After PPPD, we have consistently performed gastrointestinal reconstruction byImanaga procedure that entailed an end-to-end dudenojejunostomy, end-tosidepancreatojejunostomy (pancreatic duct to jejunal mucosa anastomosis) andcholedochojejunostomy, performed in that order.PPPD-Imanaga, which leaves no blind intestinal segment, simulates the normalanatomic arrangement and provides a physiological mixture of food and bilein the upper portion of the jejunum. The good mixing was evidenced by dualscintigraphy with few exceptions. As another advantages, insertion of endoscopyis easier postoperatively and as a result, we can check patency of pancreatic andbiliary anastomotic stomas. This is important to evaluate postoperative functionof remnant pancreas and liver, and early to detect local recurrence.Since 1986, we have experienced 272 cases of PPPD/PD-Imanaga (PPPD 233/ PD 39), which consists of patients with pancreatic head cancer 122, bile ductcancer 55, Vater cancer 36 and another 61.Overall 5-year-survival is 14.2% in pancreatic head cancer, and 25.3% in distalbile duct cancer.

For the treatment of pancreatic cancer, it is most important to perform radicalresection (R0) and in addition, an adequate and effective adjuvant therapy will berequired. We have performed radical operation including combined resection ofthe vessels, if necessary. On the other hand, to maintain the patient’s quality oflife and to adopt sufficient adjuvant therapy, we have also made effort to preserveorgan function as much as possible.In cases of pancreatic body and/or tail cancer, cancer often invades to the originof the common hepatic artery, the splenic artery or the celiac axis (CA). Forsuch cases, we performed “whole stomach-preserving distal pancreatectomy withcombined resection of the celiac axis (WSP-DP-CAR)” in 1987, and published asthe first report in 19911).In this procedure, the arterial blood supply to the whole stomach and the liver issecured only via the inferior pancreaticoduodenal artery arising from the superiormesenteric artery (SMA). So the bifurcation of the gastroduodenal artery (GDA)from the common hepatic artery must be safely preserved after strict evaluationwhether cancer invades to this site or not.The indications of this procedure should be applied to patients who diagnosed as1) no distant metastases, 2) no tumor involvement of the SMA and GDA and 3)resectable extrapancreatic nerve plexus invasion or lymph node metastases, andwill undergo pancreatectomy with curative intent.Since June 1987, we have performed this procedure to sixteen cases. For twocases, we were able to preserve the left gastric artery, and for five cases, theportal vein was resected and reconstructed. There were no severe postoperativecomplications, though delayed gastric emptying (DGE) in two cases, pancreaticfistula (Grade B: ISGPF) in three cases were observed, and there was no problemwith the blood supply to the stomach and the liver. For ten cases, we obtainedcomplete resection (R0). Due to the good postoperative state, adjuvant therapycould be applied to all cases intended. Up to the end of July 2014, five patientsstill survive (four have no recurrences), eight patients lived more than oneyear (one year survival rate: 69.6%), two patients lived more than five years,including one 205-months-survivor. Median survival time (MST) of all patientsis 18.8 months. There was no local recurrence except for only one non-curativeresection case due to the tumor invasion to the pancreatic cut margin.This procedure of WSP-DP-CAR has been safely performed and the postoperativecourse is almost same as that of standard distal pancreatectomy. We will performthis procedure because there is a chance that it may enhance local control andimprove survival of pancreatic cancer invading around the CA.I will present this procedure of WSP-DP-CAR, using the motion picture.

After PPPD, we have consistently performed gastrointestinal reconstruction by Imanaga procedure that entailed an end-to-end dudenojejunostomy, end-toside pancreatojejunostomy (pancreatic duct to jejunal mucosa anastomosis) and choledochojejunostomy, performed in that order. PPPD-Imanaga, which leaves no blind intestinal segment, simulates the normal anatomic arrangement and provides a physiological mixture of food and bile in the upper portion of the jejunum. The good mixing was evidenced by dual scintigraphy with few exceptions. As another advantages, insertion of endoscopy is easier postoperatively and as a result, we can check patency of pancreatic and biliary anastomotic stomas. This is important to evaluate postoperative function of remnant pancreas and liver, and early to detect local recurrence. Since 1986, we have experienced 272 cases of PPPD/PD-Imanaga (PPPD 233 / PD 39), which consists of patients with pancreatic head cancer 122, bile duct cancer 55, Vater cancer 36 and another 61. Overall 5-year-survival is 14.2% in pancreatic head cancer, and 25.3% in distal bile duct cancer.

For the treatment of pancreatic cancer, it is most important to perform radical resection (R0) and in addition, an adequate and effective adjuvant therapy will be required. We have performed radical operation including combined resection of the vessels, if necessary. On the other hand, to maintain the patient’s quality of life and to adopt sufficient adjuvant therapy, we have also made effort to preserve organ function as much as possible. In cases of pancreatic body and/or tail cancer, cancer often invades to the origin of the common hepatic artery, the splenic artery or the celiac axis (CA). For such cases, we performed “whole stomach-preserving distal pancreatectomy with combined resection of the celiac axis (WSP-DP-CAR)” in 1987, and published as the first report in 19911). In this procedure, the arterial blood supply to the whole stomach and the liver is secured only via the inferior pancreaticoduodenal artery arising from the superior mesenteric artery (SMA). So the bifurcation of the gastroduodenal artery (GDA) from the common hepatic artery must be safely preserved after strict evaluation whether cancer invades to this site or not. The indications of this procedure should be applied to patients who diagnosed as 1) no distant metastases, 2) no tumor involvement of the SMA and GDA and 3) resectable extrapancreatic nerve plexus invasion or lymph node metastases, and will undergo pancreatectomy with curative intent. Since June 1987, we have performed this procedure to sixteen cases. For two cases, we were able to preserve the left gastric artery, and for five cases, the portal vein was resected and reconstructed. There were no severe postoperative complications, though delayed gastric emptying (DGE) in two cases, pancreatic fistula (Grade B: ISGPF) in three cases were observed, and there was no problem with the blood supply to the stomach and the liver. For ten cases, we obtained complete resection (R0). Due to the good postoperative state, adjuvant therapy could be applied to all cases intended. Up to the end of July 2014, five patients still survive (four have no recurrences), eight patients lived more than one year (one year survival rate: 69.6%), two patients lived more than five years, including one 205-months-survivor. Median survival time (MST) of all patients is 18.8 months. There was no local recurrence except for only one non-curative resection case due to the tumor invasion to the pancreatic cut margin. This procedure of WSP-DP-CAR has been safely performed and the postoperative course is almost same as that of standard distal pancreatectomy. We will perform this procedure because there is a chance that it may enhance local control and improve survival of pancreatic cancer invading around the CA. I will present this procedure of WSP-DP-CAR, using the motion picture.