腹腔鏡補助下幽門側胃切除術後に発生した残胃壊死の1例

Necrosis of gastric remnant following laparoscopic asssisted distal gastrectomy : a case report

◆要旨：患者は62歳，男性．胃角部の早期胃癌に対して腹腔鏡補助下幽門側胃切除術を行った．術後3日目，腹腔内出血のために緊急開腹術を施行した．残胃肛門側は全周性に壊死しており，膵表面の小動脈から出血を認めたため止血とともに残胃全摘術を施行した．病理組織学的に粘膜の脱落，潰瘍形成，腺管萎縮などを認め，虚血性壊死と判断した．脾動脈，短胃動脈の血流は維持されていたことから，胃壁内での血流網が乏しかったため残胃の肛門側に虚血による壊死が生じたと考えられた．胃壁内の血流網には個体差があるものと認識し，胃切除時には残胃の血流を考慮した手技を心掛ける必要がある．

　We report a very rare case of ischemic necrosis of gastric remnant following laparoscopic assisted distal gastrectomy. A 62-year-old man underwent laparoscopic assisted distal gastrectomy for early gastric cancer. On the 3rd postoperative day, emergency laparotomy was required due to intra-abdominal bleeding. On laparotomy, the distal side of gastric remnant was circumferentially necrotic and a bleeding from a small artery on the surface of the pancreas was found. Total gastrectomy was performed along with the hemostasis. Histopathological examination showed venous congestion, ulceration, and tubular atrophic change of the gastric remnant, indicating ischemic necrosis. Because the splenic and short gastric vessels were intact, we postulated that poorly developed intra mural vascular network attributed to the necrosis of the distal part of the gastric remnant. Attention should be made to the individual differences in mural capillary networks to maintain enough blood flow to the gastric remnant.