腹腔鏡下に切除し得た腸閉塞で判明した転移性小腸腫瘍の1例

A case of metastatic small intestinal tumor resected by laparoscopic surgery

転移性小腸悪性腫瘍は頻度が低く診断が難しい．手術既往がなく突然の腸閉塞で発症した転移性小腸腫瘍を腹腔鏡下に切除し，卵巣癌の転移と診断した1例を経験した．症例は49歳，女性で，主訴は腹痛，嘔吐であった．腸閉塞と診断しイレウス管にて減圧後，腹腔鏡下手術を施行した．手術所見で回盲部から約50cm口側の小腸壁に4cm大の腫瘍を認め，小腸部分切除を施行した．病理組織所見で筋層を主体として粘膜下層から漿膜下に広がった分化型腺癌で，転移性腺癌と診断した．卵巣癌の転移と診断し，化学療法後に子宮全摘を行い，両側付属器切除術を施行し，卵巣癌を確認した．発見より約3年7か月の現在も生存中である．

　Metastatic tumor of small intestine is rare and it is difficult to diagnose accurately. We have treated a woman who had abdominal pain and nausea without any previous surgical history. She was diagnosed as primary ileus due to unknown reason and underwent laparoscopic surgery after reduction of intestinal fluids by a ileus tube. During surgery, we found a soft tumor located on small intestine at 50 cm oral side from the terminal ileum. The size of the tumor was 4 cm in diameter and it was obviously the cause of bowel obstruction. Partial resection of small intestine was performed. The pathological findings revealed that the tumor was differentiated adenocarcinoma. The tumor was mainly located in the muscular layer of the intestinal wall and invaded into submucosal layer and subserosal layer. The mucosal layer of the intestinal wall was intact, indicating that the tumor was a metastatic lesion. Before and after the surgery, we examined the whole body to find the primary site of the tumor, but no significant finding could be obtained. We came to the conclusion that the primary lesion may be ovary and explained to the patient and she desired to start the treatment for ovarian carcinoma. After neoadjuvant chemotherapy for ovarian carcinoma, we performed hysterectomy and bilateral adnexotomy. The primary adenocarcinoma was found in the left ovary by pathological study. The patient was still alive after 3 years and 7 months from the initial hospitalization.