内容紹介
Urgent Gastrectomy in a Patient Who Developed Perforated Gastric Cancer during Preoperative Chemotherapy with S-1 plus Cisplatin
Summary
A 66-year-old man presenting with a chief complaint of upper abdominal pain was diagnosed as having an advanced adenocarcinoma, type 2, of the lower third of the stomach after endoscopy was performed. An abdominal computed tomography(CT)scan revealed 4 lymph node metastases at the infrapyloric nodes(station No. 6)and the nodes around the proximal splenic artery(station No. 11p)and the abdominal aorta(station No. 16a2). The clinical stage was determined to be T3(SS)N2M1(LYM), Stage Ⅳ. Gastrectomy with D2 plus para-aortic node dissection was scheduled after 2 courses of S-1 plus cisplatin(CDDP)with curative intent. On day 14 after starting S-1 therapy, the patient complained of severe abdominal pain and peritoneal irritation of acute onset. Because the abdominal CT scan showed a large amount of intra-abdominal free air, we performed an urgent laparotomy with a tentative diagnosis of perforation of the gastric cancer. On laparotomy, we found a perforated malignant ulcer, 5 cm in maximum diameter, in the lesser curvature of the stomach; therefore, distal gastrectomy with D1 plus lymphadenectomy and reconstruction using the Roux-en-Y method were performed. At the end of the surgery, a macroscopic residual tumor remained in the para-aortic lymph node. The postoperative course was uneventful, and the patient was discharged on day 23 after surgery. In the present case, despite the performance of urgent gastrectomy while the patient was receiving strong chemotherapy, perioperative management was successful, with no serious postoperative complication or adverse events as a result of the chemotherapy.
要旨
症例は66歳,男性。上腹部痛を主訴に受診し,内視鏡検査で幽門前庭部の2型進行胃癌の診断となった。腹部CT検査では幽門下(No. 6),脾動脈近位(No. 11p),腹部大動脈周囲(No. 16a2)リンパ節に計4個の転移を認め,臨床病期はT3(SS)N2M1(LYM),Stage Ⅳと診断した。治療方針はS-1+CDDP療法を2コース投与後に,胃切除術,D2+大動脈周囲リンパ節郭清を予定した。化学療法開始から14日目に突然の上腹部痛と腹膜刺激症状が出現した。腹部CT検査で腹腔内遊離ガスを認め,胃癌穿孔の診断で緊急手術を行った。開腹所見では約5 cmにわたり胃癌の穿孔を認め,手術は幽門側胃切除術,Roux-en-Y再建,D1+リンパ節郭清を行った。大動脈周囲リンパ節が遺残したが,術後経過は順調で第23病日に退院した。本症例は強力な化学療法中の緊急胃切除術であったが,術後合併症や化学療法の有害事象を生じず安全に周術期管理が可能であった。
目次
Summary
A 66-year-old man presenting with a chief complaint of upper abdominal pain was diagnosed as having an advanced adenocarcinoma, type 2, of the lower third of the stomach after endoscopy was performed. An abdominal computed tomography(CT)scan revealed 4 lymph node metastases at the infrapyloric nodes(station No. 6)and the nodes around the proximal splenic artery(station No. 11p)and the abdominal aorta(station No. 16a2). The clinical stage was determined to be T3(SS)N2M1(LYM), Stage Ⅳ. Gastrectomy with D2 plus para-aortic node dissection was scheduled after 2 courses of S-1 plus cisplatin(CDDP)with curative intent. On day 14 after starting S-1 therapy, the patient complained of severe abdominal pain and peritoneal irritation of acute onset. Because the abdominal CT scan showed a large amount of intra-abdominal free air, we performed an urgent laparotomy with a tentative diagnosis of perforation of the gastric cancer. On laparotomy, we found a perforated malignant ulcer, 5 cm in maximum diameter, in the lesser curvature of the stomach; therefore, distal gastrectomy with D1 plus lymphadenectomy and reconstruction using the Roux-en-Y method were performed. At the end of the surgery, a macroscopic residual tumor remained in the para-aortic lymph node. The postoperative course was uneventful, and the patient was discharged on day 23 after surgery. In the present case, despite the performance of urgent gastrectomy while the patient was receiving strong chemotherapy, perioperative management was successful, with no serious postoperative complication or adverse events as a result of the chemotherapy.
要旨
症例は66歳,男性。上腹部痛を主訴に受診し,内視鏡検査で幽門前庭部の2型進行胃癌の診断となった。腹部CT検査では幽門下(No. 6),脾動脈近位(No. 11p),腹部大動脈周囲(No. 16a2)リンパ節に計4個の転移を認め,臨床病期はT3(SS)N2M1(LYM),Stage Ⅳと診断した。治療方針はS-1+CDDP療法を2コース投与後に,胃切除術,D2+大動脈周囲リンパ節郭清を予定した。化学療法開始から14日目に突然の上腹部痛と腹膜刺激症状が出現した。腹部CT検査で腹腔内遊離ガスを認め,胃癌穿孔の診断で緊急手術を行った。開腹所見では約5 cmにわたり胃癌の穿孔を認め,手術は幽門側胃切除術,Roux-en-Y再建,D1+リンパ節郭清を行った。大動脈周囲リンパ節が遺残したが,術後経過は順調で第23病日に退院した。本症例は強力な化学療法中の緊急胃切除術であったが,術後合併症や化学療法の有害事象を生じず安全に周術期管理が可能であった。