Search

Few studies compared the oncological and biological characteristics between ampullary carcinoma (AC) and cancer of the second portion of the duodenum (DC-II), although both tumors arise from anatomically close locations.To elucidate differences in clinicopathological characteristics, especially the patterns of lymph node metastasis (LNM), between AC and DC-II.This was a retrospective cohort study of 80 patients with AC and 27 patients with DC-II who underwent pancreaticoduodenectomy between January 1998 and December 2018 in two institutions. Clinicopathological factors, LNM patterns, and prognosis were compared between the two groups.The patients with AC and DC-II did not exhibit significant differences in 5-year overall survival (66.0% and 67.1%, respectively) and 5-year relapse-free survival (63.5% and 62.2%, respectively). Compared to the patients with DC-II, the rate of preoperative biliary drainage was higher (Although there were no significant differences in the prognosis and recurrence rates between the two groups, metastases to N-He and N-Py were more frequent in patients with DC-II than in those with AC.

The incidence of postoperative adhesions is directly correlated with the difficulty level of repeat hepatectomies. However, the incidence, location, and severity of postoperative adhesions in relation to hepatectomy-related operative procedures are yet unclear.First hepatectomy-induced hard dense adhesions were evaluated from the surgical records and/or videos of 168 patients who underwent second hepatectomies.The incidence of postoperative hard dense adhesions around the liver was significantly associated with locations, such as the hepatic cut surface, dissected areas around the liver, and peri-incision peritoneum, and hepatectomy-related operative procedures, such as Pringle maneuver and cholecystectomy. The incidence of hard dense adhesions after dissection was higher around the right liver than in the left infraphrenic space. Further, the incidence of hard dense adhesions around the hepatoduodenal ligament or Morison pouch was greater than 30% even in patients who did not undergo Pringle maneuver, cholecystectomy, or hepatorenal ligament dissection. Although the incidence of hard dense adhesions of the peritoneum around the incision was higher after open hepatectomy than after laparoscopic hepatectomy, adhesion barrier use reduced the incidence of such adhesions in patients after open hepatectomy.Hepatectomy-related operative procedures such as peri-hepatic dissection, Pringle maneuver and cholecystectomy are directly associated with postoperative hard dense adhesions. However, the incidence of postoperative hard dense adhesions around the hepatoduodenal ligament and Morison pouch was high even when the above-mentioned operative procedures were not performed. These findings may help inform clinical decisions regarding the indications and sites for adhesion barrier use during hepatectomies.

Introduction and importance Recently, laparoscopic liver resection has been established as a standard procedure for a certain group of hepatic resections; its indications and procedures have been expanding. Case presentation A 67-year-old woman was referred with a chief complaint of left subcostal pain. Eight years and nine months before, she underwent pancreatoduodenectomy for cancer of the ampulla of Vater after endoscopic retrograde biliary drainage for obstructive jaundice. A trans-anastomotic internal-external retrograde transhepatic biliary drainage (RTBD) catheter was placed intraoperatively. Based on radiological findings, intrahepatic cholangiocarcinoma, or local recurrence of cancer of the ampulla of Vater, invading the anterior thoracoabdominal wall, diaphragm, and pericardium, without distant metastasis, were considered. Laparoscopic lateral segmentectomy of the liver combined with open en bloc resection of the invaded portion of the anterior thoracoabdominal wall with costal cartilage, diaphragm, and pericardium was performed. The postoperative course was uneventful, and the patient was discharged 17 days post-surgery. The patient died of cancer recurrence 46 months later. Clinical discussion The cancer invaded along the RTBD tract. Although the mechanisms of carcinogenesis remain unclear, transhepatic biliary drainage is a risk factor for cancer invasion along the tract. Laparoscopic liver resection before open thoracoabdominal wall resection ensured clear delineation of the cancer margins invading the thoracoabdominal wall and minimized the defect of the thoracoabdominal wall. Conclusion Laparoscopic liver resection for hepatic cancer invading adjacent structures or organs would be feasible and useful in selected patients, even if resection of the invaded area is performed by open surgery., Highlights • Cancer developed along the retrograde transhepatic biliary drainage tract after pancreatoduodenectomy. • Laparoscopic liver resection and simultaneous open en bloc partial resection of the thoracoabdominal wall was performed. • The patient’s 46-month survival post-operation was relatively long for recurrent cancer of the ampulla of Vater.

