膵臓癌外科的治療上の問題点とその対策

Forty-four cases of radical or palliative operations for the cancer of pancreas are collected and analized during recent ten years period at the Mito National Hospital.<br>We rather perform radical operation than palliative procedure, but it is very difficult to overcome the various problems of pancreatico-duodenectomy for the cancer of the head of the pancreas.<br>Courvoisier's sign and severe jaundice are always seen in the case of cancer of the head of the pancreas, because of obstruction of common bile duct by neoplasm.<br>Abdominal exploration reveals the significant stasis of portal vein and it is necessary to;confirm the diagnosis and determine resectability.<br>These portal vein stasis and severe jaundice cause hemorrhagic tendency and huge bleeding prevents the progress of operative dissection and the fare of portal vein replacement discourage the operator to carry out the pancreatico-duodenectomy. These are the reason why the resection rate of this operation is very poor such as 20% or so. The first trial to improve the poor resectability is to decompress the portal vein initially.<br>This procedure has the remarkable advantage to perform the pancreatico-duodenectomy. One is clear to determine the resectability because of complete separation of portal vein, another is to realize the remarkable decrease of bleeding by portal decompression. That is why our rate of resection become very high such as 826 in these 4 years.<br>In all of 28 cases except one, cancer invasion directly to the portal vein wall is not observed. This means most of the cases may be able to resect the head of the pancreas without portal veinn replacement.<br>Next problem concerned reconstrution is how to prevent the leakage from the part of pancreatico-jejunostomy caused auto-digestion by activated pancreas juics. We lost several cases owing to eritonitis from this anastomosis. Results of our clinical studies, the most important factor to prevent the leakage from this part, are to put the external drainage into the main pancreas duct as shown in atlas. After these procedure, leakage is not seen in all cases.<br>The third problem is concerned about the total pancreatectomy. Our experience is 3 cases. 2 cases died, another is alive more than one and a half year. He is controlled well by insulin and pancreatin. And his social work is active more than one year. That is why we prefere to recommend the total pancreatectomy.<br>Over the 3 years survival rate of pancreatico-duodenectomy is very poor, because the radical operation may be impossible owing to difficult early diagnosis.<br>So, if one expect radical operation, total pancreatectomy must be much better than pancreatico-duodenectomy, because of more radicality and safer surgical risk.<br>Conclusion;<br>1. It is recommended to separate the portal vein at first stage of operation to confirm resectability and to reduce portal vein stasis which is inhibiting factor to perform pancreatico-duodenectomy.<br>2. It is the most important factor to prevent the leakage from the pancreatico-jejunostomy to put the complete external drainage of pancreas juice by canulation into the main pancreas duct.<br>3. We are planning to perform the total pancreatectomy more often in near future and further biophysiological investigation after total pancreatectomy.<br>4. Pre- and post-operative management are discussed.