内容紹介
A Case of Transduodenal Ampullectomy for an Ampullary Neoplasm Coexisting with Gastric and Colon Cancer
Summary
We present here a case of transduodenal ampullectomy for an ampullary neoplasm coexisting with gastric and colon cancer. The patient was a 72-year-old man who was referred to our hospital with a positive fecal blood test. Colonoscopy revealed advanced cancer in the descending colon. As part of the preoperative examination, for the colonic cancer, upper gastrointestinal endoscopy was performed. Endoscopy showed a 2 cm elevated lesion(0′-Ⅱa type)with subserosal infiltration on the small curvature side of the upper part of the stomach, and a 2 cm elevated lesion on the papilla of Vater. Histopathological examination showed that the former was a well differentiated tubular adenocarcinoma and the latter was a villous tubular adenoma with severe atypia. First, laparoscopic colectomy for advanced descending colon cancer was performed. Total gastrectomy with Roux-en-Y reconstruction, cholecystectomy, and transduodenal ampullectomy for the ampullary neoplasm 21 days after the first surgery. The patient was discharged without any complications, such as postoperative suture failure. According to pathological tissue diagnosis, the degrees of progress of the colorectal cancer and the gastric cancer were pT2(MP)and pT1b(SM2), respectively, and there was no lymph node metastasis. The duodenal papillary tumor was a tubular villous adenoma(high grade). Local excision of the papilla is minimally invasive, leaves easy-to-secure stumps, and has less risk of complications such as bleeding and pancreatitis. Taking into account the balance with coexisting gastrointestinal cancer treatment, local excision of the papilla in this case was considered to be an appropriate treatment.
要旨
胃癌・大腸癌に併発した乳頭部腫瘍に対する経十二指腸乳頭切除術を経験した。症例は72歳,男性。進行下行結腸癌の術前検査で行われた上部消化管内視鏡検査において,胃体上部小弯にSM浸潤が考えられる2 cm大の隆起性病変(0′-Ⅱa型)がみられ,十二指腸乳頭部には2 cm大に腫大した腫瘍を認めた。病理組織所見は前者が高分化管状腺癌であり,後者が異型性の強い絨毛管状腺腫であった。まず下行結腸癌に対して腹腔鏡下左結腸切除術を施行し,21日後に胃全摘術(D1),Roux-en-Y法,胆囊摘出術,十二指腸切開,経十二指腸乳頭切除術を施行した。術後縫合不全など合併症もなく軽快退院した。病理組織診断では大腸癌,胃癌の深達度はそれぞれpT2(MP),pT1b(SM2)でありリンパ節転移はなかった。十二指腸乳頭部腫瘍は管状絨毛腺腫(high grade)であった。乳頭部局所切除は,低侵襲であるとともに断端を確保しやすく,出血や膵炎などの合併症のリスクが少ない。併存する消化器癌の治療とのバランスを考え,本症例での乳頭部局所切除は有用な方法と考えられた。
目次
Summary
We present here a case of transduodenal ampullectomy for an ampullary neoplasm coexisting with gastric and colon cancer. The patient was a 72-year-old man who was referred to our hospital with a positive fecal blood test. Colonoscopy revealed advanced cancer in the descending colon. As part of the preoperative examination, for the colonic cancer, upper gastrointestinal endoscopy was performed. Endoscopy showed a 2 cm elevated lesion(0′-Ⅱa type)with subserosal infiltration on the small curvature side of the upper part of the stomach, and a 2 cm elevated lesion on the papilla of Vater. Histopathological examination showed that the former was a well differentiated tubular adenocarcinoma and the latter was a villous tubular adenoma with severe atypia. First, laparoscopic colectomy for advanced descending colon cancer was performed. Total gastrectomy with Roux-en-Y reconstruction, cholecystectomy, and transduodenal ampullectomy for the ampullary neoplasm 21 days after the first surgery. The patient was discharged without any complications, such as postoperative suture failure. According to pathological tissue diagnosis, the degrees of progress of the colorectal cancer and the gastric cancer were pT2(MP)and pT1b(SM2), respectively, and there was no lymph node metastasis. The duodenal papillary tumor was a tubular villous adenoma(high grade). Local excision of the papilla is minimally invasive, leaves easy-to-secure stumps, and has less risk of complications such as bleeding and pancreatitis. Taking into account the balance with coexisting gastrointestinal cancer treatment, local excision of the papilla in this case was considered to be an appropriate treatment.
要旨
胃癌・大腸癌に併発した乳頭部腫瘍に対する経十二指腸乳頭切除術を経験した。症例は72歳,男性。進行下行結腸癌の術前検査で行われた上部消化管内視鏡検査において,胃体上部小弯にSM浸潤が考えられる2 cm大の隆起性病変(0′-Ⅱa型)がみられ,十二指腸乳頭部には2 cm大に腫大した腫瘍を認めた。病理組織所見は前者が高分化管状腺癌であり,後者が異型性の強い絨毛管状腺腫であった。まず下行結腸癌に対して腹腔鏡下左結腸切除術を施行し,21日後に胃全摘術(D1),Roux-en-Y法,胆囊摘出術,十二指腸切開,経十二指腸乳頭切除術を施行した。術後縫合不全など合併症もなく軽快退院した。病理組織診断では大腸癌,胃癌の深達度はそれぞれpT2(MP),pT1b(SM2)でありリンパ節転移はなかった。十二指腸乳頭部腫瘍は管状絨毛腺腫(high grade)であった。乳頭部局所切除は,低侵襲であるとともに断端を確保しやすく,出血や膵炎などの合併症のリスクが少ない。併存する消化器癌の治療とのバランスを考え,本症例での乳頭部局所切除は有用な方法と考えられた。