Patient: Female, 36-year-old Final Diagnosis: Pancreatitis Symptoms: Abdominal and back pain Medication:— Clinical Procedure: Laparoscopic pancreatic surgery Specialty: Gastroenterology and Hepatology • General and Internal Medicine • Surgery Objective: Unusual clinical course Background: Chronic pancreatitis is a slowly progressive inflammatory disease, affecting patients’ quality of life due to chronic pain as well as endocrine and exocrine pancreatic insufficiency. Patients often choose surgery if medical and endoscopic interventions fail. Surgical approaches for chronic pancreatitis can be categorized as follows: resection of the diseased gland, diversion and drainage of the dilated pancreatic duct, or a combination of these approaches. Frey’s procedure, which involves resection and drainage by longitudinal pancreaticojejunostomy and coring out of the pancreatic head, is reserved for patients with debilitating pain. Although laparoscopic surgery is gaining popularity in recent years due to its noninvasiveness and cosmetic benefit, few reports describe performing Frey’s procedure laparoscopically. Case Report: A 36-year-old Japanese female with chronic pancreatitis complained of back pain and pain in the left upper quadrant abdomen. Plain computed tomography of her abdomen revealed a dilated main pancreatic duct containing diffuse calculi extending to the pancreatic parenchyma. Laboratory findings, including amylase level, were within normal ranges. She was diagnosed with chronic pancreatitis, and subsequently underwent a laparoscopic Frey’s procedure. To our knowledge, we are the first to improve operative field visibility by using a Penrose drain to move the stomach from the line of sight. Postoperatively, the patient did well and was discharged 10 days after surgery. She remained symptom-free without medications for 80 months. Conclusions: Due to its noninvasive nature and cosmetic advantages, laparoscopic Frey’s procedure may be an attractive therapeutic option for chronic pancreatitis.

症例は34歳，男性．腹痛を自覚し近医を受診した．腹部超音波検査，腹部CT検査にて膵鈎部尾側に4cm大の腫瘤と多発肝腫瘍を認めた．同病院にて試験開腹術を施行し，術中診断は膵腫瘍及び多発肝転移であった．術中に施行した肝生検の組織診断は高分化型膵内分泌細胞癌であった．術後軽快退院後，当院を紹介受診した．血液検査所見では血中インスリン値，ガストリン値，グルカゴン値は正常範囲内であった．以上より，非機能性膵内分泌細胞癌の多発肝転移と診断し，etoposide（ETP）とcisplatin（CDDP）による化学療法を行った．化学療法後の腹部CT検査では膵腫瘍と肝転移巣の増大はなく，新たな肝転移巣も認めず，肉眼的に切除可能と判断し，幽門輪温存膵頭十二指腸切除術，横行結腸部分切除術及び肝部分切除術を施行した．切除標本の病理組織診断は高分化型膵内分泌癌であり，免疫組織学的にはsynaptophysin（+）， chromograninA（-），glucagon（+），serotonin（-），insulin（-），SSTR2a（+）であった．術後14カ月後の現在，残肝再発を認めるも健存中である．

はじめに：肝切除施行例における腹腔ドレーンの管理法について検討した．対象と方法：肝切除術中に閉鎖式ドレーンが留置された104例を術後4日目以内腹腔ドレーン抜去72例（短期間留置群）と術後5日目以降抜去32例（長期間留置群）に分類し，ドレーン留置期間延長の要因や術後合併症の観点から肝切除術における適切な腹腔ドレーン抜去時期について検討した．なお，腹腔ドレーンは胆汁混入がみられない（総ビリルビン値5 mg/dL未満）場合，抜去した．結果：腹腔ドレーン長期間留置に関わる因子は，単変量解析によると腫瘍径（大型腫瘍），1区域以上切除，手術時間，術中出血量，術後4日目のドレーン排液量（200 mL以上）で，多変量解析によると手術時間，術中出血量およびドレーン排液量が独立因子であった．胆汁漏は短期間留置群の2例にみられ，そのうち1例に腹腔内感染が発症した．創感染は両群のそれぞれ1例に，難治性胸腹水は短期間留置群の2例にみられたが，両群のそれら術後合併症の頻度に差はみられなかった．まとめ：肝切除例において，手術時間，術中出血量および術後4日目のドレーン排液量が腹腔ドレーン長期留置に関わる独立した因子であった．胆汁混入がみられない場合，腹腔ドレーンの術後4日目以内抜去は妥当であると考えられた．

