Natural orifice specimen extractionを用いた腹腔鏡下大腸癌手術における完全体内吻合の技術的および腫瘍学的な安全性の評価

Technical and oncological safety of complete intracorporeal anastomosis during laparoscopic colorectal surgery with natural orifice specimen extraction

◆要旨：［目的］大腸癌切除標本を自然孔から摘出する術式における，完全体内吻合の技術的および腫瘍学的な安全性を評価する．［方法・対象］標本摘出の後，右側結腸切除では自動縫合器を腟から挿入して機能的端々吻合（FEE）を行った．S状結腸切除，高・低位前方切除では，口側結腸に体内で自動吻合器のアンビルを留置し，double stapling technique （DST）で吻合した．2009〜2016年に完全体内吻合を試みた104例（DST: 72例，FEE: 32例）を対象として，短期および長期手術成績を後向きに検討した．［結果］対象症例での手術時間は227分，出血量は5.0ml，術後在院日数は6日であった（中央値）．DSTを試行した1例で体内吻合を完遂できなかった．Clavien-Dindo分類Grade III以上の術後合併症は腹腔内出血1例であった．pStage IIIbのFEE2例で腹膜播種再発を来した．［考察］患者選択を行うことで，大腸癌切除標本を自然孔から摘出する術式におけるFEEは技術的に安全に施行可能であった．しかし，進行癌では腹膜播種再発のリスクを上昇させる可能性は否定できず，現状では患者選択を慎重に行い，安易に行うべきではない．

　［Objectives］ We have been performing laparoscopic natural orifice specimen extraction （NOSE） with intracorporeal anastomosis （IA） in patients with colon cancer. In this study, we examined the technical and oncological safety of IA during NOSE. ［Methods］ In right colectomy, resected specimens were removed transvaginally. Subsequently, a linear stapler was inserted through a GelPOINT Mini ^® advanced-access platform （Applied Medical） that was attached to the posterior colpotomy to perform functional end-to-end anastomosis （FEE）. In sigmoid colectomy and anterior resection, resected specimens were removed either transanally or transvaginally. Subsequently, an anvil of the circular stapler was inserted into the proximal colon and fixed with intracorporeal purse-string sutures and Endoloop PDS-II ^® prior to performing anastomosis with the double stapling technique （DST）. Data from a total of 104 cases of IA during NOSE procedure （72 DST, 32 FEE） performed between 2009 and 2016 were reviewed to determine the short- and long-term outcomes. ［Results］ The median operative time was 227 minutes, with a median blood loss of 5.0 mL and hospital stay of 6 days. IA could not be completed in one patient who underwent DST. Postoperative complication above Grade III in Clavien-Dindo classification was intra-abdominal bleeding that occurred in one patient in the DST group. Two patients in the FEE group （pathological stage IIIb） had peritoneal metastasis. ［Conclusion］ Laparoscopic NOSE with IA-FEE could be performed safely technically in carefully selected patients. However, IA-FEE might increase the risk of peritoneal recurrence, therefore, strict operative indication should be made in patients with advanced disease.