Yasuki Unemura

Pancreatic granular cell tumor combined with carcinoma in situ

A 58‐year‐old man was treated for a granular cell tumor (GCT) of the pancreas; a very rarely occurring tumor. The patient, who had been followed for 6 years due to alcoholic hepatitis, chronic pancreatitis and elevated carcinoembryonic antigen (CEA) levels from smoking, was admitted to our hospital for evaluation of back pain, diarrhea and constipation. The patient was diagnosed as having pancreatic head cancer using clinical imaging studies, and a pylorus‐preserving pancreatico‐duodenectomy was done. In the resected specimen, a white tumor measuring 13 mm in diameter was observed at the pancreatic head, and there was marked fibrous change surrounding the tumor. The microscopic appearance of the pancreas showed atrophy of acinar cells, fibrosis, and dilatation of the main pancreatic duct (MPD). Within the tumor were oval cells with low‐grade atypia and an increased number of diffuse eosinophilic granules. Neither mitosis nor invasive findings were observed. Periodic acid–Schiff staining and immunohistochemical staining for the S‐100 protein were positive, thus the tumor was diagnosed as a benign GCT. In addition, carcinoma in situ was found at the dilatated MPD. Therefore, this patient was diagnosed as having GCT with carcinoma in situ of the pancreas. To the best of our knowledge, this is only the fourth case of GCT of the pancreas to be reported.

Ultrasonographic assessment of the risk of injury to branches of the middle hepatic vein during laparoscopic cholecystectomy

BACKGROUND Although hemorrhage from the gallbladder bed during laparoscopic cholecystectomy is one of main reasons for conversion to open cholecystectomy, the cause of this life-threatening complication is unclear. PATIENTS AND METHODS Color Doppler ultrasound was used to examine the cause of venous hemorrhage from the gallbladder bed during laparoscopic cholecystectomy in 4 patients postoperatively and to examine the anatomic relationship between the gallbladder bed and branches of the middle hepatic vein in 50 healthy volunteers. RESULTS Injury to a large branch of the middle hepatic vein adjacent to the gallbladder bed was diagnosed in all 4 patients. One patient required conversion to open cholecystectomy while the bleeding in 2 patients was immediately controlled by direct pressure with the gallbladder. The branch of the middle hepatic vein was completely adherent to the gallbladder bed in 5 of the 50 volunteers, and in 1 the diameter of the branch was as large as 3.5 mm. In 3 volunteers branches 3.0 to 3.8 mm in diameter traversed as close as 1.0 mm from the gallbladder bed. CONCLUSIONS Patients with large branches of the middle hepatic vein close to the gallbladder bed are at risk of hemorrhage during laparoscopic cholecystectomy and should be identified preoperatively with ultrasound.

Patients' Recognition on the Laparoscopic Cholecystectomy. Propriety of Switching to the Day-care Surgery.

今後, day surgery(DS)への移行が予測される腹腔鏡下胆曩摘出術(LC)施行患者の意識調査を施行した. 希望入院時期は術前日: 55%, 2～3日前: 43%, 術当日: 2%であり, また当日入院は忙しさよりも個々の価値観から派生すると考えられた. 83%以上が入院期間延長による負担増額を気にせず入院していた. 民間の保障制度には80%が加入し, うち86%が請求していた. 術後入院期間短縮を考慮する負担増額は1万円/日程度と思われた. 術後入院期間は全例で4.5±1.9日, 非常に多忙, 多忙, やや余裕あり, 余裕ありそれぞれ3.7±0.8, 4.3±1.9, 4.5±1.9, 5.2±2.0日で, 余裕のある者で有意に長かった. しかし体験した程度でよいとする者が87%を占め, 短縮希望者は8%に止まった. うち自己負担額の増域によらず積極的に早期退院を望む者は全体の3%に過ぎなかった. 現行医療保険制度内では, 本調査施行患者はLCのDS化にあらゆる面で肯定的とは考えられなかった.

Hepatic resection of colorectal carcinoma metastases. Recurrent patterns after curative hepatic resection and hepatic lymphnode involvement.

大腸癌肝転移切除症例18例の再発様式について検討した. 根治的肝切除後の再発様式は残存肝再発57%, 肺転移29%, 原発巣局所再発14%であった. 原発巣が左側結腸症例, および肝転移の進展度がH2症例では残存肝における再発が多かった. 肝転移巣の発見時期が同時性と異時性の症例とでは, 同時性に対する肝切除後の再発率が高かった. 肝切除後残存肝再発は半年以内に出現するものが多かった. 18症例中術中に肝所属リンパ節転移を16.7%と高頻度に認め, 肝切除時にリンパ節郭清 (特に肝門部および肝十二指腸間膜リンパ節) を施行する必要性が示唆された. 肝所属リンパ節転移をきたした症例の原発巣はn, v, lyの各因子の進行したものが多かった.