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It has been considered that allowing patients to return to daily life earlier after surgery helps recovery of physiological function and reduces postoperative complications and hospital stay. We investigated the usefulness of fast-track management in perioperative care of patients undergoing pancreaticoduodenectomy (PD). Patients (n = 90) who received conventional perioperative management from 2005 to 2009 were included as the ‘conventional group’ (historical control group), and patients who received perioperative care with fast-track management (n = 100) from 2010 to March 2013 were included as the ‘fast-track group’. To evaluate the efficacy of perioperative care with fast-track management, the incidence of postoperative complications and the length of hospital stay were compared between the two groups (comparative study). For statistical analysis, univariate analysis was performed using the χ 2 test or Fisher’s exact test. There was no significant difference between the two groups in sex, mean age, presence/absence of diabetes mellitus, preoperative drainage for jaundice, previous disease, operative procedure, mean duration of operation, or blood loss (p

We have previously classified wall invasion patterns of gallbladder carcinoma (GBC) cases into two groups, i.e., the infiltrative growth type (IG type) and destructive growth type (DG type). The DG type was significantly associated with poor differentiation, aggressive infiltration and decreased postoperative survival in terms of its histological differentiation, lymphatic invasion, venous invasion, lymph node status, neural invasion and mode of subserosal infiltration. In the present study, we analyzed 42 surgically-resected subserosal invasive gallbladder adenocarcinomas, invading the perimuscular connective tissue (pT2). The cumulative 5-year survival rate in the series was 48.7%. Lymphatic invasion (p=0.021), venous invasion (p=0.020), mode of subserosal infiltration (p0.001), histological differentiation (p=0.030) and biliary infiltration (p=0.007) were noted, respectively, at a significantly higher incidence in more aggressive infiltration or poor differentiation in the DG type. The cumulative 5-year survival rate of curative resection cases was lower in patients with the DG type than in those with the IG type (68.9 versus 20.2%, respectively, p=0.006, log-rank test). On Cox's proportional hazard regression modeling, the low degree of venous/perineural invasion and IG type of wall invasion pattern were associated with a significant improvement in overall survival. Our data suggest that the wall invasion pattern is an independent predictor of survival in subserosal invasive GBC. Regarding the clinical application of our concept, on the classification of patients with subserosal invasive GBC based on a combination of the wall invasion pattern and lymph node status, the overall survival rate in patients with the DG type and/or N2 metastasis (n=21) was lower than in patients with the IG type and N0, 1 metastasis (n=21) (p=0.0023, log-rank test). The wall invasion pattern could contribute to decision-making concerning curative resection for subserosal invasive GBC.

Background Wrapping is thought to prevent pancreatic fistula and postoperative hemorrhage for pancreaticoduodenectomy (PD), and we analyzed whether omentum/falciform ligament wrapping decreases postoperative complications after PD. Methods This is a retrospective study of wrapping using the omentum/falciform ligament in patients that underwent PD between January 2006 and June 2008 in 139 institutions that were members of the Japanese Society of Pancreatic Surgery. Results Ninety-one institutions responded to the questionnaires, and data were accumulated from 3,288 patients. The data from 2,597 patients were acceptable for analysis; 918 (35.3%) patients underwent wrapping and 1,679 patients did not. A pancreatic fistula occurred in 623 patients (37.3%) in the nonwrapping group, in comparison to 393 patients (42.8%) in the wrapping group (P = .006). The incidence of a grade B/C pancreatic fistula was lower in the nonwrapping group than the wrapping group (16.7% vs 21.5%; P = .002). An intra-abdominal hemorrhage occurred in 54 patients (3.2%) in the nonwrapping group, which was similar to the incidence in the wrapping group (32 patients; 3.5%). The mortality was 1.3% and 1.0% in nonwrapping and wrapping groups, respectively. A multivariate analysis revealed 7 independent risk factors for pancreatic fistula; male, hypoalbuminemia, soft pancreas, long operation time, extended resection, pylorus preservation, and omentum wrapping. There were 4 independent risk factors for early intra-abdominal hemorrhage and 2 independent risk factors for late intra-abdominal hemorrhage. Conclusion This retrospective study revealed that omentum wrapping did not decrease the incidence of pancreatic fistula. An additional validation study is necessary to evaluate the efficacy of wrapping for PD.

Leiomyosarcoma of the pancreas is a rare neoplasm, with only 34 reported cases in the literature. We encountered a rare case of leiomyosarcoma of the pancreas, treated successfully by surgery. A 41-year-old woman was referred to our hospital for further examinations of a pancreatic tumor. Imaging studies demonstrated a solid and lobular mass, about 4 cm in diameter, in the body of pancreas. This mass had a nonuniform content and was encapsulated. We performed distal pancreatectomy and splenectomy for an assumed diagnosis of invasive ductal carcinoma. Macroscopically, a sagittal section of the operative specimen showed a well-circumscribed yellowish-white mass without any cystic changes. Immunohistological examination revealed that α-smooth muscle actin, desmin, and vimentin were positive, and the labeling index of MIB-1 was 50% or more. Based on these findings, we confirmed a diagnosis of leiomyosarcoma originating from the pancreas. During 14 months of follow-up to date, there has not been any evidence of local recurrence or distant metastasis.

