消化管出血を伴った孤立性胃粘膜下異所腺に対し腹腔鏡・内視鏡合同胃局所切除を施行した1例

Laparoscopy-endoscopy cooperative surgery for hemorrhagic solitary heterotopic submucosal gland of the stomach : A case report

◆要旨：患者は41歳，女性．心窩部痛と黒色便を主訴に来院した．3年前の健診で胃前庭部の粘膜下腫瘍を指摘されていた．胃内視鏡で粘膜下腫瘍からの出血を認め，焼灼止血した．超音波内視鏡では一部に囊胞様の無エコー域を認め，病変の首座は第3層に存在した．増大傾向はなかったが出血をきたしており切除の適応と考えられた．胃の変形を防ぐため，また胃内発育型であることより腹腔鏡・内視鏡合同胃局所切除（LECS）を行い，孤立性胃粘膜下異所腺と診断した．孤立性胃粘膜下異所腺の多くは症状に乏しいが，稀に出血をきたしうる．胃内発育型の孤立性異所腺に対して最低限の切除に抑えられるLECSは有用な治療選択肢になりうると思われた．

A 41-year-old woman, who had a 3-year history of an incidentally detected submucosal tumor of the stomach, presented with upper abdominal pain and tarry stool. She underwent esophagogastroduodenoscopy, and bleeding from the submucosal tumor in the antrum was detected. Endoscopic ultrasound showed cystic anechoic area in the 3rd layer. Although endoscopic biopsy of the lesion was not diagnostic, resection of the tumor was considered to be essential for preventing further bleeding. In order to prevent gastric deformation, and since the tumor developed toward the gastric lumen, she underwent laparoscopy-endoscopy cooperative surgery（LECS） as a diagnostic treatment, and the resected specimen was proven to be a solitary heterotopic submucosal gland. The postoperative course was uneventful. Solitary heterotopic submucosal glands in the shape of submucosal tumor are relatively infrequent and usually asymptomatic, but some of them have hemorrhagic potential. Currently LECS is applied mainly for resection of submucosal tumors represented by GISTs. Comparison with a conventional laparoscopic wedge resection, LECS can reduce resected area of the stomach. Hence, this technique could be a new approach to manage benign submucosal tumors with intraluminal growth.