GREAT HONOR GREAT HONOR For me For me Friendships Renew ... · Friendships Renew many Communication...

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


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.


QuickTimeý Ç²é ê^ - JPEG êLí£ÉvÉçÉOÉâÉÄ

Ç™Ç±ÇÃÉsÉNÉ`ÉÉÇ¾å©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.


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


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 %


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


AA

BB

The common channelThe common channel

The common bile ductThe common bile duct

The pancreatic ductThe pancreatic duct

Fig.3


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


Carcinoma of the Papilla of Vater of the Intestinal Type Carcinoma of the Papilla of Vater of the Intestinal Type


Carcinoma of the Papilla of Vater of the Pancreaticobiliary TypeCarcinoma of the Papilla of Vater of the Pancreaticobiliary Type


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


EUSEUS


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


19951995

In TokyoIn Tokyo


20012001In WittenbergIn Wittenberg


Kimura W, JHBPS 2000Kimura W, JHBPS 2000

Fusion Fascia of Fusion Fascia of TreitzTreitz (An Autopsy Case)(An Autopsy Case)


PVPV CBDCBD

DUDU

PLPLRPRP

SMASMA

Fusion Fascia of Fusion Fascia of TreitzTreitzKimura WKimura W．．JpmJJpmJ PancPanc Soc 19: 463Soc 19: 463--9,20049,2004


PANCREASDUODENUM

SMV SMA

FUSIONFASCIA

RP RPOR

PL

PL


PANCREASDUODENUM

SMV SMA

FUSIONFASCIA

RP RPOR

PL

PL

Kimura WKimura W J J JpnJpn PancPanc Soc 19: 463Soc 19: 463--9, 20049, 2004


QuickTimeý Ç²TIFFÅiLZWÅj êLí£ÉvÉçÉOÉâÉÄ

Ç™Ç±ÇÃÉsÉNÉ`ÉÉÇ¾å©ÇÈÇžÇ½Ç…ÇÕïKóvÇ-Ç�ÅB

Du

Du

PLce

GDACBD

Ph

PLphⅡphⅠ

Ph（断端）CHA

fusion fascia

SMA

Nerve Plexuses in the back of the pancreatic head


SMVSMV

SMASMA

**

**

**

**


PANCREASDUODENUM

SMVSMA

FUSIONFASCIA



LEFT PART OFNEURAL PLEXUSOF THE SMA

PVPV

SMVSMV

SMASMA

LIVERLIVER

IVCIVC

SMVSMV

SMASMA



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.


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.


1. Pancreaticojejunostomy2. Choledocojejunostomy

3. Gastrojejunostomy

4. Braun’s anastomosis


Lost stent


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


20032003

In In NurnbergNurnberg

German GastroGerman Gastro--enterological enterological CongressCongress


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


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


ClinicopathologicalClinicopathological Features and Features and Therapeutic Strategies forTherapeutic Strategies forHepatic bile Duct CarcinomaHepatic bile Duct Carcinoma


ERCPlt.

rt.biopsy 4個

B8

B5

B6/7

10mm

MRCPMRCPEERCPRCP

AngiographyAngiography


Extension of the Bile Duct CarcinomaExtension of the Bile Duct Carcinoma


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%


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


Atro

phy

RegenerationResection

Extended Right HepaticExtended Right HepaticResection with Caudate LobeResection with Caudate Lobe

RegenerationRegeneration


Taping of the hepatic arteriesTaping of the hepatic arteries


Liver Resection with Liver Resection with BelgithiBelgithi’’ss MethodMethod


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


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


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


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


15cm

20cm

60cm

TreitzLigasment

B2,3,4 ReconstructionReconstruction


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


Thank you very muchThank you very much


図3．内視鏡所見

図図３３. . 内視鏡的内視鏡的所見所見


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


図図６６. . 乳頭部の切除乳頭部の切除

GREAT HONOR GREAT HONOR For me For me Friendships Renew ... · Friendships Renew many Communication...

Documents

Transcript of GREAT HONOR GREAT HONOR For me For me Friendships Renew ... · Friendships Renew many Communication...