Roux-en-Y再建を伴う胃全摘術後の空腸近位部非吻合性狭窄に対する磁気圧迫吻合術：症例報告

Magnetic compression anastomosis for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction: a case report.

• Teppei Kamada
• Hironori Ohdaira
• Hideyuki Takeuchi
• Junji Takahashi
• Rui Marukuchi
• Norihiko Suzuki
• Satoshi Narihiro
• Sojun Hoshimoto
• Masashi Yoshida
• Eigoro Yamanouchi
• Yutaka Suzuki

抄録

背景:

Roux-en-Y再建術後の胃全摘術後の空腸近位部の非吻合性狭窄はまれな合併症である。内視鏡的バルーン拡張術が効果的でない場合、患者は全身麻酔下での再手術が必要となり、術後合併症の発生率が高い。磁気圧迫吻合は非外科的手技であり、手術で得られる吻合と同様の吻合を行うことができる。Roux-en-Y再建を用いた胃全摘術後の非吻合性空腸狭窄に対する再手術を回避するために磁気圧迫吻合術が成功した症例を報告する。

BACKGROUND: Postoperative non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction is a rare complication. If endoscopic balloon dilation proves ineffective, patients need re-operation under general anesthesia and experience a high rate of postoperative complications. Magnetic compression anastomosis is a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. We report a case in which magnetic compression anastomosis was successfully performed to avoid re-operation for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction.

事例紹介:

70歳の女性が空腸近位部の非吻合性狭窄の治療のために当院に入院した。2年前に他院で進行胃癌に対して開腹胃全摘術とRoux-en-Y再建術を施行している。食欲不振と食物の通過障害を訴えていた。胃癌の再発は認められなかった．食道胃十二指腸鏡検査で食道-空腸吻合部から3cm遠位に円周状の膜状狭窄を認めた．内視鏡的バルーン拡張術を3回施行したが効果なし。食道-空腸吻合部付近に狭窄が存在し、再手術は胸腔内吻合を必要とする高侵襲な術式であったため、磁気圧迫吻合術を計画した。内視鏡的バルーン拡張術により、狭窄部の肛門側に親磁石を配置した。狭窄の改善を確認し、食道胃十二指腸内視鏡下で狭窄部の肛門側に親磁石を配置した。磁石の移動を防ぐために、ナイロン糸に取り付けた親磁石を頬に固定した。親磁石を設置してから1週間後に再狭窄が確認され、娘磁石を狭窄部の口腔側にナイロン糸を介して設置した。2つの磁石は、狭窄を横切って端から端までの方向に吸着された。端から端までの方向に吸着された磁石は、配置から11日後に肛門側に移動した。食道胃十二指腸鏡検査で広汎吻合を確認した。磁気圧迫吻合後の再狭窄を防ぐために内視鏡的バルーン拡張術を定期的に行った。術後の合併症は認められなかった。患者は普通に食事をとることができ、社会復帰にも成功した。

CASE PRESENTATION: A 70-year-old woman was admitted to our hospital for treatment of non-anastomotic stenosis of the proximal jejunum. Open total gastrectomy and Roux-en-Y reconstruction were performed 2 years previously for advanced gastric cancer at another hospital. She complained of anorexia and obstructed passage of food. No recurrence of gastric cancer was identified. Esophagogastroduodenoscopy showed circumferential membranous stenosis of the jejunum 3 cm distal to the esophago-jejunal anastomosis. Endoscopic balloon dilation was performed three times, but proved ineffective. Magnetic compression anastomosis was planned because the stenosis existed near the esophago-jejunal anastomosis and re-operation was a highly invasive procedure requiring intrathoracic anastomosis. Endoscopic balloon dilation preceded placement of the parent magnet on the anal side of the stenosis. Confirming the improvement of stenosis, the parent magnet was placed on the anal side of the stenosis during esophagogastroduodenoscopy. The parent magnet attached to nylon thread was fixed to the cheek to prevent magnet migration. A week after placing the parent magnet, restenosis was confirmed and the daughter magnet was placed via nylon thread on the oral side of the stenosis. The two magnets were adsorbed in the end-to-end direction across the stenosis. Magnets adsorbed in the end-to-end direction moved to the anal side 11 days after placement. Wide anastomosis was confirmed by esophagogastroduodenoscopy. Endoscopic balloon dilation was regularly performed to prevent restenosis after magnetic compression anastomosis. No complications were observed postoperatively. The patient was able to eat normally and successfully reintegrated into society.

結論:

Roux-en-Y再建を伴う胃切除術後の空腸近位部の非吻合性狭窄に対する手術を回避するためには、磁気圧迫吻合が可能である可能性がある。

CONCLUSIONS: Magnetic compression anastomosis could be a feasible procedure to avoid surgery for non-anastomotic stenosis of the proximal jejunum after gastrectomy with Roux-en-Y reconstruction.