J.Jpn. Surg. Soc.. 55(7): 828-835, 1954

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宿題報告

Surgery of the Pancreatoduodenectomy

The operation of pancreatoduodenectomy is one of the unexplored field in surgery. The mortality is very high. Though the operation is performed at the risk of the patient, the recurrence of the tumor makes all the effort nil. Numbers of factors which makes the operation extremely difficult are enumerated as follows : 1) operation is performed simultaneously on the stomach, duodenum, bile ducts ＆ pancreas ; 2) reconstruction of the bile duct, and the problem of the remaining pancreas ; 3) existence of portal vein and superior mesenteric vein which are easily injured and contraindicated to be ligated and devided ; 4) as jaundice do not appear till the disease advance to a late stage, the jaundice patient do not visit the surgeon early enough and the optimum time for the operation are apt to be lost ; 5) secondary hepatic damags is expected in all cases.
Though the postoperative metabolism concerning digestion and absorption is improved somehow after the operation, a normal return of these function cannot be expected. Due cortsideration for postoperative care should be kept in mind. Our study has been on 30 patients, of which 13 carcinoma of the head of the pancreas ; 5 carcinoma of the common bile duct ; 6 chronic sclerosing pancreatitis ; and 6 metastasis of the pencreas from the gastric cancer. The establishment of early diagnosis of primary carcinoma of the head of the pancreas and carcinoma of the common bile duct, and a safe operative method for the operation have been investigated under the following subjects :
1) Anatomy concerning venous and lypmphatic system around the pancreas
2) Diagnostic study ; (1) diagnosis of surgical jaundice, (2) the differential diagnosis of carcinoma of the pancreas from chronic sclerosing pancreatitis, (3) the diagnosis of the obstruction in the bile duct, (4) x-ray study, especially a direct percutaneous method to visualize the bile duct
3) Indication for operation in case of hepatic damage
4) Preoperative care ; liver protection and correction of bleeding tendency
5) Operation ; continuous segmental anaesthesia is used, The method which differs from the conventional way is as follows. The operation is first performed from the body and tail of the pancreas towards the head of the pancreas and special care is made to avoid injury to the portal vein, and a new safe and simple method to reconstract the bile duct is presented. The circulatory system should be preserved as much as possible from the standpoint of the function of the remaining pancreas is investigated by may pathological studies. The most important problem is how to deal with the portal vessels. Anastomosis of fhe splenic vein with the superior mesenteric vein after partial resection of the portal vein, and polyethylene tube inserted with 70% alcohol preserved vein graft have been studied clinically and experimentally.
6) Postoperative fluid maintenance
7) Physiologic change after resection of the head of the pancreas and duodenum
8) Enlargement of the indication for carcinoma of the stomach by resection of the pancreas.
The operative results are as follows : The direct mortality till 1952 was as high as 50%. However, it is reduced to 18% up to the present. The cases of death in the latter period is due to the enlargement of the indication. This means that if patients are strictly ·selected for the operation, we believe that the direct mortality can be reduced to 0. There is no case which lived over one year. It is probably due to the fact that patients do not visit the doctor early enough to be operated.
(author's abstract)

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