術前診断され腹腔鏡下に切除した原発性小腸癌3例の手術症例の検討

Three patients with primary small intestinal adenocarcinoma diagnosed preoperatively and treated with laparoscopic surgery

◆要旨：原発性小腸癌は従来早期に発見されることが少なく予後不良の疾患とされてきたが，小腸内視鏡検査の普及に伴い，転移のない原発性小腸癌が術前診断されるようになってきた．当科における3例を報告する．2例は便潜血の精査で，もう1例は家族性大腸腺腫症手術後のサーベイランス検査で病変が指摘された．3例とも腹腔鏡下小腸切除を行った．はじめに，術中操作による腫瘍播種予防のため，腫瘍をガーゼで覆い手術を行った．リンパ節郭清は，Treitz靭帯病変以外の2例はできるだけ大腸の中間リンパ節に相当する程度の中枢側まで行った．小腸癌に対する腹腔鏡下手術は小開腹法と比べ低侵襲で，十分な腹腔内観察や速やかな病変部位の同定が可能である．

　We report three patients with small intestinal adenocarcinoma diagnosed preoperatively and treated with laparoscopic surgery. Two patients were diagnosed by fecal occult blood. The other patient was diagnosed during the surveillance check-up after the operation for familial adenomatous polyposis. Their tumor locations were ileum, jejunum, and anal side of the Treitz ligament, respectively. Laparoscopic operation was performed. First, the tumor was wrapped in gauze to prevent peritoneal dissemination. The lymph nodes at the point of origin from the SMA were dissected in two patients. Histopathological examination showed moderately-differentiated adenocarcinoma in two patients and well-differentiated adenocarcinoma in one patient. Tumor invasions were ss, ss, and m, respectivelyand no lymph node metastasis was confirmed. There were no recurrences in all patients. In recent years, the incidence rates of small intestinal adenocarcinoma diagnosed preoperatively have begun to rise. It would be an important issue to establish a new treatment plan since no clear indication on surgical treatment has been produced yet, and there are no guidelines regarding the appropriate extent of lymph node dissection. Laparoscopic surgery for small intestinal adenocarcinoma has better view of the intra-abdominal field and is easier to find tumor than the open surgery.