胃石を伴った残胃癌の1手術例

Phytobezoar Formation with Carcinoma in the Remnant Stomach, Report of a Case

要旨　患者は46歳の男性で，16年前に十二指腸潰瘍にてBillroth Ⅱ法による広範囲胃切除術を受けた．7か月にわたる上腹部膨満感と黒色便を主訴として来院し，臨床検査成績上では軽度の貧血を呈したのみであったが，上腹部に小児頭大の腫瘤を触知し，上部消化管造影（Fig. 1），胃内視鏡検査（Fig. 2）にて巨大な胃石を認めた．これに対し，内視鏡的に3度にわたってポリペクトミースネアを用いて砕石し，完全に除去した．しかしこの処置の際，内視鏡にて白苔を伴った潰瘍形成が吻合部にみられた（Fig. 3）．その後の上部消化管造影にても，胃壁の不整，狭窄の所見が吻合部近傍に認められた（Fig. 4）．生検の結果，中等度分化型腺癌であった．この患者に対し胃の再切除を行いRoux-en Y吻合にて再建し根治しえた．切除標本（Fig. 5）では肉眼的に吻合部の狭窄を起こしたのであろう，悪性を思わせる隆起牲病変が吻合部に認められ，組織学的には中等度分化型腺癌の像を呈していた（Fig. 6）．

　With the success of surgical method for gastroduodenal lesion with no malignancy, a unique population of patients with partial gastrectomy and vagotomy were recognized as being susceptible to bezoar formation. But it is very rare that phytobezoar is associated with carcinoma in the remnant stomach. We report one of such rare cases.

　The patient was a 46 year-old man who came to our institute with a sense of upper abdominal fullness and tarry stool for seven months. He had undergone partial gastrectomy with Billroth Ⅱ reconstruction for duodenal ulcer 16 years before. Laboratory data revealed only mild anemia. But a childhead-sized tumor was palpated in the upper abdomen. Furthermore, radiologic and endoscopic examination revealed a giant phytobezoar in the remnant stomach (Fig. 1, 2). Using endoscope, we tried to tear apart the bezoar three times, and it was completely removed. During this treatment, carcinoma in the remnant stomach was found out at the portion of stoma (Fig. 3, 4). For this patient, curative re-resection of the stomach with Roux-en Y anastomosis was performed. Macroscopic findings showed carcinoma in the remnant stomach causing the stenosis of the stoma (Fig. 5). Microscopic findings showed that tumor cells consisted of moderately differentiated adenocarcinoma cells (Fig. 6). Therefore, we diagnosed this case as a very rare case of phytobezoar associated with carcinoma in the remnant stomach. And we were able to carry out a curative operation for this case.