Yasuhiro Matsugu

Pancreatic Duct Obstruction Is an Aggravating Factor in the Canine Model of Chronic Alcoholic Pancreatitis

BACKGROUND & AIMS Chronic alcoholic pancreatitis occurs in only a limited number of heavy drinkers. Other factors than alcohol are necessary for the occurrence of chronic alcoholic pancreatitis. The aim of this study was to examine whether pancreatic duct obstruction resulted in increased alcohol-induced parenchymal cell damage. METHODS Four groups of adult mongrel dogs were used. In group A, 2. 0 g . kg-1 . day-1 of ethanol was administered via a gastric cannula. In group O, after ligation of the minor pancreatic duct, a polyethylene tube was inserted transduodenally into the major duct. In group AO, the protocols used in groups A and O were combined. Laparotomy was repeated after 3 months in each group. RESULTS Three of the 9 dogs in group AO had pancreatic calculi in the main pancreatic duct. Moderate interlobular fibrosis, parenchymal cell loss, and inflammatory cell infiltration resembling human chronic alcoholic pancreatitis were observed in group AO. Little change was observed in groups A and O. Exocrine function assessed by secretin test in group AO was significantly reduced. Total protein, hexosamine, and calcium contents of the pancreatic juice in group AO were significantly increased. CONCLUSIONS Pancreatic duct obstruction is an aggravating factor in chronic alcoholic pancreatitis.

Safety of hepatectomy for elderly patients with hepatocellular carcinoma

The number of elderly patients with hepatocellular carcinoma (HCC) has been increasing. Characteristics of elderly HCC patients are a higher proportion of females, a lower rate of positive hepatitis B surface antigen, and a higher rate of positive hepatitis C antibodies. Careful patient selection is vital for performing hepatectomy safely in elderly HCC patients. Treatment strategy should be decided by not only considering tumor stage and hepatic functional reserve, but also physiological status, including comorbid disease. Various assessment tools have been applied to predict the risk of hepatectomy. The reported mortality and morbidity rates after hepatectomy in elderly HCC patients ranged from 0% to 42.9% and from 9% to 51%, respectively. Overall survival rate after hepatectomy in elderly HCC patients at 5 years ranged from 26% to 75.9%. Both short-term and long-term results after hepatectomy for strictly selected elderly HCC patients are almost the same as those for younger patients. However, considering physiological characteristics and the high prevalence of comorbid disease in elderly patients, it is important to assess patients more meticulously and to select them strictly if scheduled to undergo major hepatectomy.

Histopathologic difference between chronic pancreatitis animal models and human chronic pancreatitis.

Objectives: There are many experimental models for chronic pancreatitis. However, it remains unclear which animal models of pancreatic fibrosis can be categorized as chronic pancreatitis models. We compared the histologic features of some animal models of pancreatic fibrosis/chronic pancreatitis and chronic pancreatitis in humans. Methods and Results: Human chronic pancreatitis due to chronic alcohol abuse and unknown etiology showed interlobular fibrosis and a cirrhosis-like appearance. Histopathologically, spontaneous pancreatitis models, WBN/Kob rats and OLETF rats, showed localized/nodular fibrotic lesions, which consisted of swollen, aggregated, atrophic islets of Langerhans; loss of the exocrine parenchyma and hemosiderin deposition that was seldom distributed in the interlobular area. On the other hand, fibrosis in the canine model, which was produced by combining alcohol administration with incomplete pancreatic duct obstruction, was characterized by interlobular fibrosis admixed with a cirrhosis-like appearance very similar to that in human chronic pancreatitis. Conclusion: Most experimental models for chronic pancreatitis, except alcohol administration combined with other procedures such as incomplete pancreatic duct obstruction, are different from human chronic pancreatitis.

Celiac axis stenosis due to median arcuate ligament compression in a patient who underwent pancreatoduodenectomy; intraoperative assessment of hepatic arterial flow using Doppler ultrasonography: a case report

BackgroundCeliac axis stenosis due to compression by the median arcuate ligament has been reported in patients undergoing pancreaticoduodenectomy; it leads to the development of major collateral pathways that feed the hepatic artery. Dividing these important collaterals during pancreaticoduodenectomy can cause ischemic complications which may lead to a high mortality rate. To prevent these complications, it is necessary to assess intrahepatic arterial flow.Case presentationA 71-year-old Japanese man with anorexia was referred to us for the treatment of alcoholic chronic pancreatitis. Computed tomography revealed a pancreatic head tumor with a calculus, associated with the dilatation of the main pancreatic duct and intrahepatic bile duct. Three-dimensional imaging demonstrated focal narrowing in the proximal celiac axis due to median arcuate ligament compression and a prominent gastroduodenal artery that fed the common hepatic artery. The preoperative diagnosis was alcoholic chronic pancreatitis with common bile duct obstruction and celiac axis stenosis due to median arcuate ligament compression. Pancreaticoduodenectomy with median arcuate ligament release was scheduled. Before the division of the median arcuate ligament, the peak flow velocity and resistive index of his intrahepatic artery measured with Doppler ultrasonography decreased from 37.7 cm/second and 0.510, respectively, to 20.6 cm/second and 0.508 respectively, when his gastroduodenal artery was clamped. However, these values returned to baseline levels after the division of the median arcuate ligament. These findings suggested that pancreaticoduodenectomy could be performed safely. Our patient was discharged on postoperative day 17 without significant complications.ConclusionThe intraoperative quantitative evaluation of intrahepatic arterial blood flow using Doppler ultrasonography was useful in a patient who underwent pancreaticoduodenectomy, who had celiac axis stenosis due to compression by the median arcuate ligament.

