Naohiro Sata

The genesis of the “complex type” classification of pancreaticobiliary maljunction (PBM) is unclear, and the pancreaticobiliary anatomy is also varied according to each case. We encountered a patient with PBM and incomplete pancreatic divisum (PD). We herein discussed about the embryological etiology of pancreaticobiliary system predicted from PBM with incomplete PD. A 67-year-old man was found to have a dilatation of the common bile duct (CBD) during a medical examination at 62 years of age. The dilatation of the CBD subsequently progressed, and he was admitted to our hospital for surgical treatment. Magnetic resonance cholangiopancreatography revealed a dilatation from the common hepatic duct to the middle bile duct with PBM. Endoscopic retrograde cholangiopancreatography from the papilla of Vater revealed the pancreatic main duct via the pancreatic branch duct, and PBM with dilatation of the CBD and incomplete PD were revealed. We performed an extrahepatic bile duct resection and hepaticojejunostomy because of high risk of malignant transformation. Taping and transection of the bile duct without dilatation on the pancreatic side were performed, and thereafter, two orifices of the common channel and ventral pancreatic duct were ligated. The level of amylase in the bile was 7217 IU/L, and a histological examination of the CBD showed an inflammatory change of CBD, not a malignant transformation. It is somewhat easy to identify the pancreatobiliary anatomy when the cause of embryology of both PBM and PD is thought to be an abnormal embryology of the ventral pancreas.

症例は44歳，女性．主訴は心窩部不快感．CTで膵尾部に径約70mmの嚢胞性病変，それと連続し胃壁内に小嚢胞の集簇を認めた．経過観察中に突然の腹痛で当院へ救急搬送され，CTで胃側の嚢胞が長径95mmと増大しており入院した．超音波内視鏡検査で胃側の嚢胞は胃壁筋層内に存在し，膵尾部の嚢胞との交通を認めた．穿刺内容液は血性で，内容液中のamylase（AMY），CEAが高値であった．膵粘液性嚢胞腫瘍（MCN）が胃壁内へ穿破したことによる胃壁筋層内出血と診断し，待機的に手術を行った．手術は膵体尾部脾合併切除を行い，胃側の嚢胞は胃壁の筋層を温存し嚢胞壁のみ合併切除した．膵嚢胞内容液のAMY，CEAは高値で胃壁側の嚢胞液と類似していた．病理組織診断ではMCNの診断であった．MCNが膵管と交通を持ち，胃壁筋層内へ穿破し出血を生じたと考えられる1例を経験したため，文献的考察も含めて報告する．

症例は76歳，女性．右季肋部痛を主訴に近医受診し，精査目的に当院紹介となった．上部内視鏡では胃体上部大彎に小陥凹病変を認め，生検で印環細胞癌と診断された．腹部造影CTにて胃周囲リンパ節の腫大と胃壁肥厚を認めた．リンパ節転移を伴う胃癌の診断で胃全摘術を施行した．術中所見で小腸間膜の一部に数個の結節を認めたため，摘出し病理検査へ提出した．最終診断は低分化型腺癌／印環細胞癌，pT1a（M），ly0，v0，n（18/69）（#４sa，#７，#８a，#10）であり，原病変は約10mm×10mmの胃粘膜内癌で潰瘍瘢痕はなかった．小腸間膜結節は胃癌の転移と診断された．腹膜播種をきたした胃粘膜内癌の極めて稀な１例を経験したので報告する．