Tashiro Yoshihiko, Murakami Masahiko, Otsuka Koji, Saito Kazuhiko, Saito Akira, Motegi Kentaro, Date Hiromi, Yamashita Takeshi, Ariyoshi Tomotake, Goto Satoru, Yamazaki Kimiyasu, Fujimori Akira, Watanabe Makoto, Aoki Takeshi
Department of General and Gastroenterological Surgery, Showa University School of Medicine, Tokyo, Japan.
Case Rep Gastroenterol. 2016 May 19;10(1):1-6. doi: 10.1159/000443268. eCollection 2016 Jan-Apr.
Intrathoracic hernias after total gastrectomy are rare. We report the case of a 78-year-old man who underwent total gastrectomy with antecolic Roux-Y reconstruction for residual gastric cancer. He had alcoholic liver cirrhosis and received radical laparoscopic proximal gastrectomy for gastric cancer 3 years ago. Early gastric cancer in the remnant stomach was found by routine upper gastrointestinal endoscopy. We initially performed endoscopic submucosal dissection, but the vertical margin was positive in a pathological result. We performed total gastrectomy with antecolic Roux-Y reconstruction by laparotomy. For adhesion of the esophageal hiatus, the left chest was connected with the abdominal cavity. A pleural defect was not repaired. Two days after the operation, the patient was suspected of having intrathoracic hernia by chest X-rays. Computed tomography showed that the transverse colon and Roux limb were incarcerated in the left thoracic cavity. He was diagnosed with intrathoracic hernia, and emergency reduction and repair were performed. Operative findings showed that the Roux limb and transverse colon were incarcerated in the thoracic cavity. After reduction, the orifice of the hernia was closed by suturing the crus of the diaphragm with the ligament of the jejunum and omentum. After the second operation, he experienced anastomotic leakage and left pyothorax. Anastomotic leakage was improved with conservative therapy and he was discharged 76 days after the second operation.
全胃切除术后胸内疝较为罕见。我们报告一例78岁男性患者，因残胃癌接受了结肠前Roux-Y重建全胃切除术。他患有酒精性肝硬化，3年前因胃癌接受了根治性腹腔镜近端胃切除术。通过常规上消化道内镜检查发现残胃早期胃癌。我们最初进行了内镜下黏膜下剥离术，但病理结果显示垂直切缘阳性。我们通过剖腹手术进行了结肠前Roux-Y重建全胃切除术。由于食管裂孔粘连，将左胸与腹腔相连。未修复胸膜缺损。术后两天，胸部X线检查怀疑患者患有胸内疝。计算机断层扫描显示横结肠和Roux袢被嵌顿在左胸腔内。他被诊断为胸内疝，并进行了急诊还纳和修补。手术所见显示Roux袢和横结肠被嵌顿在胸腔内。还纳后，通过将膈肌脚与空肠韧带和网膜缝合来关闭疝孔。第二次手术后，他出现了吻合口漏和左侧脓胸。吻合口漏经保守治疗后好转，第二次手术后76天出院。
