残胃の良性病変―主として吻合部潰瘍について

Benign Lesions in the Gastric Remnant: Chiefly on stomal ulcer

　胃手術後の残胃病変で何といっても一番問題となるのは吻合部潰瘍であろう．吻合部潰瘍の名称，定義は種々^1)～12)であるが，本稿では胃切除後の吻合口やその近傍に認められる術後再発潰瘍を総括した広い意味の潰瘍病変を指し，吻合部縫合線上の潰瘍も空腸潰瘍も一括して吻合部潰瘍と呼ぶこととする．

　吻合部潰瘍は1897年Bergによって観察記載され，1899年BraunにょってUlcus pepticum jejuniと命名されたといわれる¹⁾．この胃切除あるいは胃空腸吻合術後の後遺症は診断，治療に問題が多いのみならず自覚症状も強く治り難い性質がある．われわれの施設で経験した56症例について術式を中心に，内科的あるいは外科的治療の成績を検討する．

　Stomal ulcer is of great importance among benign lesions of the remnant stomach including gastritis, bezoars and polyps. So far we have come across 56 such patients in the Institute of Gastroenterology. Of these, six patients were experienced by us at the institution. From 1966 to June 1976 we treated surgically 1,799 patients with benign gastric lesions including ulcers of the stomach and duodenum. The incidence of stomal ulcer was 0.33 per cent. In many respects our observations corresponded well with those of reports hitherto published. It was more often seen in males, especially after Billroth Ⅱ type operation. Some came out within one year after operation and some appeared five to ten years later. Epigastralgia, hematemesis and melena accounted for most of the complaints. Especially, hematemesis and melena were most frequent. Ulcers were often seen on the suture line in the Billroth I operation, and typical jejunal ulcers were most frequent in the Billroth Ⅱ operation with gastrojejunal anastomosis.

　Of 39 medically managed patients with stomal ulcer, 14 later underwent surgical intervention because either it remained intractable or signs and symptoms became worse. Eight patients were cured by medical management alone (20.5 per cent). Recurrence, persistence or aggravation of ulcers was seen in 21 patients. Surgical correction was done in 31 patients including 14 mentioned above. Twentythree patients (74.2 per cent) were cured by it. Operational death was encountered in one, and ulcers recurred or persisted in four.

　We believe stomal ulcer can be managed to far better advantage by surgery. In 5 out of 56 patients ulcers re-recurred (10.7 per cent). As two patients with surgical management were cured, operation should be done actively in re-recurred stomal ulcers, too. The causes of stomal ulcer are set forth in many reports. They are deemed not solely due to acidity of the gastric juice. They are seemingly more complicated. Tissue reaction of the stomach, duodenum and jejunum must also be taken into account.