笹沼 英紀

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.

膵癌においては外科治療が治癒の期待できる唯一の治療法であるが,手術侵襲についても十分に考慮されるべきである.2000年代以降,膵癌に対する化学療法・放射線治療の治療成績が目覚ましく向上する中で,集学的治療の一環として拡大手術の最新のエビデンスと位置づけを理解することは重要である.PV/SMV合併切除は比較的安全に施行可能で,R0切除になる場合に考慮される術式であり,術後治療が行えた場合は良好な予後が期待できる.動脈合併切除の意義は乏しいが,長期生存の報告もある.腹腔動脈合併切除を伴う尾側膵切除は合併症率が高く,症例・施設を厳選して行われるべきである.拡大リンパ節郭清の意義は否定されたが,至適リンパ節郭清範囲は未だ定まっていない.(著者抄録)

BACKGROUND: Familial adenomatous polyposis (FAP) is characterized by the presence of hundreds to thousands of colonic polyps, and extracolonic manifestations are likely to occur. Pancreatic tumors are rare extracolonic manifestations in patients with FAP, among which solid-pseudopapillary neoplasm (SPN) are extremely rare. We report here a patient with an SPN of the pancreas found during the follow-up of FAP. CASE PRESENTATION: A 20-year-old woman was diagnosed with FAP 3 years previously by colonoscopy which revealed less than 100 colonic polyps within the entire colon. She complained of left upper abdominal pain and a 10-cm solid and cystic pancreatic tumor was found by computed tomography scan. Solid and cystic components within the tumor were seen on abdominal magnetic resonance imaging. Simultaneous laparoscopic resection of the distal pancreas and subtotal colectomy was performed. Histopathological findings confirmed the pancreatic tumor as an SPN without malignancy. Abnormal staining of beta-catenin was observed by immunohistochemical study. Multiple polyps in the colorectum were not malignant. Molecular biological analysis from peripheral blood samples revealed a decrease in the copy number of the promoter 1A and 1B region of the APC gene, which resulted in decreased expression of the APC gene. CONCLUSIONS: A rare association of SPN with FAP is reported. The genetic background with relation to beta-catenin abnormalities is interesting to consider tumor development. So far, there are few reports of SPN in a patient with FAP. Both lesions were treated simultaneously by laparoscopic 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.

BACKGROUND: Capicua transcriptional repressor (CIC) -rearranged sarcoma is characterized by small round cells, histologically similar to Ewing sarcoma. However, CIC-rearranged sarcoma has different clinical, histological, and immunohistochemical features from Ewing sarcoma. It is important to differentiate between these tumors. CASE PRESENTATION: The patient is a 44-year-old man with a duodenal tumor diagnosed in another hospital who presented with a history of melena. Laboratory studies showed anemia with a serum hemoglobin of 6.0 g/dL. He was hospitalized and gastrointestinal bleeding was controlled successfully with endoscopy. However, he suffered from appetite loss and vomiting and progression of anemia a few weeks after presentation. Upper gastrointestinal endoscopy showed a circumferential soft tumor in the second portion of the duodenum and the endoscope could not pass distally. Computed tomography scan showed a greater than 10 cm tumor in the duodenum, with compression of the inferior vena cava and infiltrating the ascending colon. A definitive pathologic diagnosis could not be established despite four biopsies from the tumor edge. Due to gastrointestinal obstruction and progression of anemia, a pylorus-preserving pancreaticoduodenectomy with partial resection of the inferior vena cava and right hemicolectomy was performed as a complete tumor resection. The tumor was diagnosed as a CIC-rearranged sarcoma, but 2 months postoperatively local recurrence and distant metastases to the liver and lung were found. The patient died 3 months after surgery. CONCLUSIONS: Although the only definitive treatment for CIC-rearranged sarcoma is surgical resection, the CIC-rearranged sarcoma is highly malignant with a poor prognosis even after radical resection. More research is needed to establish optimal treatment strategies.

BACKGROUND: Thymomas are typically slow-growing tumors and AB type thymomas are considered no/low risk tumors with a better prognosis. Extra-thoracic metastases are extremely rare. To the best of our knowledge, no patient with an isolated splenic metastasis from a thymoma has been reported. We report a patient who underwent laparoscopic splenectomy for a slow-growing, isolated splenic metastasis, eight years after thymectomy. CASE PRESENTATION: The patient is a 78-year-old man. Eight years previously, the patient underwent extended thymectomy and postoperative radiation therapy for a thymoma. Five years after thymectomy, a nodule appeared in the spleen, and the lesion enlarged gradually for three years thereafter. The patient was referred for further examination and treatment. Computed tomography scan showed a sharply circumscribed 50 mm tumor slightly hypodense and heterogeneous lesion in the spleen. On T2-weighted images on Magnetic Resonance Imaging, the tumor had high intensity, equivalent to or slightly lower than that on T1-weighted images, and no decrease on diffusion-weighted images. The tumor was multinodular and showed a low-signal spoke-wheel sign in the margin, enhanced gradually in the dynamic study. Positron emission tomography-CT scan, showed relatively low accumulation. Surgical resection was undertaken, and pathological examination showed metastatic thymoma. The patient is without recurrence and has no other symptoms three years after splenectomy. CONCLUSIONS: This is the first report of an isolated splenic metastasis from a thymoma. Further cases are needed to standardize this surgery for such lesions.

症例は70歳の男性で，塵肺（エリスロマイシン内服），慢性腎不全（血液透析中），ANCA関連血管炎（プレドニゾロン内服）の併存症があり，定期CT検査で肝腫瘤を認め当院を紹介受診した．CTで肝S3に単純で低吸収，動脈相で濃染，門脈相でwash outされる腫瘤を認めた．MRIではT1低信号・T2高信号，diffusionで拡散低下，肝細胞相でdefectを認め，エコーではhaloや後方エコーの増強を伴っていた．画像所見から肝細胞癌と術前診断し，腹腔鏡下肝S3部分切除術を施行した．腫瘍は大きさ40×37×33mmの被膜を有する壊死組織で，viableな細胞は認めなかった．中心壊死・硝子化線維性組織・弾性線維を特徴とする肝孤立性壊死性結節を鑑別としたが被膜に弾性線維がなく，肝細胞癌完全自然壊死を最終診断とした．自然壊死の機序として透析による血流障害，エリスロシンやステロイドの薬剤関与が考えられた．

症例1は30歳男性で、発熱と左腹部痛で来院した。CTで感染性Walled-off necrosis(WON)と診断し、保存的治療を行ったが、症状ならびに炎症所見の改善を認めず、インターベンション治療目的に当院転院となった。造影CT所見から壊死物質を主成分とした感染性WONと診断し、小切開Videoscope補助下に後腹膜経路でネクロセクトミーを行った。1回のネクロセクトミーで炎症所見とCT所見は速やかに改善し、追加の処置は不要となった。左後腹膜のドレーンは留置したまま入院40日目に退院した。症例2は34歳男性で、急性膵炎の診断で保存的治療が開始され、退院約2週間後に間歇的腹痛と発熱で来院し、炎症反応高値、CTで感染性WONと診断され再入院した。造影CT所見から膵体尾部の壊死物質を主成分とする左側感染性WONと診断し、腹腔経路で小切開Videoscope補助下にネクロセクトミーを行った。その後、右側WON増大による閉塞性黄疸が出現し、開腹ネクロセクトミーと胆道ドレナージが必要となった。症状出現から7ヵ月後、ERCPで左右肝管にERBD tubeを留置し退院した。