術前診断が困難だった残胃のびまん浸潤癌の1例

Diffuse Infiltrative Carcinoma of the Gastric Remnant, Report of a Case

　胃切除後の残胃の病変についての診断は，術後の癒着や変形などの要素も加わって診断法の発達した現在でも困難さを感じることが少なくない．最近，われわれは術前に残胃の小さなIIc型早期胃癌と診断したが，切除標本にてびまん浸潤型進行癌で再手術を余儀なくさせられた症例を経験した．術前のX線写真と内視鏡写真をretrospectiveに検討すると，極めて特異な所見を見逃していたので，反省を含めて報告する．

　症　例

　患　者：53歳，男性．

　主　訴：易疲労感，上腹部痛，体重滅少．

　家族歴：特記すべきことなし．

　既往歴：1970年6月（約11年前）に胃癌にて他院で胃亜全摘，Billroth II法で再建術を受けている．借用した当時の術前の内視鏡フィルムでは（Fig. 1），幽門前庭部の全周性のBorrmann 3型胃癌である．切除標本の病理組織学的報告では，adenocarcinoma tubulare et mucocellulare，深達度pm，infβ，ow（－），aw（－），

リンパ節転移なし，とのことであった．その後同院で胃X線検査と胃内視鏡検査を毎年のように繰り返し施行されていたが，特に異常は指摘されなかった．

　The patient, a man 53 years of age, underwent subtotal gastrectomy and Billroth Ⅱ reconstruction 11 years before at another hospital because of Borrmann 3 type of gastric cancer in the pyloric antrum. Recently he visited the same hospital with chief complaints of easy fatiguability, weight loss and epigastralgia. As cancer of the gastric remnant was found by endoscopic examination, he was referred to our hospital. X-ray and endoscopic examination of the remnant stomach before the operation gave us a diagnosis of early cancer of Ⅱc type, so that subtotal excision of the remnant stomach was carried out. Histological examination of the resected specimen revealed that it was diffuse infiltrative advanced cancer with cancer infiltration at the oral margin. He had to undergo total resection of the residual stomach with distal pancreatectomy and splenectomy. One year and a half later the patient is free from any symptoms of recurrence.

　In the resected specimen were seen small erosions scattered about on the folds of the greater curvature besides Ⅱc-like lesions diagnosed before the operation. Retrospective study of the x-ray films and endoscopic pictures showed that these erosive lesions were well depicted but they were overlooked. It is quite a rare finding for small erosions to be scattered about over the folds of the greater curvature.

　If we had been able preoperatively not to overlook these lesions, we might have been able to arrive at an accurate diagnosis. Some reference to the literature was made.