症例は38歳，男性．突然の心窩部痛を主訴に当院を受診した．腹部超音波検査で胆嚢は腫大し，正中側へ偏位していた．腹部CT検査では正中腹壁直下に胆嚢を認め，MRCPでは総胆管の左側に胆嚢を認め，胆嚢捻転症の診断で緊急手術を予定した．術前に再度超音波検査を施行したところ，胆嚢は正中側より胆嚢床に戻り，腹痛も消失した．CT検査，MRCPを再検すると胆嚢は正常位に戻っていた．胆嚢壊死を示唆する所見を認めず，第4病日に腹腔鏡下胆嚢摘出術を施行した．術中所見で胆嚢は一部に壊死を認め，胆嚢床付着部は僅かであった．術後経過は良好で第8病日に退院した．捻転が解除された場合でも胆嚢壊死を念頭に置き，速やかに手術を施行する必要があると考えられた．

多彩な病理組織像を示した粘液産生性胆管腫瘍の1例を経験したので報告する．症例は78歳の男性で，1日前からの下腹部痛，腹満症状にて当院受診となった．CT，超音波検査で虫垂炎と肝S4に内部隆起を有する30mm大の嚢胞性腫瘤を認め，入院となった．MRI，造影超音波検査ではmultilocularな嚢胞性腫瘤を認め，内部隆起性病変に一部造影効果を認めた．DIC-CTでは左肝管に狭小化を認めたが，内部に粘液は認めなかった．肝嚢胞性腫瘍の診断で左葉切除を施行した．病理組織学的検査所見ではさまざまな程度に乳頭状増殖した粘液産生性腫瘍上皮からなる多嚢胞性病変で，胆管との交通を認めた．腫瘍上皮は，carcinomaからadenomaまで多彩な異型を呈した．粘液形質は，MUC1，MUC5AC，MUC6は一部陽性で，MUC2は陰性だった．分枝型膵管内乳頭粘液性腫瘍に類似した粘液産生性胆管腫瘍と考えられた．

The surgical decision regarding where to resect the pancreas is an important judgement that is directly linked to the surgical procedure. An appropriate surgical margin to resect intraductal papillary-mucinous neoplasm (IPMN) of the pancreas based on the distance of tumor spread (DTS) in the main pancreatic duct has not been adequately documented. We analyzed the appropriate surgical margin based on the DTS in the main pancreatic duct of IPMN and the positive rate at the pancreatic cut end margin.Forty patients with main duct- or mixed-type IPMN diagnosed histopathologically who underwent surgery at Tokai University Hospital between 1991 and 2008 were retrospectively analyzed. The resection line was determined to achieve a 2-cm surgical margin in patients with main duct- or mixed-type IPMN and as limited a resection as possible to remove the dilated branch duct in patients with branch duct-type IPMN according to macroscopic type. The dysplastic state of the epithelium was judged as positive for carcinoma in situ (high-grade dysplasia) or adenoma (very low to moderate dysplasia) and judged as negative for hyperplasia or normal.The mean DTS in the main pancreatic duct was 41.6 +/- 30.0 mm, and that of the distance of tumor absence was 13.6 +/- 12.4 mm. The positive rate at the pancreatic cut end margin in frozen sections was 29.7%. The final positive rate at the pancreatic cut end margin was 26.2%. There has been no evidence of local recurrence in the remnant pancreas. DTS in the main pancreatic duct of IPMN was correlated with the maximum diameter of the duct (R = 0.678).Distance of tumor spread offered important insights about the appropriate site to resect the pancreas and the positive rate at the cut end margin in IPMN.

症例は40歳男性．上腹部痛にて他院受診し，CT，MRI上，膵尾部に4cm大の嚢胞性病変を指摘され，当科紹介受診．腹部超音波，超音波内視鏡，CT，MRIにて内部に充実成分を有する嚢胞性病変を認めた．内視鏡的逆行性胆管膵管造影（ERCP）では嚢胞性病変は膵管と交通を有していたが，十二指腸乳頭部の開口部開大や粘液流出は認めず，膵管拡張もみられなかった．膵液細胞診で悪性細胞は得られなかったが悪性の可能性が否定出来ず，膵体尾部脾合併切除術を施行した．嚢胞内部には黄白色調のゼラチン様粘液結節が認められ，粘液内に腺癌細胞が浮遊する粘液癌と診断した．比較的若年に発生し診断に苦慮した膵管内乳頭粘液性腫瘍（IPMN）分枝型に由来した膵粘液癌の1例を経験したので，文献的考察を加え報告する．

A perivascular epithelioid tumor (PEComa) is a rare tumor probably arising from the perivascular epithelioid cells. Only three cases of pancreatic PEComa have been reported in the English-language literature. The present report describes an extremely rare case of pancreatic PEComa. A 47-year-old Japanese woman complained of lower abdominal pain and a well-demarcated solid tumor was found in the pancreatic head. There was no history of tuberous sclerosis complexes. Pylorus-preserving pancreaticoduodenectomy was thus performed. There was a well-demarcated, solid tumor measuring 17 mm in the pancreatic head. The tumor was composed of a diffuse proliferation of epithelioid tumor cells with many blood vessels but no adipose tissue. The tumor cells expressed HMB45 and alpha-smooth muscle actin. Ultrastructurally, the tumor cells possessed many membrane-bound granules that were positive for HMB45 on immunoelectron microscopy. The results of immunoelectron microscopy show that some PEComas possess not only typical melanosomes or premelanosomes but also aberrant melanosomes.

