上部消化管内視鏡観察下に腹腔鏡下十二指腸局所切除術を施行した早期十二指腸癌の1例

Laparoscopic full thickness partial duodenectomy for primary early duodenal cancer with duodenoscopic intervention : a case report

◆要旨：内視鏡的粘膜切除術（以下，EMR）困難な原発性早期十二指腸癌に対し，上部消化管内視鏡（以下，GIS）補助下腹腔鏡下十二指腸局所切除術を施行した．患者は64歳，男性．便潜血陽性のためGISを受け，下行脚後壁にⅡa病変を指摘された．病理診断はgroupⅣ, suspect of tub1であったが，non-lifting signのためEMRを断念した．手術はGIS観察下に病変の周囲4点をマーキングし，腹腔鏡下十二指腸局所全層切除を行った．迅速病理診断はtub1, pMであった．腹腔鏡下に欠損部を長軸に直交する方向で2層に縫合閉鎖し，さらに大網を被覆した．手術時間は217分，出血量は少量であった．最終病理診断はtub1, 6mm, pM, ly0, v0, PM（－）, DM（－）であった．本術式は，EMR困難な早期十二指腸癌に対する有効な治療法の1つと考える．

　We treated a patient with early duodenal cancer that was contraindicated for endoscopic mucosal resection（EMR）by laparoscopic full thickness partial duodenectomy under endoluminal duodenoscopic intervention. The patient was a 64-year-old male who received an upper endoscopic examination because of positive fecal occult blood test. The so-calledⅡa type early cancer was detected in the second portion of the duodenum. Pathological diagnosis was groupⅣ, suspected of tub 1. Although we intended to treat the lesion by EMR, with the detection of non-lifting sign which contraindicate the use of EMR, full thickness partial duodenectomy was performed. Operative procedure : At first, duodenum was mobilized and the lesion was marked with indigocarmine under duodenoscopic view. Full thickness partial duodenectomy was then completed using ultrasonic coagulating shears. Frozen section of the resected specimen was diagnosed as tub 1, pM. Defect of the duodenal wall was closed from oral to anal side by two layers manual suturing and was wrapped with the omentum majus. Operation time was 217 minutes and blood loss was little. Final pathological diagnosis was tub 1, 6 mm, M, ly 0, v 0, PM（－）, DM（－）. Although further evaluations would be required, our procedure may be feasible for duodenal cancer that is difficult to treat by EMR.