膵頭十二指腸切除術後のCholedochojejunostomy吻合部の狭窄による肝切除術後の術後胆汁漏出-症例報告-

[Postoperative Bile Leakage Following Liver Resection Due to Stenosis of a Choledochojejunostomy Anastomosis after Pancreaticoduodenectomy - A Case Report].

• Yoshihito Nakayama
• Nobukazu Watanabe
• Harue Akasaka

抄録

膵頭十二指腸切除術後に胆管吻合部の狭窄により肝切除後に難治性胆汁漏出を起こした稀な症例を報告する。65 歳女性が膵臓癌と右乳癌と診断され，膵頭十二指腸切除術と右乳房切除術を受け，腋窩リンパ節郭清を同時に行った．当科で補助化学療法と経過観察を行った。18ヶ月後にコンピュータ断層撮影の結果、セグメント8に2.5cmの肝転移が認められた。肝転移の原発巣が不明であり，場所的に生検が困難であったため，肝臓の部分切除を行った．病理検査では乳癌からの肝転移が確認された。術後33日目に右横隔膜下膿瘍のため再入院した。膿瘍ドレナージの結果胆汁の漏出が認められ，原因は胆道切開による吻合部の狭窄と考えられた．経皮経肝的胆管ドレナージを行い、胆汁漏出は直ちに消失した。しかし、胆管内視鏡検査では吻合狭窄を解除することが困難であったため、内視鏡検査で逆行性ドレナージチューブを肝管内に留置し、内瘻を形成した。肝切除術後16ヶ月後に認められた残肝の再発に対し、化学療法を継続して行っている。結論として、膵頭十二指腸切除術後に肝切除を行う場合には、胆汁漏出の可能性があるので注意が必要である。

We report a rare case of intractable bile leakage after liver resection due to stenosis of the anastomosis of a choledochojejunostomy after pancreaticoduodenectomy. A 65-year-old woman was diagnosed with pancreatic and right breast cancer, and underwent pancreaticoduodenectomy and right mastectomy with simultaneous axillary lymph node dissection. Adjuvant chemotherapy and follow-up were performed in our department. After 18 months, computed tomography revealed a liver metastasis of 2.5 cm in segment 8. Because the primary nest of liver metastasis was unknown and performing a biopsy was difficult due to the location, partial resection of the liver was performed. Pathological examination confirmed liver metastasis from the breast cancer. She was rehospitalized due to a right subdiaphragmatic abscess 33 days post-surgery. Abscess drainage revealed bile leakage, and the cause was believed to be stenosis of the anastomosis created by the choledochojejunostomy. Percutaneous transhepatic cholangiographic drainage was performed, and the bile leakage disappeared immediately. However, it was difficult to release the anastomotic stenosis by choledochoscopy; therefore, a retrograde drainage tube was placed in the hepatic duct using enteroscopy, and it formed an internal fistula. The patient has continued to undergo chemotherapy for recurrence in the remnant liver that was observed 16 months after the hepatectomy. In conclusion, when hepatic resection is performed after pancreaticoduodenectomy, attention should be paid to the possible occurrence of bile leakage.