Although the outcome of surgery for locally advanced pancreatic cancer remains poor, it is improving, with 5-year survival up to about 10% in Japan. The preliminary results of our multi-institutional randomized controlled trial revealed better survival after surgery than after radiochemotherapy. We report the final results of this study after 5 years of follow-up. Patients with preoperative findings of pancreatic cancer invading the pancreatic capsule without involvement of the superior mesenteric or common hepatic arteries, or distant metastasis, were included in this randomized controlled trial, with their consent. If the laparotomy findings were consistent with these criteria, the patient was randomized to a surgery group or a radiochemotherapy group (5-fluorouracil 200 mg/m2/day and 5040 Gy radiotherapy). We compared the mean survival time, 3-and 5-year survival rates, and hazard ratio. The surgery and radiochemotherapy groups comprised 20 and 22 patients, respectively. Patients were followed up for 5 years or longer, or until an event occurred to preclude this. The surgery group had significantly better survival than the radiochemotherapy group (P < 0.03). Surgery increased the survival time and 3-year survival rate by an average of 11.8 months and 20%, respectively, and it halved the instantaneous mortality (hazard) rate. Locally invasive pancreatic cancer without distant metastases or major arterial invasion is treated most effectively by surgical resection.

Ileosigmoid knotはS状結腸と小腸の間で結節を形成し腸閉塞を起こす疾患で，術前診断は困難とされている1)．今回術前診断しえたileosigmoid knotの1例を経験したので報告する．症例は59歳，男性．腹痛を主訴に当院を受診した．来院時腹部は膨隆し腹部全体に圧痛を認めたが，腹膜刺激症状は認めなかった．腹部CT検査では，左側腹部を中心に拡張した小腸と右側腹部に軸捻転様に拡張したS状結腸を認め，腹水も中等量存在した．小腸とS状結腸がともに関与した絞扼性イレウスであることからileosigmoid knotと診断し，緊急手術を施行した．手術所見ではS状結腸に小腸が絡みつくように結節を形成し，小腸は広範囲にわたり壊死していた．約3mの小腸とともにS状結腸を切除した．腹部CT検査で腸間膜の収束像を中心として，右側に軸捻転様に拡張したS状結腸，左側に拡張した小腸が位置し，さらに腹部単純X線像での遠位下行結腸の正中への偏位は本疾患の重要な所見と考えられた．

Surgical indications or method of resection for intraductal papillary mucinous neoplasm of the pancreas (IPMN) are controversial. The aim of the current study was to evaluate surgical indications including cancer prevention and selection of specific surgical procedures. A group of 244 patients who underwent pancreatectomy for IPMN from 1981 to 2005 was examined retrospectively for clinicopathologic features. Carcinomas (carcinoma in situ + invasive carcinoma) were observed in 72% of the patients with main duct IPMN. The mural nodules for patients with carcinomas were larger than 3 mm. The maximum diameter of branch duct IPMN for patients with borderline atypia was larger than 30 mm. Lymph node metastasis and extrapancreatic invasion were observed only in patients with invasive carcinoma. In limited pancreatic resection, pancreatic fistulae were observed in 7.9% of patients. The indication for IPMN resection, including for cancer prevention, is lesions above IPMN with borderline atypia (main duct IPMN, mural nodule ≥3 mm, maximum diameter of branch duct IPMN ≥30 mm). A pancreatectomy with lymph node dissection should be performed for invasive IPMNs and a limited pancreatic resection has a role for noninvasive IPMNs.

Various immunological strategies for tolerance induction against allogeneic tissue grafts (allografts) have been tested in islet transplant recipients; for example, T cell activating co-stimulatory pathway blockade has been shown to prolong islet allograft survival. However, little is known about whether infiltrating inflammatory cells (e.g., basophils) affect islet allograft fates before antigen-specific immune cell development. Herein, we treated mice with a basophil-specific monoclonal antibody (mAb) and examined whether early acute-phase islet allograft rejection could be prevented in recipients.Pancreatic islets isolated from C57BL/6 (H-2b) or DBA/2 (H-2d) mice were transplanted under the renal capsules of C57BL/6 recipient mice. Recipients receiving allografts were administered the anti-basophil mAb MAR-1 to examine the antibody-mediated effect on graft survival. At days 4 and 7 post-transplantation, graft-bearing recipient kidneys were harvested for immunohistological analysis and stained with anti-insulin antibody to compare the sizes of grafted islets.On day 7 post-transplantation, the transplanted pancreatic islet clusters in allograft-recipient kidneys had rapidly decreased in size, whereas those in syngeneic recipients remained larger in both size and number. However, MAR-1-treated recipients had increased the numbers of larger insulin-positive allograft islet cell clusters.Basophil-specific mAb treatment contributes to enhance and prolong transplanted islet survival in allogeneic recipient mice.

