家族性大腸腺腫症に合併した十二指腸乳頭部病変の局所手術

Local Resection of the Duodenal Papillary Lesion of Familial Adenomatous Polyposis

要旨　家族性大腸腺腫症（FAP）について，十二指腸乳頭部病変の局所切除術の可能性を検討した．対象は十二指腸内視鏡所見を検討しえた52例のFAP患者で，乳頭部の変化を正常，表層型，腫瘤型，明らかな癌と分類した．14例に乳頭部に対する手術が行われた．5例に膵頭十二指腸切除（PD）が行われたが，このうち2例には乳頭筋を越える浸潤やリンパ節転移を認めなかった。9例には乳頭部局所切除が行われた．3例に癌を認めた．この9例中，大腸癌による早期死亡1例を除く8例では5年2か月までの観察で局所に再発を認めなかった．合併症についても検討した．腫瘤型変化を示す乳頭部病変で，臨床検査上Oddi筋以上の浸潤の可能性が少なければ局所切除のよい適応と考えられた．

　The relative risk of peri-ampullary carcinoma is high in patients with familial adenomatous polyposis (FAP). We evaluated the effectivity of local treatment of the ampullary lesion of FAP patients. By August 1996, 52 FAP patients underwent duodenal endoscopic examinations. We classified the change of ampullary lesions as follows: normal, the superficial type, the protruding type and overt cancer.

　Among them, 14 cases were treated for the ampullary lesions: Five cases underwent pancreato-duodenectomy (PD) and nine cases were treated by local excision (LE) of the ampulla. All PD cases were preoperatively diagnosed as the protruding type or overt cancer. Except for two cases who were operated for both colon and ampullary lesions simultaneously, the average time span between colorectal surgery and treatment of ampullary lesion was 11.3 years. Two out of five PD cases had neither invasion into duodenal wall and pancreas nor lymph node metastases. In nine LE cases, two cases were complicated with temporal bile leak, and one of which underwent choledocho-duodenostomy due to stenosis. One case developed desmoid tumor. Three LE cases was diagnosed as carcinoma; two of their endoscopic diagnosis were the protruding type and the other one was the superficial type. Blood chemistry results of these three cancer cases were within normal limits, and their cholangiographic examinations were also normal. One of LE case died of recurrence of rectal cancer. The other eight cases had no recurrence on the ampullary lesion during the follow-up period from two years and four months to five years and two months. Local excision in an appropriate indication for ampullary tumor of the protruding type without evidence of invasion to the pancreas or duodenal wall in the FAP patients.