Upside down stomachを伴う進行胃癌に対して腹腔鏡下手術を施行した1例

Laparoscopic total gastrectomy for an advanced gastric cancer associated with an upside down stomach : Report of a case

◆要旨：患者は91歳，女性．食欲不振と体重減少を主訴に近医を受診し，進行胃癌の診断で当科紹介となった．食道胃接合部直下に長径11cm大の3型胃癌を認め，upside down stomachを呈する食道裂孔ヘルニアを合併していた．PS2の超高齢者であったが本人と家族の希望もあり，腹腔鏡下胃切除を行った．術中腹腔内洗浄細胞診が陽性で，年齢も考慮しD1＋郭清を伴う腹腔鏡下胃全摘ならびにヘルニア修復術を行った．胃を腹腔内に牽引しても縦隔側に戻ってしまい視野確保に難渋したが，ヘルニア囊内にガーゼを充塡することで胃を腹腔側へ展開し，手術を完遂した．Upside down stomachを伴う進行胃癌で，腫瘍径が大きく，周囲組織と癒着のある症例でも，手技的工夫により，腹腔鏡下胃切除術が可能である．

A 91-year-old female with complaints of anorexia and weight loss was referred to our hospital. An upper endoscopy detected a huge advanced gastric cancer at the upper part of the stomach. Abdominal CT scan showed an extramural invasion of the tumor and demonstrated an esophageal hiatal hernia with an upside down stomach. Although the patient was a very elderly woman with a performance status of grade 2, she underwent laparoscopic surgery. However, intraoperative peritoneal lavage cytology was positive, and the patient underwent a laparoscopic total gastrectomy with D1＋ lymph node dissection, as a reduction surgery, together with hiatus hernia repair. We filled some pieces of gauze in the hernia sac for drawing the intrathoracic stomach into the abdominal cavity prior to performing a gastrectomy, which facilitated a successful laparoscopic gastrectomy. Inserting gauze in the hernia sac to draw the intrathoracic stomach into the abdominal cavity enabled us to handle a large gastric cancer associated with upside down stomach in laparoscopic surgery.