GREAT HONOR GREAT HONOR For me For me Friendships Renew ... · Friendships Renew many Communication Japan - Germany GREAT HONOR GREAT HONOR For me For me ... Fusion Fascia of Treitz(An
Post on 03-Feb-2020
4 Views
Preview:
Transcript
First Department of Surgery Yamagata University School of Medicine
Friendships Renew many Friendships Renew many
Communication Japan - GermanyCommunication Japan - Germany
GREAT HONOR For meGREAT HONOR For me
Falk symposium to advance interactions Falk symposium to advance interactions in Dresden, 11October 2007in Dresden, 11October 2007
WataruWataru KimuraKimura
First Department of Surgery Yamagata University School of Medicine5th Joint Meeting of the German and Japanese Surgical Societies 17-19 June, 2002: Berlin, Germany
DDW, 1991:New Oleans
First Department of Surgery Yamagata University School of Medicine
Location of YAMAGATALocation of YAMAGATA
Yamagata is situated about 300 km north of Tokyo. Yamagata is situated about 300 km north of Tokyo. You can reach Yamagata in about 3 hours You can reach Yamagata in about 3 hours
by the Yamagataby the Yamagata--shinkansenshinkansen..Inhabitance of Yamagata city is about 260,000.Inhabitance of Yamagata city is about 260,000.
First Department of Surgery Yamagata University School of Medicine
QuickTimeý Dzé ê^ - JPEG êLí£ÉvÉçÉOÉâÉÄ
ǙDZÇÃÉsÉNÉ`ÉÉǾå©ÇÈÇ…ÇÕïKóvÇ-Ç�ÅB
QuickTimeý Dzé ê^ - JPEG êLí£ÉvÉçÉOÉâÉÄ
ǙDZÇÃÉsÉNÉ`ÉÉǾå©ÇÈÇ…ÇÕïKóvÇ-Ç�ÅB
QuickTimeý Dzé ê^ - JPEG êLí£ÉvÉçÉOÉâÉÄ
ǙDZÇÃÉsÉNÉ`ÉÉǾå©ÇÈÇ…ÇÕïKóvÇ-Ç�ÅB
QuickTimeý Dzé ê^ - JPEG êLí£ÉvÉçÉOÉâÉÄ
ǙDZÇÃÉsÉNÉ`ÉÉǾå©ÇÈÇ…ÇÕïKóvÇ-Ç�ÅB
The YAMAGATA University School of Medicine
and Yamagata Univ.
Hospital
The YAMAGATA University School of Medicine
and Yamagata Univ.
Hospital
Yamagata University school of medicine and university hospital is surrounded by mountains in a very natural setting.We have about 600 of beds.
First Department of Surgery Yamagata University School of Medicine
Professor & ChairmanProfessor & ChairmanYamagata University School of MedicineYamagata University School of Medicine
WATARU KIMURAWATARU KIMURA
Falk symposium to advance interactions Falk symposium to advance interactions in Dresden, 11October 2007in Dresden, 11October 2007
Recent AdvancesRecent Advancesin Diagnosis and Treatment of in Diagnosis and Treatment of
BiliaryBiliary Neoplasm Neoplasm
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
Japanese experience 1988Japanese experience 1988--19941994((JpnJpn BiliaryBiliary Assoc)Assoc)
ExtrahepaticExtrahepatic biliarybiliary tract carcinoma: tract carcinoma: 73807380 casescases
Ca. of the papilla of Ca. of the papilla of VaterVater: : 939939 casescasesExtrahepaticExtrahepatic bile duct ca.: bile duct ca.: 3294 3294 casescasesGallbladder carcinoma: Gallbladder carcinoma: 3147 3147 casescases
939 / 7380 = 12.7 %939 / 7380 = 12.7 %
First Department of Surgery Yamagata University School of Medicine
11 22 33 44 55
100100
5050
(%)(%)
86%86%
69%69%59%59% 54%54% 51%51%48%48%
28%28%16%16%39%39%
4%4%
resection (n=857)resection (n=857)palliative operation (n=43)palliative operation (n=43)prove laparotomy (n=5)prove laparotomy (n=5)not operated (n=34)not operated (n=34)
Fig.1
First Department of Surgery Yamagata University School of Medicine
AA
BB
The common channelThe common channel
The common bile ductThe common bile duct
The pancreatic ductThe pancreatic duct
Fig.3
First Department of Surgery Yamagata University School of Medicine
Table 1. Incidence of atypical epithelium in the Table 1. Incidence of atypical epithelium in the sites of the papilla of sites of the papilla of VaterVater (from reference 1)(from reference 1)
SitesSitesTotal no. Total no. of casesof cases
% of cases by groups% of cases by groups11 22 33 44 55
Common channelCommon channel
Bile ductBile duct
Pancreatic ductPancreatic duct
