肝細胞癌に対する重粒子線治療のために腹腔鏡下スペーサー挿入術を行った1例

Laparoscopic spacer insertion for carbon ion radiotherapy in patients with hepatocellular carcinoma : a case report

◆要旨：重粒子線治療は消化管と近接する場合は対象外とされたが，近年では人工物（以下，スペーサー）を留置し，スペースを作る方法が考案されたことにより適応拡大が図られている．従来では開腹術によっていたスペーサー留置を今回筆者らは腹腔鏡下で行ったので報告する．患者は70歳代，男性．肝右葉に9cm大の腫瘍を認め，萎縮した肝表面に大腸が入り込み照射野に含まれた．気腹下4ポートにて大網・大腸を肝・胆囊から剝離し，スペーサーを挿入後，展開した．四辺をhernia stapler，手縫い縫合で固定した．壁側腹膜，後腹膜，鎌状靭帯と固定することにより確実な消化管の隔離が可能で，合併症なく第4病日に退院し，重粒子線治療を行え得た．スペーサー挿入術も内視鏡下手術の恩恵を得られるものと思われた．

　INTRODUCTION : Carbon ion radiotherapy has a higher cytocidal effect than ordinary radiotherapy（RT）in locally advanced cancer control. In the digestive system, the use of carbon ion RT has begun and excellent results have been reported especially in local recurrence of rectal cancer. This article describes a new technical procedure of laparoscopic spacer insertion（LSI）to prevent radiation induced intestinal damages for hepatocellular carcinoma（HCC）. METHOD : A patient with HCC, 9 cm in size located in the right lobe, underwent carbon ion RT. A large bowel was located near the tumor on the surface of the atrophic right lobe. As a preparation, this bowel was isolated from the tumor to prevent radiation induced injuries to the digestive systems. In order to fix the spacer to the upper side of the abdominal cavity, LSI was selected rather than open laparotomy. At first, adhered omentum and the colon were separated from the liver. Then the spacer, GORE-TEX^ⓇSoft tissue patch（2 mmthicknes, 20×12 cmin size）was fixed below the right lobe laparoscopically via two 5 mm and two 12 mm ports.. Post clinical course was uneventful and the patient was discharged on 4 th POD. CONCLUSIONS : This LSI procedure was less invasive, effective and easy to reduce intestinal sequelae and it offers new possibilities for carbon ion RT in the treatment of HCC.