Treitz靱帯近傍GISTに対し完全腹腔鏡下で切除・再建を施行した2例

Two cases of gastrointestinal stromal tumor near the ligament of Treitz resected by complete laparoscopic surgery

◆要旨：Treitz靱帯近傍に発生した空腸GISTの2症例に対して完全腹腔鏡下で手術を施行した．症例1は73歳，男性．黒色便の精査中，CTで左上腹部に腫瘤を認め，近位空腸もしくはその腸間膜腫瘍が疑われ手術の方針とした．single incision laparoscopic surgery（SILS）＋1ポートで手術を開始し，Treitz靱帯から2cmの空腸に60mm大の腫瘤を認めた．完全腹腔鏡下に小腸を切除し，再建は十二指腸水平脚の軸に合わせて1ポートを追加し，機能的端端吻合を施行した．症例2は74歳，男性．スクリーニング検査のCTで空腸起始部に石灰化を伴う腫瘤を認めた．経過観察中，緩徐に増大することから手術の方針とした．4ポートで手術を開始し，Treitz靱帯から5mmの空腸に40mm大の腫瘤を認めた．完全腹腔鏡下に小腸を切除し，再建は十二指腸水平脚の軸に合わせ1ポートを追加し，機能的端端吻合を施行した．症例1，2ともにGISTと診断した．Treitz靱帯近傍の腫瘍切除に対する再建は，後腹膜に固定された十二指腸水平脚との吻合となる．完全腹腔鏡下での再建に際し，十二指腸側の血流とポート位置が重要と考えられ，当科で行った工夫について報告する．

　We report two cases of gastrointestinal stromal tumor near the ligament of Treitz, which were resected by complete laparoscopic surgery. Case1: A 73-year-old man presented with melena, and a tumor measuring 65mm in size was discovered in the proximal jejunum or mesentery by CT. We performed the operation using SILS＋1 ports, and found a jejunal tumor measuring 60mm in size 2 cm from the ligament of Treitz. We resected the tumor and reconstructed the intestine by intracorporeal functional end-to-end anastomosis aided by the addition of another port parallel to the third part of the duodenum. Case2: A 74-year-old man presented with a cough, and a calcified tumor was discovered in proximal jejunum by CT. We performed the operation using 4 ports, and found a jejunal tumor measuring 40mm in size, which was 0.5cm from the ligament of Treitz. We resected the tumor and reconstructed the intestine by intracorporeal functional end-to-end anastomosis aided by the addition of another port parallel to the third part of the duodenum. Both tumors were GIST. Through these two cases, we optimized the location of the ports in order to carry out the procedure completely through laparoscopic surgery.