Duodenal epitheliumDuodenal epithelium
451451
531531
531531
481481
7171
8383
9393
9797
2525
1515
66
33
2.92.9
1.71.7
0.60.6
0.40.4
0.90.9
0.60.6
0.40.4
0.20.2
0.20.2
0.20.2
0.20.2
00
Kimura W, et al. Cancer 1988Kimura W, et al. Cancer 1988
First Department of Surgery Yamagata University School of Medicine
Carcinoma of the Papilla of Vater of the Intestinal Type Carcinoma of the Papilla of Vater of the Intestinal Type
First Department of Surgery Yamagata University School of Medicine
Carcinoma of the Papilla of Vater of the Pancreaticobiliary TypeCarcinoma of the Papilla of Vater of the Pancreaticobiliary Type
First Department of Surgery Yamagata University School of Medicine
PERCENT SURVIVALPERCENT SURVIVAL
100100
9090808070706060505040403030
20201010
0020002000 40004000 60006000 DAYSDAYS
INTENSTINAL TYPEINTENSTINAL TYPE
PANCREATICOBILIARY TYPEPANCREATICOBILIARY TYPE
Kimura W, Jpn J Cancer Res 1994Kimura W, Jpn J Cancer Res 1994
Fig.13
First Department of Surgery Yamagata University School of Medicine
EUSEUS
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
Kimura W, et al. Incidence, sites of origin, and immunohistochemicaland histochemicalcharacteristics of atypical epithelium and minute carcinoma of the papilla of Vater. Cancer 61: Cancer 61: 13941394--1402,1402,19881988
First Department of Surgery Yamagata University School of Medicine
19951995
In TokyoIn Tokyo
First Department of Surgery Yamagata University School of Medicine
20012001In WittenbergIn Wittenberg
First Department of Surgery Yamagata University School of Medicine
Kimura W, JHBPS 2000Kimura W, JHBPS 2000
Fusion Fascia of Fusion Fascia of TreitzTreitz (An Autopsy Case)(An Autopsy Case)
First Department of Surgery Yamagata University School of Medicine
PVPV CBDCBD
DUDU
PLPLRPRP
SMASMA
Fusion Fascia of Fusion Fascia of TreitzTreitzKimura WKimura W..JpmJJpmJ PancPanc Soc 19: 463Soc 19: 463--9,20049,2004
First Department of Surgery Yamagata University School of Medicine
PANCREASDUODENUM
SMV SMA
FUSIONFASCIA
RP RPOR
PL
PL
First Department of Surgery Yamagata University School of Medicine
PANCREASDUODENUM
SMV SMA
FUSIONFASCIA
RP RPOR
PL
PL
Kimura WKimura W J J JpnJpn PancPanc Soc 19: 463Soc 19: 463--9, 20049, 2004
First Department of Surgery Yamagata University School of Medicine
QuickTimeý DzTIFFÅiLZWÅj êLí£ÉvÉçÉOÉâÉÄ
ǙDZÇÃÉsÉNÉ`ÉÉǾå©ÇÈǞǽDžÇÕïKóvÇ-Ç�ÅB
Du
Du
PLce
GDACBD
Ph
PLphⅡphⅠ
Ph(断端)CHA
fusion fascia
SMA
Nerve Plexuses in the back of the pancreatic head
First Department of Surgery Yamagata University School of Medicine
SMVSMV
SMASMA
**
**
**
**
First Department of Surgery Yamagata University School of Medicine
PANCREASDUODENUM
SMVSMA
FUSIONFASCIA
Kimura WKimura W J J JpnJpn PancPanc Soc 19: 463Soc 19: 463--9, 20049, 2004
First Department of Surgery Yamagata University School of Medicine
LEFT PART OFNEURAL PLEXUSOF THE SMA
PVPV
SMVSMV
SMASMA
LIVERLIVER
IVCIVC
SMVSMV
SMASMA
Kimura WKimura W J J JpnJpn PancPanc Soc 19: 463Soc 19: 463--9, 20049, 2004
First Department of Surgery Yamagata University School of Medicine
Suggestions for surgical resection Suggestions for surgical resection of of extrapancreaticextrapancreatic nerve plexus nerve plexus during a Whipple procedure. during a Whipple procedure.
2. The entire cut end of the nerve plexus should be 2. The entire cut end of the nerve plexus should be investigated during the operation using frozen investigated during the operation using frozen specimens and confirmed to be negative for cancer. specimens and confirmed to be negative for cancer. If the cut end is positive for cancer, additional If the cut end is positive for cancer, additional resection of the nerve plexus should be performed resection of the nerve plexus should be performed to achieve curative resection. to achieve curative resection.
