術中上部消化管内視鏡を併用し腹腔鏡補助下に切除した空腸GISTの1例

A case of gastrointestinal stromal tumor in the jejunum resected by laparoscopy assisted surgery with intraoperative endoscopy

症例は63歳の女性．下血に伴う高度の貧血にて入院した．腹部CTでは小腸に腫瘤を認め，小腸造影では腸管内腔の陰影欠損，腹部血管造影では第二空腸動脈から栄養される腫瘍濃染像を認め，空腸のGIST（gastrointestinal stromal tumor）を疑った．腹腔鏡補助下空腸切除術を施行したが，術中に腹腔鏡下の鉗子操作で上部消化管内視鏡の先進を誘導し，管腔内外からの観察を行い，粘膜下腫瘍と診断した．腫瘍は4.5×4.0×4.0cm大，管外発育型，充実性で粘膜面では潰瘍を形成していた．免疫組織学的に低リスク群のGISTと診断した．空腸腫瘍に対する腹腔鏡下手術時において，上部消化管内視鏡の併用は正確な診断と適切な治療法の選択のために有用である．

　A 63-years-old woman was admitted for severe anemia due to melena. Abdominal CT revealed a solid enhanced tumor in the small intestine. Radiography of the small intestine showed a filling defect in the jejunum. Angiography of superior mesenteric artery showed a hypervascular tumor stain supplied by the second jejunal artery. Due to these findings, the jejunal tumor was suspected to be a GIST. Laparoscopy assisted surgery was performed, the tumor was diagnosed a submucosal tumor by laparoscopy and operative endoscopy. Effective laparoscopic manipulation is helpful in endoscopic examination. Macroscopic findings showed a solid tumor with exoluminal growth, 4.5×4.0×4.0 cm in size. Immunohistochemically, a diagnosis of jejunal GIST with a low risk was made. In laparoscopy assisted surgery for jejunal GIST, intraoperative endoscopy is useful for accurate diagnosis and an appropriate treatment.