早期胆嚢癌の精密検査―内視鏡を中心に

The Detailed Examination for Early Diagnosis of Gallbladder Cancer with Percutaneous Transhepatic Cholecystoscopy (PTCCS)

要旨　胆囊癌の診断体系，特に，早期癌を発見するための診断体系の確立が望まれている．超音波検査法で胆囊内隆起性病変あるいは胆囊壁の異常をなるべく広く拾い上げ，いかにして効率よく，次の精密検査へもっていくかである．また，超音波内視鏡は，診断精度がかなり高く，コレステロールポリープの除外診断は十分可能である．また，進行癌では超音波内視鏡と他のX線診断法にて，ある程度診断は可能である．しかし，問題となるのはⅡaあるいはⅡbといった表在型の癌であり，その確定診断あるいは拡がり診断は直接，粘膜面を観察できる内視鏡検査および生検による病理組織検査が是非とも必要である．筆者らは1982年より経皮経肝胆囊内視鏡検査法を50例に行ったが，胆囊癌全例で正診を得た．また，重篤な合併症もなく，安全で，かつ非常に有用な検査法である．

　A system for early diagnosis of gallbladder cancer should be established without delay, because its incidence is increasing and it grows very quickly. It is recognized generally that ultrasonography is the most usefull method for a screening test of gallbladder carcinoma. In a diagnosis system, ultrasonography would detect an elevated lesion or irregularity in the gallbladder wall, and the patient would be recommended to proceed to the next detailed examination. Because cholesterol polyps have typical features-sessile polyps with multiple high-echoic spots-they can be distinguished as such by EUS, so EUS is recommended as the second step in the diagnosis system. EUS is also capable of diagnosing advanced acrcinoma of the gallbladder because it shows the destruction of the gallbladder wall due to the invasion of the carcinoma. This can also be determined by other radiological examinations, e.g. ERCP, computed tomography, angiography, etc. However, neither EUS nor the other radiological examinations can diagnose carcinoma of the gallbladder located in the mucosal layer and the cancer extention on the mucosa.

　For this reason the diagnosis system must include a further step. Percutaneous transhepatic cholecystoscopy (PTCCS) is recommended as this further and last step. PTCCS is a reliable method for the differential diagnosis between early gallbladder cancer and adenoma or other kinds of polyp, and diagnosis of the cancer extention on the mucosa to the cystic duct, Endoscopy and pathological examlnation in addition to x-ray examination are necessary for the diagnosis of gallbladder carcinoma just as they are necessary for the diagnosis of the gastrointestinal diseases. The normal mucosa of the gallbladder is observed with PTCCS as having a fine reticular pattern (FRP). In gallbladder cancer, PTCCS shows the elevated lesion with rough surface, erosion and redness, and the FRP has disappeared.

　Using PTCCS at our hospital, the destruction of the fistula between the liver and the abdominal wall occurred in only three of 50 patients. However, there is no other severe complication brought about by PTCCS. PTCCS is a useful and safe method for the early diagnosis of gallbladder carcinoma.