3D血管再構築画像が診断に有用であった胃切除・Roux-en-Y再建術後内ヘルニアの1例

Three dimensional angiography using multidetecter-row CT for the diagnosis of internal hernia after distal gastrectomy with Roux-en-Y reconstruction : Report of a case

◆要旨：患者は39歳, 女性．7年前に早期胃癌に対して幽門側胃切除・Roux-en-Y再建術を施行され術後外来経過観察されていた．食後の腹痛と自然軽快を繰り返していたため腹部造影CTを施行したところ，腸間膜根部にwhirl signが認められたが明らかな通過・血流障害を疑う所見は指摘できなかった．3D-CT画像では上腸間膜静脈の完全閉塞と側副血行路の発達を認め，空腸空腸間隙へ小腸が陥入した術後内ヘルニアと診断し腹腔鏡下にヘルニア修復を施行した．術後経過良好で7日目に退院となった．術前血管再構築画像は症状の乏しい症例でも正確なヘルニア状態を診断し安全な腹腔鏡下修復術を行ううえで有用であると考えられた．

A 39-year-old woman who underwent open distal gastrectomy with antecolic Roux-en-Y reconstruction for early gastric cancer 7 years ago developed intermittent abdominal discomfort. Enhanced abdominal CT-scan revealed mesenteric vessel twisting, so called “whirl sign”, around the root of superior mesenteric artery. However, the findings of the obstruction or ischemic change of small intestine was not observed. 3D-angiography showed complete obstruction of superior mesenteric vein and development of the collateral blood flow via right colonic vein to the portal vein. From these findings, we diagnosed this case as postoperative internal hernia and laparoscopic repair was performed. Postoperative course was uneventful and she was discharged on day 7. 3D-angiography by volume rendering is helpful for the patient even without clinical symptom to elucidate the internal hernia in detail and very useful for the safe execution of laparoscopic operation.