腹腔鏡下幽門保存胃切除術における術中病理診断の重要性を示す1例

Importance of intraoperative frozen section examination during laparoscopic pylorus preserving gastrectomy : a case of lymph node metastasis along the right gastric artery

◆要旨：患者は65歳，男性．近医で胃癌を指摘され当院紹介となった．粘膜内癌と診断され，2012年2月にendoscopic submucosal dissection（以下，ESD）を施行した．病理診断でM, Ant, 0-IIa＋IIc, 16×9mm, pT1b（SM1）, por>tub2, UL（＋），ly（＋），v（-）であり追加切除となった．2012年5月，腹腔鏡下幽門保存胃切除術，D1＋リンパ節郭清を予定した．術中に6mm大の5番リンパ節を認め，迅速病理診断に提出したところ転移陽性であり，腹腔鏡下幽門側胃切除術，D2郭清へ変更した．M領域のSM癌において非常に稀な5番リンパ節転移を認めた症例を経験したので報告する．このような転移もあることを念頭に置き，腹腔鏡下手術の欠点である触診ができないことを補うように積極的に癌を疑う姿勢が重要と考えられた．

A 65-year-old man was referred to our hospital after being diagnosed with gastric cancer. Because the diagnosis was mucosal cancer, endoscopic submucosal dissection was performed in February, 2012. Pathological examination revealed poorly differentiated adenocarcinoma with submucosal invasion and lymphatic invasion. For an additional treatment, laparoscopic pylorus-preserving gastrectomy with D1＋ lymph node dissection was planned in May, 2012. During the operation, a station 5 lymph node measuring 6mm in diameter was noted. Intraoperative pathological examination revealed metastasis in this lymph node. The operation was converted to laparoscopic distal gastrectomy with D2 lymph node dissection and Roux-en-Y reconstruction. Even though the rate of metastasis to station 5 lymph nodes from submucosal gastric cancer located at the middle of the stomach is low, special attention should be given during laparoscopic surgery because of the lack of palpation which is one of the greatest disadvantages of laparoscopic surgery.