左上腹部腫瘤の腹腔鏡下切除による驚きの診断

Laparoscopic Resection of a Left Upper Quadrant Mass Leading to a Surprise Diagnosis.

• Hugo J R Bonatti
• Reinhardt O Sahmel
• Rodrigo B Erlich

抄録

.脾臓切除術は、欠損した付属脾臓の再生により内科的管理が困難な再発性特発性血小板減少性紫斑病（ITP）の治療のために最も一般的に行われる。66歳の男性が40年前に外傷性破裂のために脾臓開放摘出術を受けた。彼は下腿部の平滑筋肉腫を呈し、外科的に摘出された。転移性疾患を発症したため，化学療法を開始した．左上腹部痛を発症し，CT検査では膵臓尾部と左副腎の間に肉腫と思われる5cmの腫瘤が認められた．腹腔鏡検査では、前の脾臓摘出術で摘出された黄体の腹壁と胃への緻密な癒着が認められた。小嚢は胃腸靭帯を介して開腹し、脾弯を取り除いた。左副腎横の膵臓の尾部より上側と背側に腫瘤を同定し、慎重に解剖した。膵臓尾部にある脾臓血管の側枝に由来する血管ペディクルをステープルで留置した。胃底に複数の結節を認めたため、修正スリーブ胃切除術を行い、肝臓5節の2cmの結節と卵巣結節を切除した。腫瘍と胃切除標本はエンドバッグに入れられ、腹腔鏡下ミニ切開で切除された。患者は手術の合併症もなく回復し、LUQの疼痛も消失した。病理検査では肉腫の転移はなかったが、すべての標本に付属脾臓が認められた。.外傷による脾臓摘出術後の腹腔内に複数のインプラントを有する脾臓症は稀な状態である。我々の患者では、肉腫に対する化学療法により髄外造血を引き起こしたことが引き金となったようである。腹腔鏡下での付属脾臓摘出は安全に行うことができる。

. Resplenectomy is most commonly done for the treatment of recurrent idiopathic thrombocytopenic purpura (ITP) refractory to medical management due to the regrowth of a missed accessory spleen. . A 66-year-old male had undergone open splenectomy for traumatic rupture 40 years ago. He presented with a leiomyosarcoma of his leg, which was surgically removed. When he developed metastatic disease, chemotherapy was started. He developed left upper quadrant pain, and on CT scan, a 5 cm mass compatible with a sarcoma was found between the tail of the pancreas and the left adrenal gland. During laparoscopy, dense adhesion of the omentum to the abdominal wall and the stomach from his previous splenectomy was divided. The lesser sac was opened through the gastrocolic ligament, and the splenic flexure was taken down. Superior and dorsal to the tail of the pancreas next to the left adrenal gland, the mass was identified and carefully dissected out. The vascular pedicle, which originated from a side branch of the splenic vessels at the tail of the pancreas, was stapled. The gastric fundus showed multiple nodules, and therefore, a modified sleeve gastrectomy was done; also, a 2 cm nodule in segment 5 of the liver and an omental nodule were removed. The tumors and gastrectomy specimen were placed in an endobag and removed through a periumbilical mini-incision. The patient recovered without any complications from the procedure and his LUQ pain resolved. Pathology revealed no sarcoma metastases but accessory spleens in all specimens. . Splenosis with multiple implants within the abdomen after splenectomy for trauma is a rare condition. In our patient, this seems to have been triggered by chemotherapy for his sarcoma resulting in extramedullary hemopoiesis. Laparoscopic removal of accessory spleens can be safely done.

Copyright © 2020 Hugo J. R. Bonatti et al.