First Department of Surgery Yamagata University School of Medicine
Suggestions for surgical resection Suggestions for surgical resection of of extrapancreaticextrapancreatic nerve plexus nerve plexus during a Whipple procedure. during a Whipple procedure.
2. (continued)2. (continued)Because, it is impossible to completely Because, it is impossible to completely investigate positive or negative carcinoma in investigate positive or negative carcinoma in the cut end of the nerve plexus the cut end of the nerve plexus after surgery, after surgery, since the cut end is long and some specimens since the cut end is long and some specimens are deformed by formalin fixation; are deformed by formalin fixation; thus, it is difficult to identify the true surgical thus, it is difficult to identify the true surgical cut end. cut end.
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
1. Pancreaticojejunostomy2. Choledocojejunostomy
3. Gastrojejunostomy
4. Braun’s anastomosis
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
Lost stent
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
00-2.64.3114KimuraKimura
4.814.4 6.4 8.0 1252004Behman (16)
0--27.7 472004Okabayashi(15)
1.62.0 3.2 3.2 6172003Buchler (14)
4.92.5 7.4 9.9 811998Petrazzoli(13)
1.45.0 -14.0 6501997Yeo (12)
3.10.7 1.48.8 2851988Trede (11)
OperaOpera--tive tive deathdeath
IntraIntra--abdominal abdominal abscessabscess
IntraIntra--abdominal abdominal bleedingbleeding
PanPan--creatic creatic fistulafistula
No. of No. of casescasesYearYearAuthorsAuthors
2007
First Department of Surgery Yamagata University School of Medicine
20032003
In In NurnbergNurnberg
German GastroGerman Gastro--enterological enterological CongressCongress
First Department of Surgery Yamagata University School of Medicine
1010
2020
3030
∫∫00 55 1010 1515 2020 2525 3030 3535 4040 4545 5050 5555 6060 6565 7070 7575 8080 8585 9090
44∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫ ∫∫99 1414 1919 2424 2929 3434 3939 4444 4949 5454 5959 6464 6969 7474 7979 8484 8989 9494
(%)(%)
FemaleFemale((553553//22452245))MaleMale((404404//22372237))
ageage
Incidence of Gallbladder StonesIncidence of Gallbladder Stonesfound in 4482 Autopsy Cases by Agefound in 4482 Autopsy Cases by Age
Kimura W, et al. Am J Gastroenterology 1989Kimura W, et al. Am J Gastroenterology 1989
First Department of Surgery Yamagata University School of Medicine
Relationship between Gallbladder Carcinoma (Relationship between Gallbladder Carcinoma (GBcaGBca) and ) and Gallbladder StonesGallbladder Stones((GBstonesGBstones))in Both Males and Females*in Both Males and Females*
* Gallbladder carcinoma occurred more often in patients * Gallbladder carcinoma occurred more often in patients with gallbladder stones than in those without stones, with gallbladder stones than in those without stones, and more often in females than in males.and more often in females than in males.
GBcaGBca//GBstonesGBstones(+)(+)No.No. %%
MaleMale
FemaleFemale
TotalTotal
GBcaGBca//GBstonesGBstones(-)(-)No.No. %%
14/40414/404 3.53.5
43/55343/553 7.87.857/95757/957 6.06.0
11/183311/1833 0.60.6
26/169226/1692 1.51.5
37/352537/3525 1.01.0
Kimura W, et al. Am J Gastroenterology 1989Kimura W, et al. Am J Gastroenterology 1989
First Department of Surgery Yamagata University School of MedicineDr. Frank Meyer in my house, TokyoDr. Frank Meyer in my house, Tokyo
May 2005May 2005
RieRieKeyKey
First Department of Surgery Yamagata University School of Medicine
ClinicopathologicalClinicopathological Features and Features and Therapeutic Strategies forTherapeutic Strategies forHepatic bile Duct CarcinomaHepatic bile Duct Carcinoma
First Department of Surgery Yamagata University School of Medicine
ERCPlt.
rt.biopsy 4個
B8
B5
B6/7
10mm
MRCPMRCPEERCPRCP
AngiographyAngiography
First Department of Surgery Yamagata University School of Medicine
Extension of the Bile Duct CarcinomaExtension of the Bile Duct Carcinoma
First Department of Surgery Yamagata University School of Medicine
Percutaneous Transhepatic Portal Embolization (PTPE)
PercutaneousPercutaneous TranshepaticTranshepatic Portal Portal EmbolizationEmbolization (PTPE)(PTPE)
05 Dec. 2000 26 Dec. 2000
21 Dec. 2000
26%26%
23%23%
17%17%
48%48%
First Department of Surgery Yamagata University School of Medicine
1.591.594 Weeks4 Weeks6868MetaMetaElias et al.Elias et al.
1.421.424 Weeks4 Weeks3030MetaMetaAzoulayAzoulay et al.et al.
1.421.4244--8 Weeks8 WeeksNormal LiverNormal Liver2828HCC, MetaHCC, MetaFargesFarges et al.et al.
