術前ENPDチューブ留置が有用であった腹腔鏡下膵腫瘍核出術の1例

Laparoscopic enucleation with useful preoperative ENPD for pancreatic neuroendocrine tumor : A case report

◆要旨：患者は65歳，女性．糖尿病のフォロー中，エコー検査にて約8mmの膵体部腫瘍を指摘された．EUS下生検では膵神経内分泌腫瘍G1であった．手術前日にENPDチューブを留置し，完全腹腔鏡下膵腫瘍核出術を施行した．術後膵液瘻は，ISGPF Grade Aであり，術後6日目にドレーン抜去，12日目に軽快退院となった．術前留置したENPDチューブは，術中に主膵管を同定するナビゲーションとしては非常に有用であった．ただし，自験例では術中主膵管が露出してしまい損傷の危険性も高く，推奨されるべき術式とは言えなかった．腹腔鏡下膵腫瘍核出術の適応となる症例は少なく，技術的に難しい部分もある．慎重な症例選択と丁寧な手術手技，安全性の高いトラブルシューティングが重要であると考える．

　A 65-year-old woman came to our hospital because of a small pancreatic tumor that was accidentally found during follow up ultrasonography for diabetes mellitus. Abdominal enhanced CT scan and MRI revealed a tumor approximately 6mm in diameter in the pancreatic body. Diagnosis of pancreatic neuroendocrine tumor （pNET） G1 was confirmed by endoscopic ultrasound-guided fine-needle aspiration biopsy （EUS-FNAB）. Endoscopic nasopancreatic drainage （ENPD） tube was placed before the operation. Complete laparoscopic enucleation （Lap-EN） of pancreatic tumor was performed. The tumor size was 10×10×9 mm and pathologic diagnosis was pNET G1. After operation, the patient developed ISGPF grade A pancreatic fistula, but the drainage tube was removed on postoperative day 6. Postoperative course was uneventful and she was discharged on postoperative day 12. During surgery, ENPD tube that was inserted preoperatively was very useful as a navigation tool for the main pancreatic duct. For the dissection of pancreas parenchyma, short pitch crash technique and the use of energy device were very safe. The number of cases indicated for Lap-EN is few. Some of the techniques required for the operation are difficult. Therefore, case selection for Lap-EN and operative procedures are important and should be considered carefully.