膵頭十二指腸切除術後の反復性胆管炎に対して腹腔鏡下消化管経路変更術が有用であった1例

Laparoscopic gastrointestinal tract conversion for recurrent cholangitis after pancreaticoduodenectomy : A case report

◆要旨：症例は76歳，男性．55歳時に十二指腸乳頭部癌に対して膵頭十二指腸切除術（PPPD-Ⅲ），術後13年に反復性胆管炎に対して開腹で消化管経路変更術（SSPPD-Ⅱ，BillrothⅡ法，Braun吻合付加）を施行した．再手術後も胆管炎を再燃し月に1回程度の入院を要するようになり，再手術後8年に腹腔鏡下消化管経路変更術（SSPPD-Ⅱ，Roux-en-Y再建）を施行した．輸入脚側を胃空腸吻合近くで離断し，Braun吻合を自動縫合器で離断した．解除したBraun吻合から20cm肛門側と輸入脚断端をオーバーラップ法で腹腔内吻合した．術後2年経過し，半年に1回程度の胆管炎をきたすものの，速やかに軽快しQOLは改善している．膵頭十二指腸切除術後の反復性胆管炎に対して腹腔鏡下消化管経路変更術は選択肢の一つとなりうる．

　The present study reports a case of a 76-year-old male patient that underwent pylorus-preserving pancreaticoduodenectomy（PPPD-Ⅲ）for duodenal carcinoma at the age of 55. After the surgery, he suffered recurrent cholangitis and underwent tract conversion surgery（SSPPD-Ⅱ, Billroth-Ⅱmethod with Braun anastomosis）by laparotomy 13 years after the first surgery. Despite the surgery, he was readmitted once a month due to recurrent cholangitis. Therefore, a laparoscopic tract conversion（SSPPD-Ⅱ, Roux-en-Y reconstruction）was performed 21 years after the first surgery（8 years after the re-operation）. The afferent limb near the gastrointestinal anastomoses was transected with a stapling device. Next, the Braun anastomosis was removed with the stapling device. An intracorporeal anastomosis was performed of the efferent limb at the anal position of the detached Braun anastomosis and the cut end of the afferent limb using the overlap method. Follow-up after two years of the surgery has shown that patient's cholangitis repeats after about every six months. However, this cholangitis usually resolves quickly, and the patient's quality of life has improved. Finally, in case of recurrent cholangitis after pancreaticoduodenectomy, laparoscopic gastrointestinal realignment surgery might be considered a good alternative.