肝癌切除後の孤立性リンパ節転移を摘除することで, 術後2年6か月の現在, 無再発生存中の症例を経験したので報告する. 症例は58歳の男性で, C型慢性肝炎に伴う肝癌に対して肝切除術を2回施行されていた. 経過観察中のCT像上, 肝尾状葉に約4cm大の腫瘤性病変を認め, AFP, PIVKA-II値の著明な上昇がみられた. 腹部血管造影像では腫瘤は中肝動脈および左胃動脈より栄養される腫瘍濃染像として描出され, 肝癌の尾状葉再発と診断し開腹した. 腫瘍は肝尾状葉に接するように総肝動脈の腹側に存在していたが, 肝臓からは独立しており肝癌の総肝動脈幹リンパ節転移と考え摘除した. 病理組織学的検査では中分化型肝癌のリンパ節転移と診断された. AFP, PIVKA-IIは術後2か月目に標準値範囲内へ低下し, 以来, 再発徴候を認めていない. 原発巣がコントロールされた肝癌の孤立性リンパ節転移は摘除により良好な予後が得られる可能性が示唆された.

S-allyl cysteine (SAC) is the most abundant compound in aged garlic extracts (AGEs). AGE has been reported to ameliorate the oxidative damage implicated in a variety of diseases. However, the effects of SAC have not been established in liver cirrhosis. The aim of this study was to examine the effect of therapeutic administration of SAC in liver cirrhosis by chronic carbon tetrachloride (CCl4) administration in rats. SAC or other cysteine compounds were administered from 4 weeks when liver fibrosis was confirmed to be in process. CCl4 administration elevated plasma alanine aminotransferase, plasma lipid peroxidation, liver hydroxyproline, and liver transforming growth factor (TGF)-β at 12 weeks. SAC prevented these changes induced by CCl4. Furthermore, SAC improved survival in a dose-dependent manner following consecutive CCl4 administration. The inhibitory mechanisms may be associated with a decrease in the profibrogenic cytokine, TGF-β as well as the antioxidative properties of SAC.

Accumulating evidence suggests that alcohol, hepatitis C virus infection, steatosis with obesity, and insulin resistance are accompanied by iron overload states. Phlebotomy and oral iron chelators are effective treatments for these conditions and for hemochromatosis. However, the mechanisms by which iron depletion improves clinical factors remain unclear. We examined the effect of iron depletion in a model of type 2 diabetes, Otsuka Long-Evans Tokushima Fatty (OLETF) rats. Age-matched Long-Evans Tokushima Otsuka (LETO) rats were used as controls for all experiments. Iron restriction was performed by eliminating iron in the diet from 15 wk of age or by phlebotomy. Phlebotomy was commenced at 29 wk of age by removing 4 and 3 ml of blood from the tail vein every week in OLETF and LETO rats, respectively. Rats were euthanized at 43 wk of age, and detailed analyses were performed. The plasma ferritin concentration was markedly higher in OLETF rats and decreased in iron-deficient (ID) diet and phlebotomy rats. Hemoglobin A1c (Hb A1c) was decreased significantly in OLETF rats fed the ID diet and in the phlebotomy group. Increased levels of triglycerides, glucose, free fatty acids, and total cholesterol were found in ID OLETF rats. Plasma, liver, and pancreas lipid peroxidation and hepatic superoxide production decreased in both groups. Pancreatic fibrosis and insulin levels improved in both groups of OLETF rats. Pancreatic levels of peroxisome proliferator-activated receptor-β/δ (PPARβ/δ) ligands and hypoxia-inducible factor (HIF)-1α were decreased significantly in OLETF rats. These factors were normalized in both rats fed ID and phlebotomy groups of OLETF rats. In conclusion, iron depletion improved diabetic complications by inhibition of oxidative stress and TGFβ signal pathways and the maintenance of pancreatic PPARβ/δ and HIF-1α pathways.