近年, 十二指腸乳頭部早期癌や良性疾患に対して, 根治的かつ縮小手術として, 膵温存の十二指腸下行脚分節切除, 部分切除の報告が散見される. 紹介した本術式は膵温存が可能で膵管, 胆管共通管を十二指腸壁外, 膵外で切離して十二指腸乳頭部を完全摘出でき, 十二指腸腔内の水平方向へ進展した腫瘍に対応できる. 今回, 我々は十二指腸乳頭部早期癌の2症例に膵温存十二指腸下行脚分節切除を行ったので文献的考察を含め報告する. 症例1は61歳の女性で, 非露出腫瘤型の早期癌の診断で上記手術を行い, H0, P0, M (-), pN0, pEM0, m, stage Iであった. 症例2は77歳の女性で, 露出腫瘤型の乳頭部早期癌の診断で手術を行い, 病理診断はH0, P0, M (-), pN0, pEM0, od, stage1であった. 2症例ともに術後若干の胃排泄遅延を認めたが, その後の食事摂取は良好であった. 本症例は今後, 長期の経過観察を要するが, 十二指腸乳頭部早期癌に対する根治術式として有用であると考えた.

症例は61歳の男性.平成6年2月19日他院で盲腸癌に対し回盲部切除術を施行された.病理所見は, mucinous carcinoma, si (腹壁), ly2, v0, n2でstage IIIbであった.平成7年3月右下腹部腫瘤を自覚し,当院紹介受診した.腹部CT検査で右下腹部に40mm大の腫瘤を認め, 6月14日手術を施行した.腫瘍は腹壁,回腸へと浸潤し,腸骨リンパ節,近傍腹膜への孤立性転移も認めた.腹壁合併腫瘍切除,回腸部分切除術を施行した.病理所見より再発と診断された.平成12年6月再び右下腹部腫瘤を認め, 7月16日手術を施行した.腫瘍は回腸へ穿通し,腸間膜リンパ節転移も認められた.腫瘍切除と広範に腸切除を施行した.病理所見では同様に再発と診断された.以後平成15年11月14日肺癌,肺炎で死亡するまで再発徴候はみられなかった.大腸粘液癌では,限局した再発巣であれば,反復切除は長期生存に有効な症例もあると考えられた.

症例は60歳, 男性. 健診で指摘された膵管拡張の精査目的に来院した. ERCPでは膵頭部の主膵管に約2cmの狭窄があり, その末梢側には数珠状拡張を認めた. 狭窄部位の一次分枝は描出されなかった. 腹部超音波検査や超音波内視鏡検査では, 同部位に腫瘤性病変を同定できなかった. レボビスト® (ガラクトース・パルミチン酸混合物) を用いた造影超音波検査では, 膵頭部に境界不明瞭な造影効果の乏しい部位を, 注入直後から2分間にわたって認めた. 腹部血管造影検査では, 下膵十二指腸動脈のDigital subtraction angiography (DSA) にて膵頭部の膵実質造影の一部に欠損が認められた. CT-Angio (CTA) でも同様であった. これらはERCP, MRCPで描出された膵頭部の主膵管狭窄部位に一致していた.以上の所見より, 膵癌と考えて幽門輪温存膵頭十二指腸切除術 (PpPD ; pylorus preserving pancreaticoduodenectomy) を施行したところ, 悪性所見はなく腫瘤形成性膵炎と診断された. 病理組織学的には高度の線維化と炎症細胞の浸潤を認めた. 自己免疫性膵炎 (AIP ; autoimmune pancreatitis) に類似した病理組織学的所見 (主膵管周囲に炎症と線維化を来した点) とIgG4高値 (402mg/dl, cut off値 : 135mg/dl ) を示した本症例は, 将来的なAIPの診断基準の再検討および膵癌と腫瘤形成性膵炎の鑑別において, 示唆に富むものであった.

膵管内乳頭粘液性腫瘍 (IPMT) の自然経過を知る上で, 興味深い症例を経験した. 症例は57歳男性. 50歳時まで急性膵炎で他医に入退院を繰り返していた. この際のERCPで, 主膵管の拡張, 陰影欠損を伴う膵頭部分枝膵管の嚢胞状拡張が認められていたが, 外科的処置は行われていなかった. 2001年10月, 他医で慢性膵炎, 閉塞性黄疸と診断され胆嚢摘出術, 胆道バイパス術 (肝管空腸吻合) を施行. その後の当院入院精査で, 胃・十二指腸に瘻孔形成を伴う膵管内乳頭腺癌由来の浸潤癌と診断し, 2001年12月6日, 膵頭十二指腸切除術を施行した. 摘出標本では, 膵頭体部に径6.6×6.1cm, 内部に結節状隆起を伴う嚢胞性腫瘍を認め, 嚢胞内にはゼリー状の粘液が充満していた. 病理組織所見では, 印環細胞を含む粘液結節を広範囲に認めた. 膵管内には粘液産生を伴う乳頭状の腺癌部分がみられ, 浸潤部はほとんど粘液結節として存在し, 膵管内乳頭腺癌由来の浸潤癌 (粘液癌) と診断された.

Though the outcome of resection for locally invasive pancreatic cancer is still poor, it has gradually improved in Japan, and the 5-year survival is now about 10%. However, the advantage of resection over radiochemotherapy has not yet been confirmed by a randomized trial. We conducted this study to compare surgical resection alone versus radiochemotherapy without resection for locally invasive pancreatic cancer using a multicenter randomized design.Patients with pancreatic cancer who met our preoperative criteria for inclusion (pancreatic cancer invading the pancreatic capsule without involvement of the superior mesenteric artery or the common hepatic artery, or without distant metastasis) underwent laparotomy. Patients with operative findings consistent with our criteria were randomized into a radical resection group and a radiochemotherapy group (200 mg/m(2)/day of intravenous 5-fluorouracil and 5040 cGy of radiotherapy) without resection. The 2 groups were compared for mean survival, hazard ratio, 1-year survival, quality of life scores, and hematologic and blood chemical data.Twenty patients were assigned to the resection group and 22 to the radiochemotherapy group. There was 1 operative death. The surgical resection group had better results than the radiochemotherapy group as measured by 1-year survival (62% vs 32 %, P=.05), mean survival time (17 vs 11 months, P.03), and hazard ratio (0.46, P=.04). There were no differences in the quality of life score or laboratory data apart from increased diarrhea after surgical resection.Locally invasive pancreatic cancer without distant metastases and major arterial invasion appears to be best treated by surgical resection.

