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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.

Pancreatoduodenectomy (PD) is one of the most difficult operations in gastrointestinal surgery. Standard PD ligates and cuts superior mesenteric vein (SMV) branches after the removal of the pancreas head, which leads to congestion and bleeding of these veins. In this study, we modified the standard PD and first ligated the efferent vessels (arteries); namely, the gastroduodenal artery and inferior pancreatoduodenal artery (IPDA), before ligating and cutting the corresponding afferent vessels (veins) of the pancreas head. By doing this, congestion of these veins was relieved and bleeding from the resected surface was substantially prevented. Thirty-six patients (18 underwent standard PD and 18 had modified PD) formed the study population. The amount of bleeding in the modified PD group was significantly lower than that in the standard PD group. (678 ± 329 g vs 1225 ± 375 g, respectively; P < 0.05) However, no difference in operation time was found between the two groups. We believe this modified PD procedure is valuable to enable the safe performance of PD.

A case of invasive ductal carcinoma of the breast and localized in the right nipple is reported. The patient was a 65-year-old woman. Beginning in January 1997, she noticed gelosis surrounding the right nipple, but did nothing about it. During an examination in April of that year, she was persuaded to undergo additional tests, and was referred to this clinic. The right nipple measured 15×15mm, with a height of 10mm, and was slightly larger than the left nipple. Through palpation, a mass was found with indistinct, elastic boundaries directly under the nipple, but no bleeding or sores on the surface. Mammography confirmed the presence and shape of the mass, while ultrasonography showed a low-echo, uneven tumor area measuring 18×17×10mm with an irregular edge. Biopsy results suggested ductal carcinoma, with the possibility of an adenoid tumor; therefore, we elected to resect the nipple area. A pathological study showed the tumor to be an invasive type of ductal carcinoma, but there was no residual tumor at the resection site, and the remaining breast and axillary region were treated with radiotherapy. Discussion: Other diseases localized to the nipple include Paget's disease and adenoma of the nipple, so it is important to distinguish these from breast cancer. In particular, the latter type leads often to resection of the nipple. Most cases of cancer of the nipple are Paget's disease complicated by noninvasive ductal carcinoma, so it is unusual to find a case where the primary tumor in the nipple was an invasive tumor.

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.MSPP was performed for 4 patients. Intraoperative blood loss, hospital stay, postoperative complications, histopathological findings and prognosis were examined.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.MSPP enables maintenance of good QOL long after surgery for malignancy affecting the head and tail of the pancreas.