内視鏡外科手術ガイドラインにおける進行大腸癌の位置づけ

Current status of laparoscopic surgery for advanced colorectal cancer based on the guideline

◆要旨：内視鏡外科診療ガイドラインにおける進行大腸癌の位置づけを検討した．盲腸・上行結腸やS状結腸・直腸S状部のT2（MP），N（－）癌に対する腹腔鏡下手術は低侵襲手術として有用で推奨される．StageⅡ，Ⅲの進行大腸癌に関しては，本邦の多施設での長期成績が十分明らかになっていないため，積極的には推奨されない．特に横行結腸，左結腸曲近傍の下行結腸あるいは直腸では，難易度が高くなるため十分なインフォームド・コンセントに基づいて手術を行うべきである．T4やStageⅣの進行大腸癌に関しては，肝転移，腹膜転移や他臓器浸潤などがあっても場所・個数や程度によって開腹手術で取りきれる場合，逆に姑息切除でもリンパ節転移が高度で腹腔鏡下手術が困難な場合などがあるため，個々の症例で十分な検討と適切なインフォームド・コンセントに基づいて手術を行うことが望まれる．

　We describe the indication of laparoscopic surgery for advanced colorectal cancer based on the tentative guidelines made by JSES guideline committee. T2（MP）, N（－）cancer is a good indication for laparoscopic surgery, although the technical difficulty depends on the tumor location. For tumor located in cecum, ascending colon, sigmoid colon or rectosigmoid, laparoscopic surgery may be an optimal choice because of its minimally invasiveness without compromising the radicality of the treatment. Recently, several randomized trials mainly reported from the western countries showed no significant difference in the outcome between laparoscopic and open surgery, especially for right and left colon cancer. However, if the tumor is located in the transverse colon, descending colon or rectum, laparoscopic surgery may be technically difficult. There are some differences among institutions regarding the indication and result of laparoscopic surgery for stageⅡ, Ⅲcolorectal cancer. Therefore, laparoscopic surgery is not highly recommended for stageⅡ, Ⅲcolorectal cancers and informed consent including the technical feasibility and oncological data of the institution is mandatory. For T4 or stageⅣtumors, surgical procedures should be carefully considered depending on the patients'conditions.