胃噴門直下前壁消化管間葉系腫瘍に対しロボット支援下経皮的内視鏡下胃内手術で局所切除しえた1例

A case of gastrointestinal stromal tumor near the anterior aspect of the gastric cardia treated with robot-assisted percutaneous endoscopic intragastric surgery

◆要旨：患者は63歳，男性．食道胃接合部から5mm離れた胃穹隆部前壁に2cm大の壁内発育型消化管間葉系腫瘍（GIST）を指摘された．従来の低侵襲外科手術では噴門機能の温存が困難と判断し，ロボット支援下経皮的内視鏡下胃内手術を行った．胃壁を腹壁に固定後，12mmバルーンポートを3か所に挿入した．Trocar-in-trocar techniqueを用いてda Vinci Xi Surgical System（Intuitive Surgical, Inc. Sunnyvale, CA）をドッキングし，カメラと2本のロボット鉗子を使用した．経胃的に腫瘍を全層で局所切除，摘出し，胃壁欠損部を縫合閉鎖した．手術時間295分，出血量12ml，術後合併症なく術後8日目に退院とした．内視鏡手術支援ロボットを使用することで，噴門近傍前壁の壁内発育型GISTを経皮経胃的に安全に局所切除できる可能性が示唆された．

　The principles of surgical treatment for primary resectable gastric gastrointestinal stromal tumors （GIST） are complete resection without causing tumor rupture and negative margins. Here, we report a case of GIST near the anterior aspect of the gastric cardia successfully treated with robot-assisted percutaneous endoscopic intragastric surgery. A 63 year-old man underwent annual endoscopy for upper GI cancer screening. A gastric submucosal tumor, 2cm in size, was found at the anterior aspect of the gastric fornix 1cm above the cardia. Endoscopic ultrasound-guided fine needle aspiration biopsy resulted in GIST. Local resection with conventional use of laparoscopy and endoscopy or percutaneous endoscopic intragastric surgery was difficult, considering the location of the tumor. Therefore, based on our abundant experiences in robotic gastrectomy, we performed percutaneous endoscopic intragastric surgery using da Vinci Xi Surgical System （Intuitive Surgical, Inc., Sunnyvale, CA）. The tumor was completely removed with a necessary and sufficient margin, preserving the cardia. A total operative time was 295 minutes, and the estimated blood loss was 12ml. This patient was uneventfully discharged on postoperative day 8. Robot-assisted percutaneous endoscopic intragastric surgery may be one of the useful therapeutic options even for gastric GIST located near the anterior aspect of the cardia.