経口アンビルを用いた食道空腸吻合を安全・確実に施行するための工夫

A secure and reliable technique for esopahagojejunostomy using the transorally inserted anvil after laparoscopic assisted total gastrectomy

◆要旨：近年胃切除後の再建法として，新しいcircular stapler（以下，EEA^TM OrVil^TM, Covidien）が開発されたが，口から食道下端までアンビルをブラインドで引き出すため難点も指摘されている．本法を確実に施行するため，口腔側の工夫として，チューブに2号ナイロン糸を縫い付けて“安全糸”とすることで梨状窩に嵌頓しても“安全糸”を引っ張れば容易にアンビルを引き戻すことが可能である．腹腔側工夫として，食道断端からチューブを引き出す際，貫通孔の大きさが最小限となるよう，外膜筋層をまず切除し，その後バルブチップを透見しながら粘膜を切除する．EEA^TM OrVil^TMを安全確実に使用することで，腹腔鏡下胃全摘後の有用な再建術の1つに成り得ると考えられる．

　The newly circular stapler, EEA^TM OrVil^TM（Covidien）has been developed as a reconstruction device for upper gastric surgery, and is especially useful through the narrow operating window under the laparoscopic surgery. The technique of transoral anvil insertion, however, is sometimes technically demanding because the anvil is inserted blindly from the mouth to the esophageal stump. Before transorally introducing the anvil, 2-nylon thread, named “safety thread” is transfixed at the orogastric tube 1 cm from the proximal end. If the anvil should incarcerate into the piriform recess, it can be easily removed by pulling this safety thread back.

When the tip of the proximal orogastric tube reaches the stump of the esophagus, extramucosal layers of esophageal stump are cut with laparoscopic scissors, thereafter mucosal layers are re-cut over the tip of the orogastric tube to make the size of the hole through the center-rod as small as possible.

Among various techniques of reconstruction after laparoscopic total gastrectomy, intracorporeal circular stapling esophagojejunostomy using EEA^TM OrVil^TM is one of the most secure and reliable procedure.