腹腔鏡下手術を施行した胃切除（B-Ⅱ再建）後に発生した吻合部潰瘍穿孔の1例

A case report of perforated anastomotic ulcer after gastrectomy for duodenal ulcer treated by laparoscopic surgery

◆要旨：患者は33歳，男性．21歳時に，十二指腸潰瘍穿孔に対し胃切除（結腸後BillrothⅡ法，Braun吻合）が施行された．今回，突然の上腹部痛を主訴に当院を受診し，腹部CTでfree airを認めた．受診4日前からタール便があり，上腹部を中心にfree airを認めたことから，上部消化管穿孔に伴う急性汎発性腹膜炎と診断し，同日緊急で腹腔鏡下手術を施行した．手術では，胃空腸吻合部近くの小腸前壁に穿孔部位を認め，穿孔部閉鎖および大網被覆術を施行した．術後経過は良好で，術後7日目に自宅退院となった．胃切除後吻合部潰瘍穿孔の本邦報告を自験例を含め10例で検討したところ，腹腔鏡下手術が施行されたのは自験例のみであった．貴重な症例と考え，若干の文献的考察を加え報告する．

We report a rare case of perforated anastomotic ulcer after gastrectomy with Billroth II reconstruction for duodenal ulcer treated by laparoscopic surgery. A 33-year-old man, who had undergone a distal gastrectomy with Billroth II reconstruction for perforated duodenal ulcer at the age of 21, with acute upper abdominal pain was admitted to our hospital. The white blood cell count was 9,300/mm³, Hemoglobin was 10g/dl, CRP was 0.1mg/dl, gastrin level was low, and IgG antibody for H. plyori was negative. An abdominal CT scan showed ascites, free air and perforated site around the upper abdomen. An emergency laparoscopic surgery was performed based on the diagnosis of pan-peritonitis. During surgery, a perforated ulcer at the anastomotic site, which was reconstructed by retrocolic Billroth II procedure and Braun anastomosis, was confirmed. Primary closure of the perforation by sutures and an omental patch was performed under laparoscopy, and the abdominal cavity was thoroughly irrigated. A proton pump inhibitor was given to the patient after the operation. The post-operative course was uneventful. Laparoscopic surgery is useful for perforated anastomotic ulcer and can become one choice for emergency surgery such as gastroduodenal ulcer perforation. He was hospitalized for eight days and received medication follow. Since this method is not a radical operation, there is a possibility of recurrence.