the distance between the origin of the superior mesenteric artery (SMA) and that of the FJA; (2) by measuring the distance between the origin of the middle colic artery (MCA) and that of the FJA. Here, we report our measurements of both distances using three-dimensional (3D) models of arteries constructed with multidetector-row computed tomography (MD-CT) images and discuss which is the better measurement to determine the location of the IPDA during PD. A total of 140 patients underwent 64-MD-CT imaging to acquire early and late arterial phase scans. The distance between the origin of the SMA and that of the FJA and the distance between the origin of the MCA and that of the FJA origin were measured. In patients whose IPDA formed either a common trunk with the FJA or arose directly from the SMA, the IPDA or the common truck was located in parallel with the SMA at a very short distance of approximately 18 mm from the MCA origin towards the center. The distance between the SMA origin and the IPDA was significantly longer (approximately 36 mm). Therefore, locating the MCA origin during PD helped determine the location of the IPDA. However, in patients whose anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) arose separately, the distance between the AIPDA origin and the MCA origin was approximately 18 mm, the distance between the AIPDA origin and the PIPDA origin was approximately 19 mm, and the distance between the PIPDA origin and the SMA origin was 19 mm. Thus, locating the SMA helped determine the location of the IPDA during PD in these patients. Based on our findings that the distance between the IPDA origin and the MCA origin was short, we have shown that it is effective to locate the MCA origin in order to determine the location of the IPDA.