内視鏡外科手術における研究と治療の進歩(2)消化器外科領域(1)上部消化管 : 胃癌  [in Japanese] Up-to-date Information on Research and Treatment in Endoscopic Surgery (2) Gastrointestinal Surgery (1) Upper Gastrointestinal Tract : Gastric Cancer  [in Japanese]

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Author(s)

    • 笹川 剛 Sasagawa Tsuyoshi
    • 東京女子医科大学医学部消化器外科学 Department of Gastroenterological Surgery, Tokyo Women's Medical University School of Medicine

Abstract

1987年Mouretの胆嚢摘出術を嚆矢とする腹腔鏡下手術は周辺機器の進歩と相まって、他臓器に対しても急速に広がっている。胃における腹腔鏡下手術は胃粘膜下腫瘍に対する胃部分切除から始まり、現在、胃癌に対しても積極的に行われている。胃癌に対する胃切除術は主にESD:Endoscopic Submucosal Disseection対象外の早期胃癌を適応として行われている。その多くは腹腔鏡下に剥離とリンパ節郭清を行い、小開腹創から胃を引き出して幽門側胃切除(または幽門保存胃切除)、再建を行う腹腔鏡補助下幽門側胃切除(laparoscopy assisted distal gastrectomy:LADG)である。再建法は小開腹創からの手縫い、circular staplerによるものが多いが、体型に左右されないとの理由から腹腔内での再建も増えている。リンパ節郭清の程度、精度も当初こそ学会で批難を受けたが、経験を重ねるにつれ向上し、むしろ鏡視下の方が拡大視効果により精緻な郭清が可能とも言われるようになった。近年、噴門側胃切除、胃全摘術も行わるようになったが、食道空腸吻合の困難さから現状では一般的ではない。さらに適応を早期胃癌のみならず進行胃癌まで広げつつあり、胃癌手術に対する腹腔鏡下手術は急速に普及しつつある。しかしながら胃癌に対する腹腔鏡下胃切除と開腹胃切除の比較検討にはエビデンスの高い立証はなく2010年改訂の胃癌学会のガイドラインにおいても腹腔鏡下胃切除は臨床研究としての治療法の位置づけのままである。腹腔鏡下手術が胃癌に対する外科治療である以上、従来の開腹手術による安全性と根治性が劣ってはならず、また低浸襲治療の名のもとに、無制限に適応を拡大していってよいか十分な議論が必要である。

Since the first laparoscopic cholecystectomy was performed in 1987 by Mouret, due to the development of surgical devices, laparoscopic surgery has been widely applied to other organs. Its application for gastric lesions began as a laparoscopic partial gastrectomy for gastric subumucosal tumors, and has now expanded to include gastric cancer. Laparoscopic gastrectomy is performed primarily for early gastric cancer that is not a candidate for endoscopic submucosal dissection (ESD). The procedure includes dissection and lymphadenectomy performed laparoscopically; and gastrectomy and reconstruction performed extracorporeally through a mini-laparotomy, known as laparoscopy-assisted distal gastrectomy (LADG) whereby reconstruction is performed mainly by hand-suturing or using a circular stapler. Intracorporeal anastomosis is becoming popular, as it is not limited by the patient's somatotype. Initially, the accuracy and precision of lymphadenectomy were criticized, however, with increased experience, these two factors regarding lymphadenectomy have improved. In fact, the amplified images allow a more detailed laparoscopic lymph node dissection compared with the conventional manner. Laparoscopic proximal gastrectomy and total gastrectomy have been performed in recent years, but are still uncommon due to the difficulty of esophago-jejunostomy. Additionally the indications of laparoscopic gastrectomy are expanding not only in early gastric cancers but also in advanced cancers. However, there is a lack of accurate and reliable data evaluating and comparing laparoscopic gastrectomy and conventional gastrectomy. According to the latest guidelines for gastric cancer, laparoscopic gastrectomy is still classified as clinical research. Laparoscopic gastrectomy should be considered equivalent to conventional surgery in terms of curability and safety. Further discussion is necessary to reasonably expand the indications of laparoscopic gastrectomy as "minimally invasive surgery".

Journal

  • Journal of Tokyo Women's Medical College

    Journal of Tokyo Women's Medical College 82(2), 47-50, 2012-04

    Tokyo Women's Medical University

Codes

  • NII Article ID (NAID)
    110009004317
  • NII NACSIS-CAT ID (NCID)
    AN00161368
  • Text Lang
    JPN
  • Article Type
    Journal Article
  • Journal Type
    大学紀要
  • ISSN
    0040-9022
  • NDL Article ID
    023773613
  • NDL Call No.
    Z19-400
  • Data Source
    NDL  NII-ELS  IR 
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