肝細胞癌後縦隔リンパ節転移に対して腹臥位胸腔鏡下腫瘍摘出術を施行した1例

Thoracoscopic resection in prone position for posterior mediastinal lymph node metastasis from hepatocellular carcinoma

◆要旨：患者は63歳，女性．肝細胞癌に対するラジオ波焼灼療法の治療歴がある．今回，CTにて下縦隔に心囊，下大静脈，食道に取り囲まれるように位置する5cm大の類円形腫瘤を指摘され，当院へ紹介された．EUS-FNAにて肝細胞癌下縦隔リンパ節転移と診断し，腹臥位胸腔鏡下腫瘍摘出術を施行した．腫瘍は下部食道右側，横隔膜腱中心に強固に癒着していたが，腹臥位胸腔鏡下で良好な視野が得られ，切除可能であった．術後経過は良好で，第6病日に退院した．当院では食道癌手術において腹臥位胸腔鏡下手術を導入している．左側臥位と比較し，下縦隔の視野確保は優れており，本症例においても有用であった．

The patient was a 63-year-old female with a posterior inferior mediastinal tumor. She had a history of radiofrequency ablation（RFA） treatment for hepatocellular carcinoma. Computed tomography（CT） revealed that the tumor, which was located in the inferior mediastinum, was surrounded by pericardium, inferior vena cava, and esophagus. She was referred to our hospital for treatment. The diagnosis of a lymph node metastasis from hepatocellular carcinoma was confirmed by endoscopic ultrasound-guided fine-needle aspiration biopsy of the tumor. The posterior mediastinal tumor was removed completely by thoracoscopic resection with the patient in a prone position. Intraoperatively, the tumor adhered severely to the right side of the inferior esophagus and central tendon of the diaphragm. The prone position was useful for clear display of the surgical field, and the tumor was completely resected under good visualization. The postoperative course was uneventful, and the patient was discharged on postoperative day 6 with no complications. In our hospital, prone position is generally selected in cases of thoracoscopic resection of esophageal carcinoma. Compared to the left lateral position, the prone position provides a much better exposure of the operating field in the inferior mediastinum, and we recommend using this position whenever the tumor is located in this region.