腹腔鏡下大網充塡術後に根治度B開腹手術を追加できた進行胃癌穿孔症例の1例

A case of perforated gastric cancer treated with an emergency laparoscopic occulusion followed by radical resection

患者は60歳，男性．急激な腹痛を伴い当院へ救急搬入された．来院時，腹部症状と画像診断にて上部消化管穿孔と診断され緊急手術となった．腹腔鏡挿入時，胃前庭部前壁に直径2mmのピンホール状の穿孔部と同部を中心とした炎症所見を認めた．胃体下部の壁硬化とリンパ節腫大，さらに肝外側区域に直径3cmの転移性と思われる腫瘤を認めた．悪性疾患が疑われたが大網充塡術とドレナージ術にとどめた．術後順調に回復し，精査の結果，胃癌および肝転移と診断した．開腹にて根治度B手術を追加しえた．消化管穿孔の緊急手術において腹腔鏡下手術は，潰瘍だけではなく進行胃癌の穿孔に対しても診断・治療に有用であることが示唆された．

　Patients with perforated gastric cancer who undergo emergency gastrectomy have a poor prognosis due to incomplete resection. This is partly because perforated gastric cancer is rare and it is generally not diagnosed preoperatively or intraoperatively. We present a 65-year-old man with perforated gastric cancer who underwent an emergency laparoscopic occulusion by omental plug, later followed by radical operation. The patient had a chronic gastric ulcer and was admitted to the hospital because of severe epigastralgia. The diagnosis of upper gastrointestinal perforation was made by abdominal computed tomography which demonstrated free air and ascites in the right lateral abdomen. Beacause malignancy was strongly suspected during laparoscopic examination only omentoplasty was performed laparoscopically. Postoperative examination revealed a Borrmann type 3 advanced gastric cancer at the lower portion of the stomach with a solitary metastasis in the liver. We perfomed distal gastrectomy with lymph node resection and partial hepatectomy. The patient was discharged on the 17 th postoperative day. At 15-months follow-up, the patient is alive and free of recurrent disease.

　The laparoscopic repair with an omental patch for perforated gastric cancer might be useful in view of reduced morbidity and decreased adhesion, as well as intraoperative precise evaluation of the abdomen. Emergent laproscopic operation might contribute to the upgrade of survival for perforated gastric cancer, enabling the surgeons to perform complete resection following exact diagnosis of gastric cancer after laparoscopic surgery.