前庭部の亜全周性早期胃癌に対するESD後，狭窄と変形により通過障害を認めて外科手術を要した1例

Requiring Surgery Due to Passage Obstruction Caused by Stenosis and Deformity after ESD for Semi-circular Early Gastric Cancer in the Antrum, Report of a Case

要旨●患者は80歳代，男性．検診の上部消化管X線造影異常を契機に，前医のEGDで前庭部に早期胃癌疑いを指摘されて加療目的に当院を紹介受診された．open typeの粘膜萎縮（自然除菌後）を背景として，前庭部小彎を主座として白色調の平坦隆起性病変を認め，大彎後壁の一部を除いた亜全周性に平坦進展を認めた．術前生検で高分化管状腺癌を認め，L，Circ，Type 0-IIa＋IIb，90mm，tub1，cT1a-M，UL0と診断しESDを施行した．病理組織学的診断結果はeCura Aであったが，術後約40日後より嘔吐を繰り返したため精査した．内視鏡上，ESD後潰瘍に伴う軽度狭窄を認めたがスコープは通過可能であった．しかし変形により通過障害を来したと考えられた．計6回内視鏡的バルーン拡張術を施行したがその後も症状改善なく，最終的に腹腔鏡下幽門側胃切除術を施行した．幽門前庭部にある広範な病変の内視鏡的切除後は，術後狭窄や変形に伴う通過障害を来すことがある．単純な狭窄と違い変形を伴えば内視鏡的バルーン拡張術を行っても改善せず外科手術が必要となる場合があるため，留意しておく必要がある．

　A male patient in his 80s underwent EGD（esophagogastroduodenoscopy）due to an abnormality in his upper gastrointestinal series and had a suspected cancer lesion detected in a previous hospital. He was referred to our hospital for treatment. A whitish, flat, elevated lesion was found in the background mucosal atrophy of open type（after spontaneous eradication）in the lesser curvature, and there was extension of the flat cancer sub-circumferentially, however there was no lesion observed in the greater curvature. Upon admission, preoperative biopsy revealed a well-differentiated tubular adenocarcinoma. The lesion was diagnosed as early gastric cancer, L, Circ, Type 0-IIa＋IIb, 90mm, tub1, cT1a-M, UL0. A curative resection of this lesion was performed using ESD（endoscopic submucosal dissection）. However, 40 days after ESD, the patient was re-admitted with complaints of repeated vomiting. An EGD was performed, which demonstrated mild stenosis due to post-ESD ulcer ; however the scope passed satisfactorily. We also found a deformity, which was thought to be causing the obstruction. A total of six endoscopic balloon dilatations were performed ; however, the symptoms did not improve. Finally, laparoscopic distal gastrectomy was performed. Postoperative stenosis and obstruction of the passage can occur after ESD performed for treatment of extensive lesions of the pyloric antrum. It is important to note that unlike simple stenosis, if deformities are present, endoscopic balloon dilatation may not be of much help and surgical intervention may be required.