リンパ節転移の有無からみた胃sm癌の腹腔鏡下手術の適応

Indication for Laparoscopy-Assisted Distal Gastrectomy (LADG) in the Management of Patients with Early Gastric Carcinoma

要旨　近年，早期胃癌に対する腹腔鏡下手術の適応拡大には目をみはるものがある．しかしながら，根治性を維持するという点において，その適応は慎重でなければならない．本稿ではリンパ節郭清の必要性の有無に主眼を置き，早期胃癌，特にsm癌の腹腔鏡下手術の適応について自験例を含めて検討を行った．その結果，早期胃癌においてリンパ節郭清の必要な病変は，①20mm以上の隆起型m癌，②10mm以上の陥凹型m癌，③潰瘍(瘢痕)を有するm癌，④sm癌，であった．リンパ節の転移先の検討から，sm癌の中でもsm₁癌はm癌と同じ挙動を示し，1群と#7，8に限局しているので，腹腔鏡補助下幽門側胃切除術(D_1＋α)の適応，また他のsm癌は開腹下胃切除術(D₂)の適応と考えている．

　Laparoscopic surgery for patients with early gastric carcinoma is now becoming popular, because of minimal invasiveness, rapid recovery, less pain, and good cosmesis. In laparoscopic gastric surgery, there are three techniques including laparoscopic partial gastric resection, intragastric mucosal resection, and laparoscopy assisted distal gastrectomy (LADG). Early gastric cancer with lymph node metastasis should be resected by gastrectomy with lymph node dissection. We examined the characteristics of early gastric cancer with lymph node metastasis from our past clinical results and the literature. LADG with lymph node dissection (D_1+α) was indicated for the following cases: (1) elevated mucosal cancer (＞2 cm), (2) depressed mucosal cancer (＞1 cm), (3) mucosal cancer with ulceration, (4) submucosal cancer with slight invasion. However, the indication for submucosal gastric cancer with massive invasion is open gastrectomy with lymph node dissection (D₂).