遠藤 和洋

BACKGROUND: Pancreatojejunostomy (PJ) is one of the most difficult and challenging abdominal surgical procedures. There are no appropriate training systems available outside the operating room (OR). We developed a structured program for teaching PJ outside the OR. We describe its development and results of a pilot study. METHODS: We have created this structured program to help surgical residents and fellows acquire both didactic knowledge and technical skills to perform PJ. A manual was created to provide general knowledge about PJ and the specific PJ procedure used in our institution. Based on questionnaires completed by trainers and trainees, the procedure for PJ was divided into twelve steps and described in detail. After creating the manual, we developed organ models, needles and a frame box for simulation training. Three residents (PGY3-5) and three fellows (PGY6 or above) participated in a pilot study. Objective and subjective evaluations were performed. RESULTS: Trainees learn about PJ by reading the procedure manual, acquiring both general and specific knowledge. We conducted simulation training outside the OR using the training materials created for this system. They simulate the procedure with surgical instruments as both primary and assistant surgeon. In this pilot study, as objective assessments, the fellow-group took less time to complete one anastomosis (36 min vs 48 min) and had higher scores in the objective structured assessment of technical skill (average score: 4.1 vs 2.0) compared to the resident-group. As a subjective assessment, the confidence to perform a PJ anastomosis increased after simulation training (from 1.6 to 2.6). Participants considered that this structured teaching program is useful. CONCLUSION: We developed a structured program for teaching PJ. By implementing this program, learning opportunities for surgical residents and fellows can be increased as a complement to training in the OR.

A 48-year-old man underwent skin grafting from the left inguinal region to the left forearm one month previously. He noticed abdominal discomfort after discharge and was admitted to another hospital because of progression of abdominal pain and a decreased level of consciousness. An enhanced CT scan revealed extensive portal venous thrombosis. Lower gastrointestinal bleeding developed the following day, and he was transferred to our hospital and diagnosed with superior mesenteric venous thrombosis. Enhanced CT showed no intestinal necrosis. Anticoagulant therapy was started and the thrombosis had almost resolved 40 days later. However, after starting oral intake, the patient developed vomiting. Small bowel radiographs and 3D-CT showed significant proximal intestinal stenosis. Small bowel resection was performed on the 59th day after transfer. The pathological diagnosis was ischemic enteritis with venous thrombosis. The patient was discharged 20 days after intestinal resection and he has had no recurrence of symptoms. In this case, 3D-CT was useful to determine the range of intestinal stenosis and the required area of resection.

Traumatic injury to the main pancreatic duct requires surgical treatment, but optimal management strategies have not been established. In patients with isolated pancreatic injury, the pancreatic parenchyma must be preserved to maintain long-term quality of life. We herein report a case of traumatic pancreatic injury with main pancreatic duct injury in the head of the pancreas. Two years later, the patient underwent a side-to-side anastomosis between the distal pancreatic duct and the jejunum. Eleven years later, he presented with abdominal pain and severe gastrointestinal bleeding from the Roux limb. Emergency surgery was performed with resection of the Roux limb along with central pancreatectomy. We attempted to preserve both portions of the remaining pancreas, including the injured pancreas head. We considered the pancreatic fluid outflow tract from the distal pancreatic head and performed primary reconstruction with a double pancreaticogastrostomy to avoid recurrent gastrointestinal bleeding. The double pancreaticogastrostomy allowed preservation of the injured pancreatic head considering the distal pancreatic fluid outflow from the pancreatic head and required no anastomoses to the small intestine.

＜文献概要＞早期慢性膵炎の概念は,早期治療介入により病状進行の抑制が期待できる点で重要である.早期慢性膵炎の診断基準は「慢性膵炎臨床診断基準2009」で初めて定義された.その後,2011年に行われた慢性膵炎全国調査,早期慢性膵炎の前方視的コホート・スタディなどの知見の集積を受け,2019年に慢性膵炎臨床診断基準が改訂され,早期慢性膵炎の診断基準も改訂された.2019年の早期慢性膵炎診断基準では,「急性膵炎の既往」が項目として追加されたこと,アルコール摂取量の基準が1日60g(純エタノール換算)に低減されたこと,などがおもな改訂点である.今後のさらなる知見の集積により,未だ不明な点が多い慢性膵炎の病態の理解が進むことを期待したい.

＜文献概要＞早期慢性膵炎の概念は,早期治療介入により病状進行の抑制が期待できる点で重要である.早期慢性膵炎の診断基準は「慢性膵炎臨床診断基準2009」で初めて定義された.その後,2011年に行われた慢性膵炎全国調査,早期慢性膵炎の前方視的コホート・スタディなどの知見の集積を受け,2019年に慢性膵炎臨床診断基準が改訂され,早期慢性膵炎の診断基準も改訂された.2019年の早期慢性膵炎診断基準では,「急性膵炎の既往」が項目として追加されたこと,アルコール摂取量の基準が1日60g(純エタノール換算)に低減されたこと,などがおもな改訂点である.今後のさらなる知見の集積により,未だ不明な点が多い慢性膵炎の病態の理解が進むことを期待したい.

症例は66歳男性で、下血、血圧低下により当院に緊急搬送された。上部消化管内視鏡検査では、十二指腸球部は変形し、前壁と思われる部位に露出血管を伴う潰瘍を認めた。クリップによる止血を試みたが、3本目をかけたところで噴出性に出血し、内視鏡的止血は困難と判断しIVRに移行した。血管造影検査では、固有肝動脈側壁の近傍に内視鏡クリップを認め、十二指腸内に出血していた。大量輸血後もショック状態が持続していたため固有肝動脈塞栓を行ったが、塞栓後もクリップ近傍から緩徐に出血を認め、止血目的に緊急手術を施行した。総肝動脈および胃十二指腸動脈を露出し、潰瘍穿通部の固有肝動脈へ流入する総肝動脈・胃十二指腸動脈および肝門側の固有肝動脈を切離せずに二重結紮で血流を遮断した。十二指腸開放部は1層に縫合閉鎖し、さらに大網を縫着した。ウィンスロー孔にドレーンを留置し、閉腹し手術を終了した。術後10日目、発熱と上腹部痛が出現し、CTでは肝左葉に低吸収域と横隔膜経由と考えられる側副血行路を認めた。肝膿瘍の診断で緊急開腹ドレナージを行い、膿瘍部にドレーンを留置した。ドレナージ後は速やかに解熱し腹痛も消失した。術後51日目、ドレーンを抜去し退院したが、10日後に高熱と肝膿瘍ドレナージ創から胆汁様滲出液が出現し、減圧目的に胆管ステントを留置した。術後1年5ヵ月、ERCPで胆管狭窄が改善していることを確認し、胆管ステントを抜去した。半年後のCTでは肝膿瘍や胆管狭窄は認めなかった。