Naotaka Kadoya

Acute pancreatitis associated with anomalous union of the pancreaticobiliary ductal system

Between 1978 and 1989, 13 of 48 patients with anomalous union of the pancreaticobiliary ductal system (AUPBD) were diagnosed as having acute pancreatitis. We have studied the clinical, radiologic, and surgical features of these 13 patients. A transient rise in the intraductal pressure of the pancreatic duct during an episode of abdominal pain is responsible for pancreatitis in patients with AUPBD. This rise in the intraductal pressure must be due to bile reflux into the pancreatic duct when an abnormally long common channel is blocked by cholelithiasis, protein plug, or dysfunction of the sphincter of Oddi. The pancreatitis resolves when the common channel obstruction is removed, and bile and pancreatic juice flow easily into the duodenum. We believe that this phenomenon is responsible for acute relapsing pancreatitis. It is our belief that the pancreas appears almost normal during symptom-free intervals.

Currarino syndrome in an adult presenting with a presacral abscess: a case report

IntroductionCurrarino syndrome (Currarino triad) was described in 1981 as a triad syndrome with a common embryogenesis in infants and with three characteristics: anorectal stenosis, a defect in the sacral bone, and a presacral mass. We describe here an unusual case of Currarino syndrome in an adult presenting with a presacral abscess but no meningitis.Case presentationA 32-year-old Japanese man presented with fever, arthralgia and buttock pain. A digital rectal examination showed mild rectal stenosis with local warmth and tenderness in the posterior wall of his rectum. Computed tomography showed a scimitar-shaped deformity of his sacrum and an 8cm presacral mass, which continued to a pedicle of his deformed sacrum. This was diagnosed as Currarino syndrome with a presacral abscess. The abscess was drained by a perianal approach with our patient treated with antibiotics. His symptoms soon disappeared. After three months, an excision was performed through a posterior sagittal approach. His postoperative course was uneventful and he was discharged 10 days after surgery. A histopathological examination revealed an infected epidermoid cyst. He has been free from recurrence as of four years and six months after surgery.ConclusionsWe report a case of Currarino syndrome in an adult who presented with a presacral abscess but no meningitis. Abscess drainage followed by radical surgery resulted in a successful outcome.

A case of intraductal papillary adenocarcinoma of the pancreas associated with mass forming chronic pancreatitis.

A case of intraductal papillary adenocarcinoma of the pancreas associated with mass forming chronic pancreatitis without calcifications is described. Pancreatolithiasis, or calcified pancreas, is recognized as a high risk factor for pancreatic cancer. However, epidemiologic studies have found that carcinoma of the pancreas associated with chronic pancreatits was rare. The question is whether chronic pancreatitis without calcifications is actually a precancerous background lesion or not. This case suggests that hyperplasia of the pancreatic ductal epithelium may be a precancerous lesion for pancreatic cancer in some patients with chronic pancreatitis.

Malignant Mesenchymoma of the Retroperitoneum Involving Cecal Carcinoma. A Case Report.

患者は78歳の女性.後腹膜の黄色肉芽腫で左腎摘出術を施行された既往がある.主訴は左下腹部痛で, 同部に一致して径10cmの腫瘤を触知し, 血液検査ではCEA とCA19-9が高値を示した. CTでは左後腹膜に石灰化を有し周囲に脂肪成分を伴う腫瘤を認めた.注腸造影では下行結腸は内側に圧排され, また盲腸に腫瘤陰影を認めた.2型盲腸癌と黄色肉芽腫の再発との診断で手術を施行した.下行結腸周囲の後腹膜腔に複数の腫瘤を認め, 迅速病理にてmyxoid sarcomaと診断されたため結腸左半切除術を施行し, また盲腸癌にて回盲部切除術を併施した.切除標本では漿膜下から後腹膜に黄褐色または灰白色な弾性硬の腫瘤を認めた. 組織学的には分化型の軟骨肉腫や骨肉腫, 平滑筋肉腫および脂肪肉腫の成分を認め悪性間葉腫と診断された.盲腸癌は2型の高分化腺癌でss, ly2, v0, n1 (+) であった. 本疾患はまれであり組織発生を検討する上で興味ある症例と考えられたので報告する

A CASE OF RECURRENT GASTRIC CANCER WITHOUT JAUNDICE FOR 1 YEAR AND 6 MONTHS AFTER BILIARY ENDOPROSTHESIS USING AN EXPANDABLE METALLIC STENT

A 49-year-old man underwent a curative gastrectomy for a type 3 advanced gastric cancer. Liver dysfuntion was recognized 10 days after the operation. PTCD was carried out because of complete obstruction at the middle portion of the common bile duct. Under a diagnosis of biliary obstruction due to inflammation, second time operation was performed. A mass formation was recognized around the hepatoduodenal ligament. Adenocarcinoma cell invasion was found in the connective tissue in the induration at the biliary obstruction by intraoperative frozen section diagnosis. Only the biliary reconstruction was impossible. Expandable metallic stent was inserted using the route of PTCD after the operation. On the 30th day after the insertion, the PTCD tube was removed and complete biliary endoprosthesis was accomplished. From just before discharge, UFT-E 1.5g/day and PSK 3g/day were administered. Moreover CDDP 25 mg and MMC 2 mg were injected at the time of consultation. The injections were carried out 16 times until now. As of 1 year and 6 months after insertion of the stent, no evidence of exacerbation of gastric cancer has been recognized and the patient leads an ordinary life. During this period, no evidence of cholangitis and dilatation of intrahepatic bile duct on X-ray is recognized.

