下部食道噴門癌の食道浸潤状況の診断に関する一考察―ことにX線撮影方法の工夫について

A Study on Radiological Diagnosis for the Esophageal Infiltration of the Cardio-Esophageal Carcinoma

　いわゆるesophago-cardiac junction（以下ECJと略）に跨がる食道噴門癌では，食道浸潤の程度によっては，経腹的手術のみでは癌腫の充分な切除が不可能なことがあり，開胸開腹により切除しなければならない症例にしばしば遭遇する．このような症例の手術経路の適応を決定するに際しては，術中癌腫を切除食道断端に遺残させないようにするため，術前に食道浸潤先進部の詳細を充分に検討することがきわめて重要であるにもかかわらず，一般にX線上での食道浸潤そのものの撮影法に関する工夫はあまり見られないようである．これは，食道浸潤のみられるような食道噴門癌では，手術時いわゆる「手遅れ」の超進行癌が多いことから，主病巣の単純な描写だけで，X線上における食道浸潤そのものの撮影法にはあまり関心が寄せられなかったからであろう．

　一方，われわれの過去に切除された食道噴門癌の詳細な組織学的検索によると，食道浸潤先進部の肉眼的な形態と切除断端癌遺残率 ow（＋）との間にきわめて密接な関係があることがわかり，また過去の症例のX線像をretrospectiveに検討してみると，その約半数に食道浸潤の型，食道浸潤の長さのX線上の読みの誤りがあることが明らかとなったことから，食道浸潤のX線撮影法にいま一歩の工夫が望ましいことが痛感された．そこでわれわれは下部食道の二重造影を中心とした食道胃入口部附近の撮影に工夫をこらし，食道浸潤の診断に良好な成績を納めているので，その概要を紹介する．

　In the surgical resection of cardiac carcinoma involving the esophagus we have to decide whether it should be done under thoracotomy or by way of the abdomen alone. In the light of the macroscopic type and length of cancer infiltration of the esophagus and in order not to leave any cancer nests in the esophageal remnant, we have considered it necessary to resect the uninvolved part of the esophagus 2 cm oral from the uppermost tip of cancer infiltration when it is proximally localized and 4 cm oral when it is not localized.

　Prerequisite prior to such an operation means thorough roentgenological knowledge of the types and length of the uppermost part of esophageal infiltration. Generally speaking, however, cardio-esophageal cancer is mostly so far advanced that simple visualization of the chief lesion alone is often considered sufficient during fluoroscopy and too little attention is paid to the photographic method most suitable for the delineation of esophageal cancer itself. In the light of this fact we have devised various procedures to depict to the best advantage cancer infiltration from the lower esophagus to the gastric orifice. We have chosen the lateral position with the body bent down ward to the utmost (bowing from the waist) according to Matsuura as well as the concept of Okamoto et al. regarding a few slender smooth and regular lines at the mucosa of gastric orifice, and especially be right or left recumbent lateral position cancer infiltration is well demonstrated in double contrast picture against the background of the fornix amply insufflated with air. By this means we are now able to raise the positive rate of x-ray confirmation hitherto low of the macroscopic types of esophageal infiltration up to 30 per cent and of its length to 25～40 per cent.