総胆管拡張のない膵管―胆道合流異常に合併した胆囊癌の1例―胆道造影と切除標本における合流部の対比

Gallbladder Cancer Accompanied by Anomalous Pancreatico-Biliary Ductal System: A thorough study of a case by means of clinical and pathophysiological findings

要旨　総胆管拡張のない膵管―胆道合流異常を合併した胆囊癌症例に肝区域切除を伴う胆囊摘除および膵頭十二指腸切除術を施行した．切除標本は5mmごとの切片とし，乳頭部から膵―胆管合流部までの組織形態学的検索を行った．ERCPで膵管は乳頭より30mm離れた高位で総胆管に合流し，narrow distal segmentは15mmであった．切除標本で，合流部は乳頭より30mm離れた高位にあり，乳頭部より10mmの切片では，共通管に乳頭括約筋は全周性に存在していたが，15mmの切片では，括約筋は一部（全周の約1/3）に存在するのみであった．当然のことながら，膵―胆管合流部位には括約筋は存在していない．胆囊癌は高分化型腺癌であった．

　A case of gallbladder cancer, a 55 year-old woman accompanied by anomalous pancreatico-biliary ductal system has been reported. Cholecystectomy, hepatectomy and pancreatico-duodenectomy were perfomed on this patient. The histopathological criteria of anomalous pancreatico-biliary ductal system were verified in the excised specimen. Preoperative analysis of imaging techniques were in accord with the findings concerning the specimen. On ERCP an anomalous junction was located at 3 cm from the ampulla of Vater and the length of the, narrow distal segment was 1. 5 cm (Fig. la). On the specimen the cross section of every 5 mm in width from the ampulla of Vater to the junction revealed a common channel surrounded by the sphincter of Oddi and muscularis propria of the duodenum (Fig. 8 slice A). At 15 mm from the ampulla of Vater the sphincter of Oddi had partially disappeared and the muscularis propria was not completely recognizable. The length of narrow distal segment was about 15 mm. At the junction, both the common bile duct and the main pancreatic duct were excluded from the sphincter muscle. It should be stressed that a thorough study in clinical imaging technique and histopathological examination after the operation are both important for a balanced judgment in the treatment of cases with anomalous pancreaticobiliary ductal system.