脂肪肉腫は下肢,後腹膜に好発する腫瘍で,腸間膜原発は稀である.今回われわれは腸間膜原発脂肪肉腫の1例を経験したので報告する.症例は42歳男性で便通異常,腹部膨満感を主訴に来院した.下腹部に弾性硬で圧痛と可動性を有する小児頭大の腫瘤を触知した.腹部超音波では骨盤内に隔壁を有する一部充実性の14×11×7 cm大の嚢胞性腫瘤を認めた.血管造影では上腸間膜動静脈の進展,圧排のみで腫瘍濃染は認められなかった.入院後,腹痛が出現し腹部CTで腫瘤の増大と高吸収域を認め,嚢胞内出血の診断で緊急手術を施行した.腫瘤は回盲部を中心に回結腸間膜内に存在し,赤褐色で嚢胞内に凝血塊が充満していた.腫瘤の可動性は良好で容易に後腹膜から剥離できた.腫瘤切除および回結腸切除を行い腫瘤は完全に摘出された.病理組織検査では線維芽細胞への分化を一部伴う高悪性度の脱分化脂肪肉腫と診断された.術後1年9カ月現在,再発は認めず健在である.

The number of surgically resected cases of extrahepatic bile duct cancers has been increased because of the recent advances in imaging diagnoses and operative procedures. However, morphological characteristics of the extrahepatic bile duct cancers have not yet been defined. In this study, we reviewed 102 surgically resected cancer cases for clarifying growth and invasion of the extrahepatic bile duct cancer. We designated as "early cancer" cancers limited to the mucosa or invading as far as the fibromuscular layer (smooth muscle layer), i.e., Tis or Tl cancers. Approximately 12.7% (13/102) of the cases were pTis or pT1 cancers (pathologic stage of Tis or T1), which were categorized as early cancer. Only 15.4% (2/13) of the early cancers showed vascular/perineural invasion and/or lymph node metastasis. In contrast, the majority (87.3%) of the cases was pT2-3 cancers, and very frequently showed vascular/perineural invasion and/or lymph node metastasis. Desmin immunostaining was very useful for recognizing thin muscle layer, and should be performed for pathological diagnosis of early extrahepatic bile duct cancers.

Sialyl Le x (FH6) and sialyl Le a (CA19-9) antigens, members of a family of high molecular weight glycoproteins, are ligands for E-selectin and may play important roles in tumor metastasis. However, expression patterns ofsialyl Le x and sialyl Le a have not been established in human extrahepatic bile duct cancer. In this study, we examined sialyl Le x and Le a expression in human extrahepatic bile duct adenocarcinoma and their clinicopathological significance. Sialyl Le x immunoreactivity was detected not only in cancer cells (cytoplasmic type; 57.7%, 30/52), but also in cancer stroma (stromal type; 19.2%, 10/52). Sialyl Le a immunoreactivity was found in cancer cells (cytoplasmic type; 84.6%, 44/52) and in cancer stroma (stromal type; 63.5%, 33/52). Stromal sialyl Le a expression was more frequent than stromal sialyl Le x expression (p

Background: There is a high risk of anastomotic leakage after pancreaticojejunostomy after pancreaticoduodenectomy (PD) in patients with a normal pancreas because of the high degree of exocrine function. These PD are therefore generally performed using a stenting tube (stented method). In recent years, we have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stenting tube (nonstented method) and obtained good results. Methods: The point of this technique is to preserve adequate patency of the pancreatic duct by carefully picking up the pancreatic duct wall with a fine atraumatic needle and monofilament thread. The results of end-to-side pancreaticojejunostomy of the normal pancreas were compared between the nonstented method (n = 109) and the stented method (n = 39). Results: There were no differences in background characteristics between the groups, including age, gender and disease. The mean duration to complete pancreaticojejunostomy was 26.6 min in the nonstented group and 29.2 min in the stented group. The mean durations of surgical procedure and intraoperative blood loss were also similar in the groups. Morbidity rates due to early postoperative complications were 20.2 and 23.1%, with pancreatic leakage occurring in 7.3 and 7.7% of patients, respectively. These differences were not statistically significant. One patient in the stented group died of sepsis following leakage of pancreaticojejunostomy. There were also no significant differences in the mean time to initiation of solid food intake or postoperative hospital stay. Conclusion: We conclude that a stenting tube is unnecessary if the duct-to-mucosa anastomosis is completely performed. This operative technique can be considered a basic procedure for pancreaticojejunostomy because of the low risk.

Background. The Japanese Pancreas Society Registry Committee obtained data on 16 071 patients with pancrea-tic cancer diagnosed from 1981 to 1996. This is the largest multi-institutional retrospective study of the Japanese experience to describe the extent of disease and survival.