THE DIAGNOSTIC CAPACITY OF ABDOMINAL ULTRASONOGRAPHY AND PROBLEMS IN TREATMENT FOR ELEVATED LESIONS OF THE GALLBLADDER

Ninety-six cases with an elevated lesion of the gallbladder were analyzed to elucidate the diagnostic capacity of abdominal ultrasonography (US) and problems in the treatment for such elevated lesions of the gallbladder. Most of the nodular lesions on US were cancer, except adenomyomatosis. Moreover all eight cases with nodular type cancer more than 11mm in size invaded over the subserosal layer. These results indicate that the nodular lesions are necessary to be operated on as soon as possible once they are discovered and if a possibility of adenomyomatosis cannot be ruled out. In the papillary lesions less than 10mm in size, the frequency of cancer is 2%, versus 60% in the lesions more than 11mm in size. All papillary type cancers less than 20mm in size on US or macroscopic finding invaded the mucosal layer. These results suggest that the papillary lesions more than 11mm in size are necessary to be treated as cancer, but those less than 10mm in size can be followed until they grow to 10mm in size, even if the lesions are suspected of malignant potential. The lesions less than 10mm in size can remain in an early phase, if those are cancer.

A Clinicopathological Study on Surgical Cases with Bile Duct Cancer in Middle and Distal Portions.

過去16年間に経験した中下部胆管 (Bm, Bi) 癌手術症例49例につき, 臨床病理学的所見, 予後に関し検討した. 全症例における切除率は91.8%, 切除例の5年生存率は31.2%であり, 7例の5年生存例 (長期生存例) を得た. Stage分類では, Stage III, IV症例が過半数を占め, Stageの進行とともに生存率の低下を認めた. 肝転移例は8.2%, 腹膜播種例は4.1%, リンパ節転移 (n) 例は37.8%であり, リンパ節転移陽性例の生存率は陰性例に比べ有意に低かった. Bi癌, Bm癌とも高頻度に膵臓浸潤 (panc), 十二指腸浸潤 (d) を認めたが, 浸潤の有無において予後に差は認められなかった. 組織学的には, 高頻度にリンパ管浸潤 (ly), 神経周囲浸潤 (pn) を認めたが, 浸潤陰性例の予後は良好であった. 長期生存例からみた場合, 予後規定因子としてn, ly, pn因子が重要であり, panc, d因子は予後規定因子とはなりえず, 取扱い規約におけるStage分類を再考する必要性が示唆された.

A clinicopathological study of hilar cholangiocarcinoma. Surgical problems in curative resection.

肝門部胆管癌の治癒切除を得るための外科的問題点を明らかにする目的で, 切除症例19例を対象に臨床病理学的検討を行った.組織学的リンパ節転移は1例を除き, 2群までにとどまった.門脈合併切除7例中4例は組織学的門脈浸潤陽性であったが, 浸潤陰性3例中2例も門脈壁近傍にまで癌の浸潤が及んでいた.尾状葉浸潤は10例中6例 (60.0%) に認められた.切離縁における組織学的癌浸潤陽性16例中14例 (87.5%) は剥離面が陽性であった.このうち肝十二指腸間膜内大血管剥離面陽性は10例 (55.6%) (うち門脈合併切除4例), 肝側断端剥離面陽性は8例 (44.4%) であった.再発形式では原病死した全例が局所再発を伴っていた.以上より, 治癒切除を得るために門脈合併切除の必要性が示唆されたが, 今後肝動脈の剥離面の癌陰性化が必要と考えられた.一方肝側断端剥離面の癌陰性化のために術前・術中の癌浸潤のさらなる精査および尾状葉合併切除の必要性が示唆された.

Clinical Significances of External Biliary Drainage before Pancreatoduodenectomy in Patients with Obstructive Jaundice.

従来より閉塞性黄疸患者の外科的治療に当たっては, まず術前PTCDを行って, 肝機能の改善を計ってから行うべきといわれている.そこでわれわれは, 閉塞性黄疸に対する術前PTCDの意義を探るべく検討した.163例の膵頭十二指腸切除例を術前総ビリルビン3.0mg/dl以上の黄疸群 (83例), 3.0mg/dl未満の非黄疸群 (80例) に分け, 黄疸群をさらにPTCDを行ったPTCD群 (65例) とPTCDを行わなかった非PTCD群 (18例) に分け, 3群間で治療成績を比較検討した.その結果, 黄疸群, 非黄疸群の間には手術時間, 術中出血, 術後入院日数, 術後合併症のいずれにおいても差はみられなかった.ただPTCD群は非PTCD群に比べ, 術前の入院日数が有意に長かった.以上より手術手技や術中, 術後の患者の管理が向上した今日では, 閉塞性黄疸患者には血清ビリルビン値のいかんにかかわらず, 術前PTCDを行うことなしに1期的に根治術を行うことは可能と考えられた.

Adenosquamous carcinoma of the pancreas

We report a case of a primary pancreatic adenosquamous carcinoma, an unusual malignancy that displays angiographic and computed tomography (CT) features atypical of primary pancreatic adenocarcinoma.