当 院 で 経 験 し た 亜 全 胃 温 存 膵 頭 十 二 指 腸 切 除 術（sub-total stomach-preserving pancreatoduodenectomy, 以下 SSPPD）後の胃空腸吻合部に生じた吻合部潰瘍穿孔の２治療例を 報告する．症例１は十二指腸乳頭部癌に対し SSPPD を施行された51歳女性．下腹部痛を主訴に 救急外来を受診，腹部 CT にて free air を指摘された．穿孔性腹膜炎と診断し，緊急開腹手術を施行した．症例２は膵頭体部癌に対し SSPPD を施行された後，肝転移に対し化学療法中であった 69歳男性．左側腹部痛を主訴に救急搬送され腹部CTでfree airを認めるも保存的加療にて軽快した． ２例とも SSPPD 後の吻合部潰瘍穿孔であったため術後の胃酸分泌能が術前と同等に維持されていた可能性がある．症例１はプロトンポンプ阻害薬を内服中にも関わらず発症した．症例２は腰痛 に対する非ステロイド消炎鎮痛剤を常用していたことも発症の一助と推察される．SSPPD 術後の合併症として吻合部潰瘍の可能性を念頭におき予防に努める必要がある．症例に応じては保存的加 療でも改善が見込める場合がある． We herein report on two cases that were treated for a perforated ulcer at the gastrojejunostomy anastomosis site after a subtotal stomach-preserving pancreatoduodenectomy (SSPPD). The first case was a 51-year old female who received an SSPPD for cancer of the duodenal papilla. Six months after the surgery, the patient suddenly experienced lower abdominal pain and a CT scan detected free air in the peritoneal cavity. During the emergent laparotomy, a perforation was found at the site of the gastrojejunostomy. The perforation was sutured, and the postoperative course was uneventful. The second case was a 69-year old male who was receiving chemotherapy for metastatic liver cancers after receiving an SSPPD for pancreatic cancer. He was hospitalized due to left abdominal pain and a CT scan revealed intraperitoneal free air around the gastrojejunostomy anastomosis site. The patient did not require surgery because his abdominal pain was controllable and the peritonitis was localized. He recovered with antibiotics and a proton-pump inhibitor. We presumed that postoperative gastric-acid secretion would be preserved to function as well as it did preoperatively, since both cases received an SSPPD. However, and surprisingly, the first case developed an anastomotic perforation despite regularly taking a proton-pump inhibitor. In the second case, the regular usage of nonsteroidal anti-inflammatory drugs for lumbar pain might have caused the perforation. From these clinical experiences, we learned the necessity of some prophylactic treatments for patients receiving an SSPPD. It is noteworthy that nonsurgical treatments can be applicable for some selected perforated anastomotic ulcers, though in most cases an emergent laparotomy should also be considered