1996年までに切除した浸潤性膵管癌438例のうち, 5年以上長期生存した長期生存群17例と, 根治度A, B がえられたものの1年未満で癌再発死亡した早期 (再発) 死亡群29例を対象とし, 膵後方浸潤 (rp) の有無別に組織学的所見, 術式, 再発様式, quality of life (QOL) について比較検討した. rp (-) 例では, PL郭清を伴うD1+αが多かったが, ともに, 膵外神経叢浸潤 (p1) は陰性で, 長期生存群でりんぱ節転移n (+) が33%と少なかった. 早期 (再発) 死亡群では肝転移が75%であった. rp (+) 例では, PL郭清を伴うD1+αまたはD2が行われ, 長期生存群でn (+) が38%と少なく, 乳頭腺癌や高分化型管状腺癌が75%と多かった. 早期 (再発) 死亡群では肝転移, 後腹膜再発が68%, 40%で, 再発に伴うQOLの低下がみられた. 以上より, rp (-) 例ではD1+α以下の術式と効果的な肝転移対策, rp (+) 例ではPL郭清を伴うD2と局所制御のための補助療法, 効果的な肝転移対策が膵癌長期生存には必要と考えられた.

膵頭部癌に対する全胃幽門輪温存膵頭十二指腸切除 (PpPD) の適応を, 十二指腸第1部または胃への癌の直接浸潤を認めず, 胃周囲リンパ節 ((3), (4), (5), (6), (7)) への転移を認めないこととした1989年以降の膵頭部浸潤性膵管癌切除例154例を対象に, PpPD66例と胃切除を伴う膵頭十二指腸切除 (胃切除PD) 88例の2群に分け, 比較検討した. 拡大手術は, ともに約80%に安全に行われ, 進行度, 根治度もPpPDと胃切除PDで差はなかった. 5生率, 平均生存期間もともに差はなく, PpPDでおのおの, 35%, 15.0か月であった. 再発様式はともに後腹膜再発, 肝転移が多くを占め, PpPDで胃周囲リンパ節再発例はなかった. Performance, Statusと体重変動からみた術後のQuality of Life (QOL) もPpPDと胃切除PDに差はなく良好であった. 以上より, 上記の適応基準を用いれば, 根治性, 安全性, 術後QOLを損なうことなく, 膵頭部癌に対する基本術式としてPpPDを導入できると考えられた.

Castleman's disease is a rare lymphoid neoplasm that is characterized by the proliferation of lymphoid tissue. A case of young woman having the plasma cell type of retroperitoneal Castleman's disease is reported, and radiological findings of the condition are discussed with a review of the radiological literature.

Sixty-three patients who had undergone pancreatoduodenectomy for carcinoma of the ampulla of Vater were analyzed with respect to tumor extent and prognosis. The postoperative mortality rate was 3% and overall survival rates 3 and 5 years after surgery were 55% and 46%, respectively. pTNM stage did not reflect prognosis after resection in patients at stages 2 and 3, while pancreatic invasion and regional lymph node metastasis clearly reflected prognosis after resection. Of the 26 patients who had no pancreatic invasion, regional lymph node metastasis was seen in only 19%, whereas of the 37 patients with pancreatic invasion, 62% exhibited lymph node metastasis. These factors were significantly correlated (P

We report a patient in whom a polytetrafluoroethylene (PTFE) graft used for reconstruction of the portal vein was confirmed to be patent 9 years after pancreatoduodenectomy (which was performed when he was aged 51 years). The patient had advanced cancer of the head of the pancreas. Pancreatoduodenectomy was performed, and 6 cm of the portal vein was resected. The portal vein was reconstructed with a PTFE graft (internal diameter 9 mm; length about 6 cm). The graft was demonstrated to be patent on angiography 3 years after the operation. A computed tomographic (CT) scan performed 9 years after the operation showed that the portal graft was still patent. About 2 years after the operation, the patient had been able to resume physical labor, similar to the work he performed before the operation.

先天性胆道拡張症に対する肝外胆道切除, 胆道再建後の胆管炎と膵炎の原因を明らかにし, いかに対処すべきか検討した. 対象は戸谷I, IV-A型先天性胆道拡張症非癌例のうち肝外胆道切除, 胆道再建を施行した127例である. 術後胆管炎や膵炎のために経過不良となった症例は24例あった. 原因としては肝門部における胆管狭窄の遺残, 肝内胆管の高度の拡張と多発性の狭窄, 肝管消化管吻合部狭窄, 挙上空腸における胆汁うっ滞, 膵頭部における膵液の流出障害などがあった. したがって, 以下の点に注意すべきである.(1) 肝外胆道切除, 胆道再建施行時には, 肝門部における胆管狭窄や膵内の拡張胆管を遺残させないようにする.(2) 肝内胆管に高度の拡張や多発性の狭窄を有する症例, あるいは切石困難な膵石や膵管の高度な形態異常を有する症例では, 肝外胆道切除, 胆道再建のみでは対処できないこともあるため, 病態に応じて肝切除や膵頭切除も考慮する.

