胃癌に対する幽門側胃切除術後に発生した脾腫瘤に対し腹腔鏡の拡大視効果と術中ICG蛍光法により残胃血流を温存しえた腹腔鏡下脾臓摘出術の1例

A case of laparoscopic splenectomy preserving blood flow of the remnant stomach after distal gastrectomy for gastric cancer by using laparoscopic magnified view and ICG fluorography

◆要旨：症例は74歳，男性．当院でステージIAの胃癌に対して腹腔鏡下幽門側胃切除術，D1＋リンパ節郭清，Roux-Y再建を施行した．術後5年目のCT検査で脾臓に腫瘤を認め，経時的な増大やPETでの集積を認めたことから，悪性の可能性も否定できず腹腔鏡下脾臓摘出術の方針となった．術前CTで脾動脈から残胃に流入する分枝を同定し，術中にこの分枝を確保し，これより脾門側で脾動静脈は切離し脾摘を行った．脾摘後にindocyanine green（ICG）蛍光法で残胃血流の温存を確認した．術後経過は良好であった．病理組織診断は乾酪壊死を伴う類上皮細胞肉芽腫（脾臓結核症）であった．胃癌に対する幽門側胃切除後に発生した脾腫瘤に残胃血流を温存する腹腔鏡下脾臓摘出術を施行したので報告する．

　Blood flow to the remnant stomach following distal gastrectomy for gastric cancer is primarily supplied by vessels from the splenic artery. Therefore, splenectomy in such patients may lead to ischemia of the remnant stomach. We report a case of a splenic mass arising in a 74-year-old man who had undergone laparoscopic distal gastrectomy for gastric cancer 5 years and 9 months ago. A 5-year follow-up computed tomography（CT） scan revealed a splenic mass, and PET-CT showed gradual growth and high FDG accumulation, raising concerns for malignancy. Laparoscopic splenectomy was performed for a therapeutic diagnosis. Preoperative CT angiography revealed a branch of the splenic artery flowing into the remnant stomach. Intraoperatively, this vessel was identified, and the splenic artery was transected distally to preserve blood flow to the remnant stomach. Magnified laparoscopic vision aided in vessel preservation, and intraoperative indocyanine green（ICG） fluorography confirmed blood perfusion. Postoperative contrast-enhanced CT scan revealed preserved blood flow. The patient's postoperative recovery was uneventful. The histopathological diagnosis was an epithelioid cell granuloma with caseous necrosis, consistent with splenic tuberculosis.