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1 Abstract Original Articles PROBLEMS OF SURGICAL PROCEDURE FOR THE CANCER OF PANCREAS, ESPECIALLY SOME OF OUR CLINICAL STUDIES ABOUT PANCREATICO-DUODENECTOMY Akira WATANABE, Ichiro MATANO, Sanki WATANABE, Masayoshi KOBAYASHI, Osamu KABATA, Takashi MATSUMOTO, Junichi OGAWA, Hiromi NISHINO, Koichi TABAYASHI, Yoshitaka FUKUDA, Miki SHIBUSAWA, Atsushi MURAKAMI and Shingo SHIBAZAKI (Mito National Hospital, Ibaraki) Toyo NOGI (Oarai Seaside Hospital, Ibaraki) Yoichi OZEKI (Ibaraki National Insurance Hospital, Ibaraki) Forty-four cases of radical or palliative operations for the cancer of pancreas are collected andd analized during recent ten years period at the Mito National Hospital. We rather perform radical operation than palliative procedure, the various problems of pancreatico-duodenectomy but it is very difficult to overcome for the cancer of the head of the pancreas. 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. Abdominal exploration reveals the significant the diagnosis and determine resectability. stasis of portal vein and it is necessary to confirm 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. 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. 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. Next problem concerned reconstrution is how to prevent the leakage from the part of pancreaticojejunostomy caused auto-digestion by activated pancreas juics. We lost several cases owing to

2 peritonitis 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. 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. Over the 3 years survival rate of pancreatico-duodenectomy is very poor, because the radical operation may be impossible owing to difficult early diagnosis. So, if one expect radical operation, total pancreatectomy must be much better than pancreaticoduodenectomy, because of more radicality and safer surgical risk. Conclusion; 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 pancreaticoduodenectomy. 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. 3. We are planning to perform the total pancreatectomy more often in near future and further biophysiological investigation after total pancreatectomy. 4. Pre- and post-operative management are discussed. THE DIAGNOSTIC USE OF SERUM LDH-ISOENZYMES ACTIVITY IN PATIENTS WITH CARCINOMA OF THE LIVER Teruhiko MIZOGUCHI, Masato TOJYO, Tatsuo FUKUDA, Kiyoshi SATO, Toyohisa NAKAOSA, Eiichi MATSUSHIMA and Yoshiyuki IHARA (Osaka-Minami National Hospital, Osaka) The isoenzyme fraction activity was investigated in the serum of 12 patients, who were 5 primary carcinoms of the liver and 7 secondary metastatic (gastric origin) carcinoma of the liver. The serum of all patients with primary carcinoma were found to contain ƒ -feto-protein by the micro Ouchterlony's technique. On the other hand, the tissue isoenzyme patterns of LDH in liver, tumor and human fetus were studied. In the present investigation, cellulose acetate electrophoresis and elution techniques were used to test for LDH-isoenzyme activity. The average composition of the serum on 24 healthy students was found to be 23.9 }3.8 (SD), 27.1 }5.1, 20.3 }4.4, 13.3 }8, and 13.4 }3.4, % of the total activity present for LDH 1, 2, 3, 4, and LDH5 respectively. Mean values (%) of relative activity for LDH4_5, obtained in the present study, for each group of patients were serum in patients with primary carcinoma, 18.3 }2.4(SD), 31.1 }4.3, 19.9 }2.9, 11.3 }4.8 and 18.7 }3.2 and serum in patients with metastatic carcinoma, 14.5 }5.2 (SD), 31.4 }6.5,

3 Akira WATANABE Ichiro MATANO Sanki WATANABE Masayoshi KOBAYASHI Osamu KABATA Takashi Junichi Hiromi MATSUMOTO OGAWA NISHINO Koichi TABAYASHI Yoshitaka FUKUDA Miki SHIBUSAWA (Problems of Surgical Procedure for the Cancer of Pancreas, especially Some of our Clinical Studies about Pancreatico-Duodenectomy)

1) Glenn, F. & Thorbjarnarson, B.:Carcinoma of the Pancreas, Ann, Surg,, 159, 945, 1964 2) Halpert, B., Makk, L,

11 1) Glenn, F. & Thorbjarnarson, B.:Carcinoma of the Pancreas, Ann, Surg,, 159, 945, ) Halpert, B., Makk, L, & Jordan, Jr., G. L.: A retrospectiue study of 120 patients with carcinoma of the Pancreas, Surg, Gynec, Obstet,, 121, 91, ) Cattell, R. B. & Warren, K. W.:Surgery of the Pancreas, Saunders, Philadelphia, ) Loggan, P. B. & Kleisasser, L. J.:Surgery of the Pancreas:The results of Pancreaticoduodenal resection reported in the literature, Int. Abstr. Surg., 93, 521, 1951

12 7) Miller, E. M., Dockerty, M. B., Wollager, E. E. & Waugh, J. M.:Carcinoma in the region of the papilla of vater:a study of cases in which resection was performed, Surg, Gynec, Obslet., 92, 172, 1951 Jordau, G. L.:The Surgical management of carcinoma of the pnucreas and periampullary region, J. Louisiana Med. Soc., 112, 285, ) Monge, J. J., Dockerty, M. B., Wollaeger, E. E., Waugh, J. M, & Priestley, J. T.:Surg, Gynec, Obstet,, 118, 275, ) Monge, J. J. et al.: Clinicopathologic observations on radical pancreatoduodenal resection for peripapillary carcinoma, Surg, Gynec, Obstet,, 118, 275, ) Child, III C. G., Holswade, G. R., McClure, Jr., R. D., Gore, A. L. & O' Neill, E. A.: Pancreaticoduodenectomy with resection of the portal vein in the Macaca mulatta monkey and in man, Surg, Gynec, Obstet,, 94, 31, ) Asada, S., Itaya, H., Nakamura, K., Tsohashi, T. & Masuoka, S.:Radical pancreatoduodenectomy and portal vein resection. Report of two successful cases with transplantation of the portal vein, Arch. Surg,, 87, 609, ) Kikuchi, S.:A clinical and experimental study on the management of portal rein during pancreaticoduodenectomy, III. Clinical cases with operation on the portal vein during pancreaticoduodenectomy, Tohoku J. Exp. Med., 64, 143, ) Sigel, B., Bassett, J. G., Cooper. D. R. & Punn, M. R.:Resection of the mesenteric vein and replacement with a venous autograft during paucreaticoduodenectomy, Ann, Surg., 162, 941, 1965 Case report, 16) Whipple, A. O., Parson, W. B. & Mullins, C. R.:Treatment of carcinoma of the ampulla of Vater, Ann. Surg., 102, 763, ) Miller, J. R., Baggenstoss, A, H, & Comfort, M. W.:Carcinoma of the pancreas:effect of histological types and grade of malignancy its behavior, Cancer, 4, 283, ) Cattell, R. B., Warren, K. W. & Au, F. T. C.: Periampullary carcinoma:diagnosis and surgical management, Lahey Clin. Bull, 11, 66, ) Waugh, J. M. & Giberson, R. G.:Radical resection of the head of the pancreas on and of the duodenum for malignant lesions, Surg. Clin. N. America, 37, 965, 1957

日本消化器外科学会雑誌第23巻第2号

日本消化器外科学会雑誌第23巻第2号 Key words: carcinoma of the pancreatic head, carcinoma of the periampullary region, operative results of the pancreatic duodenal carcinoma, mode of tumor spread of the pancreatic duodenal carcinoma, factors