遠藤 和洋

アルコール摂取(多飲)は急性膵炎、慢性膵炎の成因として最も頻度が高い。他の成因と異なり、アルコール性膵炎は断酒・禁煙で発症・進展の予防が可能で、生活指導が重要な疾患である。その一方で「アルコール性」を規定するエタノール摂取量の明確な基準はなく、その発症・進展の機序についても不明な点が多い。慢性膵炎臨床診断基準2009では慢性膵炎をアルコール性と非アルコール性に分類し、発症前、発症早期に治療介入ができるように慢性膵炎疑診、早期慢性膵炎の診断基準を設定した。急性膵炎でも高リスク群であるアルコール多飲者の実際の発症率は低率で、遺伝子異常(SPINK1、PRSS1など)など、他の要因が深く関与していることが想定されている。アルコール性急性膵炎、慢性膵炎の診断・治療は、他の成因によるものと大きく変わるところはなく、介入治療は改訂アトランタ分類2012による膵炎局所合併症の新分類に応じた適切な時期・手技で行うことが推奨される。(著者抄録)

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.

胆道手術におけるドレーン挿入の功罪を臨床試験の結果から検討した.膿瘍・穿孔などの合併症がない胆嚢摘出術では,開腹・腹腔鏡下ともにドレーンの挿入は創感染,呼吸器感染といった術後の合併症を増やし,それに見合う利点がないとされる.胆道切開や胆管切除・吻合でも同様に,ドレーンの利点が乏しいという結果が得られている.ルーチンワークとして行われがちなドレーンの挿入であるが,evidence-based medicine(EBM)に基づき再考すべきである.(著者抄録)

BACKGROUND: The goal of this study is to examine changes in pancreatic perfusion due to pneumoperitoneum using perfusion CT in vivo. METHODS: Three pigs were studied. Under general anesthesia, pneumoperitoneum was induced to 16 mm Hg. Perfusion CT scans were acquired at a rate of 1 image per 2 seconds for 60 seconds. Scans were repeated 5 days later without pneumoperitoneum using the same protocol, in the same animals. The time density curve, color map, peak enhancement, time to peak, blood flow, blood volume, and permeability were evaluated. RESULTS: In the presence of pneumoperitoneum, peak enhancement in radiodensity was decreased and time to peak was increased, and both blood flow and blood volume decreased. However, there was no consistent change in permeability observed. CONCLUSION: This study demonstrates that pneumoperitoneum quantitatively results in decreased blood flow and blood volume to the pancreas in an in vivo animal model.

Rational treatment for neoplasms of the duodenal papilla (NDPs) is still controversial, especially for early stage lesions. Total papillectomies are indicated in patients expected to have adenomas, adenocarcinoma in an adenoma, or mucosal adenocarcinomas with no lymph node metastases. However, the preoperative pathological evaluation of NDPs is still challenging and often inaccurate, mainly because of the complicated anatomical structures involved and the possibility of an adenocarcinoma in an adenoma. Herein, we introduce a new method of total papillectomy, the extraduodenal papillectomy (ExDP). In this method, papillectomy is undertaken from outside of the duodenum, instead of resection from the inside through a wide incision of the duodenal wall as is done in conventional transduodenal papillectomy (TDP). The advantages of ExDP are precise and deeper cutting of the sphincter and shorter exploration time of the tumor compared to conventional TDP. We demonstrate three representative patients, all of whom had an uneventful postoperative course. One of them subsequently underwent a pylorus preserving pancreatoduodenectomy after detailed postoperative pathological evaluation. Including that patient, no recurrence has occurred with 37-46 months of follow-up. In conclusion, ExDP is regarded as a "total biopsy" for early stage borderline lesions and a feasible, less demanding alternative method for the treatment of NDPs.

肝内結石症の画像診断は、肝内胆管に結石が確実に存在するという存在診断と、肝内胆管全枝における結石の有無を見極める部位診断から成る。肝内結石症例の多くは胆管炎、肝内胆管癌の併存のため、正確な部位診断が困難である。厚生労働省難治性肝・胆道疾患に関する調査研究班により作成された「肝内結石症の診療ガイド」の肝内結石診断フローチャートでは、画像診断法をスクリーニングで肝内結石症の存在診断を行う1次検査法、詳細な部位診断、肝内胆管癌の有無、手術適応を判断する非侵襲的な2次検査法、治療を前提とした侵襲的3次検査法に分類している。今後肝内結石症に合併する肝内胆管癌の予後を改善するためにも、従来の超音波検査、CT、MRC(MRI)、ERC、PTCだけではなくFDG-PET、diffusion MRI、perfusion CTなど新たなmodalityを含む画像診断能の向上が望まれる。(著者抄録)