1.411.4144--6 Weeks6 Weeks3131HCC, Meta, HilarHCC, Meta, HilarHemming et al.Hemming et al.EuropeEurope
1.341.342 Weeks2 WeeksNormal LiverNormal Liver4343HCC, MetaHCC, MetaWakabayashi et al.Wakabayashi et al.
1.211.213 Weeks3 Weeks1818MetaMetaKokudoKokudo et al.et al.
1.361.3622--3 Weeks3 WeeksDiseased Diseased LiverLiver6666HCCHCCSugawara et al.Sugawara et al.
1.311.312 Weeks2 Weeks8484HCC, Meta, HilarHCC, Meta, HilarImamura et al.Imamura et al.1.241.242 Weeks2 WeeksJaundiceJaundice1212HilarHilarKawasaki et al.Kawasaki et al.
JapanJapan
Hypertrophy Hypertrophy RateRate
PVEPVE--EvaluationEvaluation
Background Background LiverLivernnDiseaseDiseaseAuthorAuthor
Hypertrophy Rate after PVEHypertrophy Rate after PVE
First Department of Surgery Yamagata University School of Medicine
Atro
phy
RegenerationResection
Extended Right HepaticExtended Right HepaticResection with Caudate LobeResection with Caudate Lobe
RegenerationRegeneration
First Department of Surgery Yamagata University School of Medicine
Taping of the hepatic arteriesTaping of the hepatic arteries
First Department of Surgery Yamagata University School of Medicine
Liver Resection with Liver Resection with BelgithiBelgithi’’ss MethodMethod
First Department of Surgery Yamagata University School of Medicine
Distribution of hepatic veins, in a dorsal view Distribution of hepatic veins, in a dorsal view after opening the dorsal wall of the inferior venaafter opening the dorsal wall of the inferior vena
cava (IVC)cava (IVC)((n=176n=176))
IRHV exists in the right and caudal side of IVC, in 59% IRHV exists in the right and caudal side of IVC, in 59% ((104/176104/176))Hirai I, Hirai I, KimuraWKimuraW. Clinical Anatomy 2003. Clinical Anatomy 2003
First Department of Surgery Yamagata University School of Medicine
The rightward course seemed to be bestThe rightward course seemed to be best
Hirai I, Kimura W. Hirai I, Kimura W. ClinClin Anatomy 2003Anatomy 2003
IRHVIRHVIRHVIRHV
MHVMHV RHVRHV
RHVRHV
Caudate Caudate veinvein
Caudate Caudate veinvein
First Department of Surgery Yamagata University School of Medicine
Anatomical location of the IVC ligamentAnatomical location of the IVC ligament
Lateral sector Right liver
Spiegel
Hirai I, Kimura W, Murakami GHirai I, Kimura W, Murakami GHepatoHepato--Gastroenterology 2003Gastroenterology 2003
First Department of Surgery Yamagata University School of Medicine
Right IVC ligament Left IVC ligament
RHV LHVSpiegel
Right liver Lateral sector
Thickness of the ligament
Size of the IVC ligament
2.5mm 0.8mm
37mm39mm
First Department of Surgery Yamagata University School of Medicine
15cm
20cm
60cm
TreitzLigasment
B2,3,4 ReconstructionReconstruction
First Department of Surgery Yamagata University School of Medicine
0102030405060708090
100
0 20 40 60 80 100 120 140
生存期間
生存率
(切除症例61例)剥離面(em)と予後
40.7%
27.2%
em陰性
em陽性
非切除
(%)
(M)
n=49
n=56
n=5
p<0.001
NS
JpnJpn HPBA SurgeryHPBA Surgery::20032003
R1: 5 cases: n=5R1: 5 cases: n=5
R0 : n=56 R0 : n=56
Not operated: n=49Not operated: n=49
Postoperative Course of Hepatic Postoperative Course of Hepatic Bile Duct CarcinomaBile Duct Carcinoma
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
Thank you very muchThank you very much
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
First Department of Surgery Yamagata University School of Medicine
図3.内視鏡所見
図図33. . 内視鏡的内視鏡的所見所見
First Department of Surgery Yamagata University School of Medicine
図5.術中乳頭部所見
図図55. . 術中乳頭部術中乳頭部所見所見
First Department of Surgery Yamagata University School of Medicine
図図66. . 乳頭部の切除乳頭部の切除
top related