径96mmの食道GISTに対して胸腔鏡・腹腔鏡併用下に切除した1例

A case of esophageal GIST of 96mm in diameter resected by thoracoscopic and laparoscopic surgery

◆要旨：症例は75歳の男性．胸部単純X線検査で縦隔腫瘍を指摘され，精査目的の胸部CTで左下胸腔内に突出する境界明瞭な96mmの腫瘍を認めた．超音波内視鏡下穿刺吸引細胞診より食道GISTと診断した．手術は内視鏡下で開始した．まず，胸腔鏡下に腫瘍の周囲剝離と口側食道の切離を行った後，腹腔鏡下に横隔膜を切離して下部食道と腫瘍を経横隔膜的に腹腔内に導出して噴門側胃とともに腫瘍を摘出した．再建は食道亜全胃管前壁吻合を内視鏡下に施行した．術後経過は良好で第14病日に軽快退院となった．大きい腫瘍では，鉗子の動作制限や腫瘍による死角が生じやすいために内視鏡手術は不向きであるが，胸腔鏡と腹腔鏡を併用することでこれらの欠点を補完できる可能性がある．

　A 75-year-old man was referred to our hospital because of a mediastinal tumor on chest X-ray. Computed tomography revealed a giant solid tumor, which was 96 mm in diameter with a well-defined border that protruded into the left thoracic cavity. Fine-needle aspiration biopsy under endoscopic ultrasonography demonstrated a c-kit-positive esophageal gastrointestinal stromal tumor （GIST）. The patient underwent thoracoscopic and laparoscopic surgery. First, we dissected tissue surrounding the tumor and transected the esophagus on the proximal side of the tumor under thoracoscopy. Secondly, we cut the left diaphragm under laparoscopy and resected the tumor through it. After resection, intrathoracic esophagogastrostomy was completed laparoscopically. The patient was discharged on the 14^th day after operation uneventfully. Endoscopic surgery may not be suitable for giant tumors because of restricted movement of the forceps and blind spots. However, this case demonstrated that thoracoscopic and laparoscopic surgery can complement each other.