膵頭部領域癌切除例527例を対象として至適切除・郭清範囲を検討した. 浸潤性膵管癌では, 第2群以上リンパ節・後腹膜神経叢郭清, 門脈系静脈合併切除, 膵頭体部切除を基本とする拡大手術が治療成績向上の必須条件であった. しかし, 局所の高度進展例ではその治療成績は極めて劣悪であり拡大手術の適応から除外すべきであった. 膵頭部癌の治療成績向上のためには, 術前術中進展度所見を評価して適切と思われるCS III期 (RP2, PV2, A (-)) 以下の症例に合理的に適応選択する必要があった. 乳頭部癌では特にNo.14リンパ節の完全郭清が, 下部胆管癌では更に十分な胆管追求切除と後腹膜郭清が必要であった. 膵頭部領域癌に対する胃切除PDをretrospectiveに検討した結果, 十二指腸第1部又は胃幽門部への直接浸潤がなければ, 胃周囲のリンパ節 (No.3, 4, 5, 6, 7) に転移する頻度は少なく, 90%以上の症例に根治性を損なうことなくPpPDを適応することが可能であった.

高齢者膵頭部癌に対する拡大手術の適応と限界を明らかにする目的で, 60歳以上の膵頭部浸潤性膵管癌切除例150例を対象に80歳以上の超高齢群5例, 70～79歳の高齢群62例, 60～69歳の非高齢群83例に分け検討した. 切除率は超高齢群で28%と高齢群 (54%), 非高齢群 (58%) より低かったが, 非切除の理由は各群とも癌の高度進展が大多数であった. 術前併存疾患は超高齢群, 高齢群で高率であったが, 各群とも80%以上に拡大手術を施行し, 術後合併症発生率に差はなかった. しかし, 高齢群の術後在院死亡率は13%と高かった. 各群とも膵後方浸潤, リンパ節転移を中心に高度な組織学的進展を示し, 年齢を問わず拡大手術の必要性を認めた. 高齢群では根治度B以上の5生率は21%, 5年以上生存3例であったが, 超高齢群では全例根治度Cで最長11か月生存であった. 術後のQOLは各群で差はなかった. 以上より, 高齢者膵頭部癌に対する拡大手術の適応は根治度B以上が期待できる症例に限るべきで, 80歳以上の超高齢者に対する適応は慎重にすべきと考えられた.

超音波検査による胆管非拡張型膵・胆管合流異常の診断について検討した. 対象は胆管非拡張型膵・胆管合流異常38例のうち癌併存例を除いた18例である. USでは12例中9例で胆嚢壁が2層または3層構造を呈し, 最内側層が主に肥厚し, 表面に凹凸を認めた. 切除胆嚢の病理組織学的検索から, 本所見は粘膜の過形成を表している可能性が高いと推測された. 合流異常のない対照群20例では, このような所見は認められなかったことから, 本所見の有無によりスクリーニング検査を行うことで, USによる胆管非拡張型膵・胆管合流異常の効率の良い拾い上げが可能になると考えられた. EUS像はUS像よりも鮮明で, 11例中9例ではUSと同様の所見が容易に認識でき, 7例では合流部も描出できた. したがって, USで今回確認された特徴的所見が認められた場合には, EUSを施行することが必要であり, 胆嚢壁における変化から膵. 胆管合流異常が疑わしい場合には積極的にERCPまで行うべきである.

教室で経験したPD 964例をもとに, 術後合併症と対策について検討した. 1) 早期合併症発生率は27%, 入院死亡率は9%で, 膵腸吻合縫合不全に起因するものがその1/3を占め, 線維化のない正常膵に11%と高率であった. 膵腸縫合不全は, 手術的膵損傷や膵管狭窄などに起因する1次合併症と, その結果として引き起こされる腹腔内膿瘍や出血などの二次合併症とに分けられた. 前者では手術時の膵損傷に留意し, 吻合部周囲のドレナージを徹底することが重要で, 後者ではUS, CT下ドレナージやTAEが有効で, 最近10年間の膵腸吻合縫合不全に起因する入院死亡率は75%から21%へと著減した. 2) 晩期合併症は吻合部狭窄のみならず, PDに特有な十二指腸乳頭機能廃絶の結果, 惹起される再建腸管内の鬱滞に起因する胆道感染症や膵炎が見られた. この対策は吻合部狭窄のブジーや再吻合, 再建腸管の癒着剥離や消化管再建配列法の変更が, また胆管炎性肝膿瘍にはUS, CT下ドレナージが有効であった.

胆管非拡張型膵・胆管合流異常38例のうち癌併存例 (全例が胆嚢癌) を除いた18例を対象とし手術術式について検討した.合流異常に起因すると考えられる膵炎や胆管炎の既往を有していた4例には肝外胆道切除, 胆道再建を施行したが, 他の14例には胆嚢摘出術のみを施行した.切除胆嚢には粘膜の過形成や化生が認められたが, 肝外胆道切除を施行した4例の胆管粘膜にはこれらの変化は認められなかった.胆嚢摘出術を行った14例の術後経過を血液生化学検査や画像検査をもとに検討した.経過観察期間は平均4年5か月 (1年1か月～9年8か月) であった.いずれの症例も経過良好で, 合流異常を遺残させたことに起因する異常所見は認められなかった.今後さらに長期間にわたる経過観察が必要と思われるが, 胆管非拡張型膵・胆管合流異常非癌例のうち合流異常に起因する膵炎や胆管炎の既往のない症例の治療に際しては, 胆嚢摘出術が第1選択となる可能性が示唆された.