A case of sclerosing angiomatoid nodular transformation of the spleen with increased accumulation of fluorodeoxyglucose after 5-year follow-up

Highlights • Although sclerosing angiomatoid nodular transformation (SANT) of the spleen is a new entity defined as a benign pathologic lesion, it is very difficult for ruling out the malignancy in preoperative imaging studies.• Even when accumulation of fluorodeoxyglucose increased slightly during the follow-up period and suggested the possibility of malignant diseases, it is necessary to make a diagnosis of splenic SANT comprehensively.

A new contrivance of single port and reduced port gastrectomy for gastric cancer

Background: Single-port laparoscopic gastrectomy (SPG) and reduced-port laparoscopic gastrectomy (RPG) are favorably accepted by patients with early gastric cancer because of less pain, early recovery time, and improving quality of life. However, performing SPG or RPG has some technical difficulties. This article focuses on the contrivance of SPG and RPG with operation technique and on the advantages of the combination of pneumoperitoneum and abdominal wall-lift method. Methods: Ninety-five patients with preoperative stage IA gastric cancer underwent SPG and RPG with D1+ lymphadenectomy between April 2005 and May 2016 at Hiroshima Prefectural Hospital. Thirty patients underwent SPG, and 65 underwent RPG. Results: No significant differences in amount of blood loss [10–357 (mean: 67) vs. 4–470 (mean: 63) mg, P=0.591] and operation time [218–471 (mean: 323) vs. 238–467 (mean: 320) min, P=0.595] were found between the SPG and RPG groups. No significant differences were also between the two groups in terms of post-operative complication and cosmetic results. Conclusions: SPG was safety performed with our special surgical technique, and RPG was safety and easily performed with the wide working space provided by the combination of pneumoperitoneum and abdominal wall lifting method.

A case of porcelain gallbladder with diffuse intramural calcification treated by single-incision laparoscopic cholecystectomy

陶器様胆囊とは,胆囊壁の広範な石灰化により外観 および硬度が陶器様に変化した病態と定義されてお り ,稀な疾患である.以前より陶器様胆囊には胆囊癌 の合併が問題となっており ,腹腔鏡下胆囊摘出術の 相対的禁忌と考えられていた.しかし最近では,胆囊 壁全体に石灰化を呈する全体型陶器様胆囊は癌の合併 は極めて稀であるとされている .今回われわれは全 体型陶器様胆囊に対して単孔式腹腔鏡下胆囊摘出術を 安全に施行しえたので報告する. 症 例 患者:75歳,女性. 主訴:右上腹部痛. 既往歴:69歳時狭心症,高脂血症. 生活歴・家族歴:特記すべきことなし. 現病歴:以前より陶器様胆囊を指摘されており当院 消化器内科で経過観察されていたが,右上腹部痛が頻 繁となったため手術適応とされ,当科紹介となった. 身体所見:腹部は平坦,軟で圧痛なく,腫瘤も触知 しなかった. 血液検査所見:血算,生化学検査に異常を認めず, 血清CEA,CA19-9も正常範囲内であった. 腹部超音波検査:後方に広範囲な音響陰影を伴う腹 側に半月状凸の高輝度エコー像を認めた(Fig.1). 腹部単純X線写真:右上腹部に3.0×3.0cm大の辺 縁明瞭な円形石灰化像を認めた(Fig.2). 腹部単純 CT検査:胆囊壁は全周性に石灰化を認 め,全体型陶器様胆囊 の所見であった.内腔に明らか な腫瘤や石灰化を認めなかった(Fig.3). DIC-CT検査:総胆管内には結石は認めず,胆管分 岐にvariationを認めなかった(Fig.4). 手術所見:臍に2cmの縦切開を加え開腹,SILS Port を装着した.12mmの腹腔鏡を挿入し気腹圧8 mmHgで気腹,腹腔内を観察した.胆囊は頸部から底 部まで石灰化のために全体的に硬く,鉗子での把持は 困難であった.そのため右季肋部より挿入したMINI LOOP RETRACTOR で胆囊全体を頭側に持ち上げ た(Fig.5).右手操作用トロッカーからストレートの バイポーラ鉗子,左手トロッカーから屈曲した Roticulator GRASP鉗子 を挿入し,屈曲鉗子で十二 指腸を足側に圧排し,胆囊頸部の視野を確保した.バ イポーラ鉗子を用いて胆囊頸部漿膜の剥離を行い, MINI LOOP RETRACTOR の牽引と屈曲鉗子を拡 げて胆囊を圧排することで胆囊頸部を展開し,背側漿

Chronic Alcoholic Pancreatitis with Pancreas Divisum

The mechanism for the onset of chronic alcoholic pancre-atitis(CAP) involves many unresolved questions. We (1,2) have succeeded in creating an animal model of CAPby inducing mild stenosis of the pancreatic duct in experi-mentalanimals given alcohol. The CAP seen in this modelis akin to that seen in humans. This means that pancreaticduct-related factors play an important role in the onset ofCAP.

Pancreatic Blood Flow in Chronic Alcoholic Pancreatitis

Circulatory impairment is known to be an important factor in the deterioration of acute pancreatitis. We reported a canine model of chronic ischemic pancreatitis and the first successful model resembling human chronic alcoholic pancreatitis. Using this model, we investigated the significance of pancreatic tissue blood flow. There was pancreatic tissue ischemia in a model of chronic alcoholic pancreatitis. We conclude that pancreatic tissue ischemia is an etiological factor involved in chronic pancreatitis, and that ischemia acts as an aggravating factor of chronic alcoholic pancreatitis.