残胃GISTに対し腹腔鏡・内視鏡合同胃局所切除術を施行した1例

Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor of the remnant stomach after distal gastrectomy : a case report

◆要旨：患者は61歳，男性．胃潰瘍で広範囲胃切除，外傷性小腸穿孔で小腸部分切除の開腹手術歴がある．噴門直下に3cm大の腫瘤を指摘され精査を行った．造影CTでは噴門直下に内腔に発育する粘膜下腫瘍を認め，針生検でGISTの確定診断を得た．腫瘍が胃内発育型であることと機能温存の観点から腹腔鏡・内視鏡合同手術（LECS）による胃局所切除の方針とした．手術は内視鏡操作を加えることで，根治性を損なわない必要最小限の胃局所切除と，噴門部の全周温存を確認しながらの縫合閉鎖が可能であった．従来なら開腹局所切除や残胃全摘が施行されたような本症例も，LECSを施行することで機能温存と根治性の両立が可能であったと思われた．

Laparoscopic wedge resections are being applied increasingly for gastrointestinal stromal tumors（GIST）. However, laparoscopic wedge resection is not applicable for intraluminal type of tumors and those located near the esophagogastric junction because it requires resection of relatively large section of healthy stomach, if linear staplers are used. We here report a case of laparoscopic and endoscopic cooperative surgery（LECS） for intraluminal GIST near the esophagogastric junction of the remnant stomach after distal gastrectomy. In the LECS procedure, the resection margin was appropriately determined by endoscopic submucosal dissection technique via intraluminal endoscopy. Then, the seromuscular layer around the tumor was laparoscopically dissected. We closed the incision line using a laparoscopic hand-sewn technique without esophagogastric junction stenosis because of the direct intraluminary visualization of the tumor and the surrounding area. The postoperative course was uneventful with no deformity of the remnant stomach and complication. GISTs of the remnant stomach are traditionally resected by open total gastrectomy or partial resection, but LECS enabled us to resect with minimum surgical margin, to prevent the deformity of the stomach, and to preserve the patient's quality of life.