In 40 patients with tumor size (TS)1 pancreatic cancer with a TS of 2 cm or less, the tumor was classified as without direct extrapancreatic invasion in 11 patients (t1a, group) and as with direct extrapancreatic invasion in 29 patients (t2t3 group). Ultrasonography (US) and endoscopic retrograde cholangio-pancreatography (ERCP) were useful for the diagnosis, with accuracy rates of 80% and 75%, respectively, in the t1a group and 78% and 75% in the t2t3 group. The accuracy rate of preoperative integrated imaging diagnosis was 83% in the t2t3 group but only 55% in the t1a group. All of the t2t3 patients were stage III or higher and 18% of the t1a patients had lymph node metastasis, indicating the need for extended radical operation in TS1 pancreatic cancer. Because standard operation is indicated when the preoperative diagnosis is not pancreatic cancer, accurate preoperative diagnosis is very important. The rate of curative resection and the 5-year survival rate were 100% and 56%, respectively, in the t1a group and there were two 5-year survivors. The rate of non-curative resection and the 5-year survival rate were 31% and 35%, respectively, in the t2t3 group and there were three 5-year survivors. In the light of these findings, it is therefore important to make an accurate diagnosis of t1a pancreatic cancer of TS1 pancreatic cancer without direct extrapancreatic invasion. As liver metastasis was frequently observed in both the t1a and t2t3 groups, the establishment of effective measures to inhibit liver metastasis is considered urgent to improve the result of TS1 pancreatic cancer surgery.

The results of duodenum-preserving total resection of the head of the pancreas (DpTRHP) in 20 patients were compared with the results of pylorus-preserving pancreatico-duodenostomy (PpPD), a procedure in conventional use for the treatment of benign diseases, in 19 patients. The mean operative time for DpTRHP was 4.5±0.9 h, this being not significantly different from that for PpPD, whereas the mean intraoperative blood loss with DpTRHP (825±508ml) was significantly less than that with PpPD (1382±798 ml) (P

化膿性肝膿瘍の治療法とその成績にっき, 膿瘍の形態別, 単発多発別に検討した.また最近導入している経カテーテル的肝動脈内抗生剤注入療法の適応と成績につき検討した.過去10年間に経験した肝膿瘍50例, 57回の治療を対象に, 単発多発および単房多房に分類し治療成績を検討した.単発単房性膿瘍には経皮経肝的穿刺ドレナージがきわめて有効であった.しかし多発または多房性膿瘍では穿刺ドレナージのみでは治療に難渋し遷延する症例が多く, 肝動脈内抗生剤注入療法などの追加療法を要した.肝動脈内抗生剤注入療法を12例16回施行した.大腿動脈よりカテーテルを挿入, 肝動脈に留置し抗生剤を注入し, 15回には明らかな改善を認めその有用性が確認されたが, 1回には無効であった.肝膿瘍の治療においてはその病態, 形態, 数に応じて穿刺ドレナージ, 動注療法, 胆道ドレナージなどを効率的に選択併用することが重要と考えられた.

We report a case of bile duct cancer with a positive surgical margin obtaining long-term survival after S-1 monotherapy. A 79-year-old male with fever and liver dysfunction was admitted to our hospital. After a series of examinations he was diagnosed as hilar cholangiocarcinoma, which was treated with bile duct resection and biliary reconstruction for adhesion and pulmonary dysfunction of tuberculosis. Histopathological findings revealed that both surgical margins of the bile duct were positive. After operation, the patient received S-1 oral monotherapy(100mg/day for 28 days, followed by 14 days of rest)for 3 years. The patient has been alive for 5 years without recurrence.

Background. Carcinoid tumors of the gastrointestinal tract are most common localized in the appendix, followed by the small intestine, the rectum, and the stomach. The localization of these tumors at the ampulla of Vater is extremely seldom. Methods. In the present study the authors describe two patients with carcinoid tumors of the ampulla Vater and review 71 previously published cases. Results. Most patients presented with jaundice, but without carcinoid syndrome. Because the tumor grows submucosally, preoperative diagnosis was correct only in 15%. Most tumors were around 2 cm in size. Metastasis to lymph nodes and/or liver was present in 45%. Standard treatment is Whipple resection or local excision in small tumors. Conclusions. Carcinoid tumors of the ampulla of Vater are an extremely rare clinical entity. Generally, the prognosis is good with a 5-year survival period of 90%.

通常型膵頭部癌切除282例を対象に, 進展・再発形式から拡大手術の評価と術中放射線療法の有効性を検討した.膵外への直接進展は93%に見られ, stage III, IVの進行癌が86%を占めた.拡大手術の治癒切除率は49%と有意に向上し, 術後合併症発生率, 手術死亡率はおのおの19%, 4%と安全に行われた.拡大手術の1生率, 3生率, 5生率は各々44%, 13%, 9%で, 5年生存例10例を得た.治癒切除例の再発形式は, 後腹膜再発, 肝転移が63%, 46%と高率であった.1988年以降, 術前進展度診断による適応選択を行い, 臨床病期IV期を拡大手術の適応外とした結果, 1987年以前に比べて生存率は有意差はないがやや良好である傾向が認められた.切除例に対する術中放射線療法は, 初期のプロトコールでは生存率・再発形式の面からは有効性は認められず, 現在は, 拡大手術と同様の適応選択を行ってprospective randomized studyにより術中放射線療法の有効性を検討している.