Yasushi Toh

Surgical Anatomy of the Pancreas and the Periampullary Region

Pancreaticoduodenectomy (Whipple operation) is still the only option to cure pancreatic adenocarcinoma, but pancreatic resection is complicated by several factors. The pancreas lies within the curve of the duodenum and extends transversely across the posterior wall to the spleen. The celiac trunk, superior mesenteric artery, and portal vein run entangled in the region because of embryological rotation of the gut. Understanding the stereological anatomy is difficult because the pancreatic head is fixed to the superior mesenteric artery by the plexus. This chapter discusses the surgical anatomy of the pancreas and possible vascular variations for performing pancreatic surgery.

Ascending colon cancer coincident with mesenteric phlebosclerosis associated with the long-term oral intake of Chinese herb containing gardenia fruit: A case report and literature review

Mesenteric phlebosclerosis is a recently discovered rare ischemic colon disease. The relationship between mesenteric phlebosclerosis and the use of herbal medicine containing gardenia fruit was recently reported. Although the relationship between colon cancer and mesenteric phlebosclerosis has not been described, some cases of colorectal cancer coincident with mesenteric phlebosclerosis have been reported. We treated a 63-year-old female who was diagnosed with ascending colon cancer coincident with mesenteric phlebosclerosis. She had been taking a Chinese herb containing gardenia fruit for over 18xa0years. The ascending colon cancer was clinically diagnosed as T2, N0, and M0 according to Japanese classification of colorectal carcinoma and the mesenteric phlebosclerosis had spread from the cecum to the descending colon. She underwent laparoscopic subtotal colectomy with en bloc removal of the regional lymph nodes, and both the ascending colon cancer and mesenteric phlebosclerosis were completely resected. The microscopic findings show that the tumor was well-differentiated tubular adenocarcinoma invading the muscular propria with no regional lymph node metastasis, and the mesenteric phlebosclerosis lesion was characterized by marked fibrous thickening of the venous walls with calcification, marked transmural fibrosis and deposition of the collagen in the mucosa, accompanied by macrophages within the vessel walls. In literature review, 10 cases with colorectal cancer coincident with mesenteric phlebosclerosis were reported. 9 of 10 cases (90%) had cancer in the right-side colon affected by mesenteric phlebosclerosis, and 5 of 10 cases (50%) were associated with the use of a Chinese herb containing gardenia fruit. It was recently demonstrated that genipin, which is a metabolite bio-transformed from gardenia fruit, possesses carcinogenesis. We speculate that genipin may be associated with not only the development of mesenteric phlebosclerosis but also carcinogenesis in the right-side colon. In conclusion, our findings suggest that the safety of gardenia fruit should be re-evaluated, and gastroenterologists should be aware that gardenia fruit may be risk factor for not only the development of mesenteric phlebosclerosis but also carcinogenesis in the proximal colon.

Anal Carcinoma Surveillance Counterpoint: Japan

There is no evidence-based, established surveillance strategy for anal carcinoma. Neither the American Society of Clinical Oncology (ASCO) nor the European Society of Medical Oncology (ESMO) has so far established any guidelines for the follow-up after initial treatment. Characteristics of anal carcinoma, such as its rarity, diverse histological types, and the various treatment modalities, make it difficult to standardize the protocol.

Colon and Rectum Carcinoma Surveillance Counterpoint: Japan

The primary aim of surveillance after curative resection of colorectal cancer is to detect metastasis, local recurrence, or metachronous primary cancers at an early stage when curative reoperations are possible, leading to improvement of the prognosis. Recent meta-analyses show that more intensive postoperative surveillance results in a reduction of mortality and an improvement in the curative reoperation rate in comparison to minimal surveillance [1-6]. Furthermore, the early detection of recurrence of colorectal cancer also results in prolongation of life by chemotherapy and/or radiotherapy, even in patients with unresectable disease [7]. While several recommendations are now available from the American Society of Clinical Oncology (ASCO), the European Society for Medical Oncology (ESMO) and so on [8,9], the best strategy for the surveillance still remains controversial.

A Successfully Surgical Treated Case of a Duodenal Bleeding with Bleeding Shock after Chemotherapy in a Patient with Osteosarcoma, Occurring after a Cure of Malignant Lymphoma

悪性リンパ腫の治癒後に発生した骨肉腫に対する化学療法後の難治性穿通性十二指腸潰瘍底からの動脈性出血に対し, 空腸被覆を施行し救命しえた1例を経験したので報告する.症例は, 35歳の女性. 主訴は吐血. 既往として, 20年前より腹腔内悪性リンパ腫に対する頻回の腹部手術と放射線, 化学療法を施行されていた. 平成14年10月2日, 出血性ショックにて緊急手術を施行した. 出血は, 十二指腸球部後壁の潰瘍底からの動脈性出血であったため, 出血部位を結紮した後, 潰瘍で欠損した十二指腸球部前壁に空腸被覆, さらに食事の十二指腸への流入を防ぐためDavine変法にて胃空腸吻合を施行した.放射線, 化学療法後は, 本症例のように著明な腸管の浮腫および硬化が認められる. このような悪条件の中, 潰瘍で欠損した十二指腸部分の修復を閉鎖後, 十二指腸前壁にRoux-Yによる遠位空腸にて被覆する手術を施行したところ, 術後合併症なく, 良好な結果を得た. その手術手技を中心に若干の文献的考察を加え報告する.