上部胃癌に対する腹腔鏡下胃切除術における肝外側区域脱転法とリトラクターによる肝挙上法の比較検討

Lateral segment displacement method in laparoscopic gastrectomy for upper stomach cancer

◆要旨：［はじめに］胃上部癌に対する内視鏡下手術において，食道裂孔周囲の操作を要する術式では，視野確保が重要である．今回われわれは，肝外側区域を授動して脱転させる肝脱転法を導入したため，その術後肝機能と安全性について従来の肝圧排法と比較した．［対象］2018年4月から2020年11月までに当院で腹腔鏡下胃全摘術（L/RTG），噴門側胃切除術（L/RPG）を施行した胃癌患者63例．そのうち左副肝動脈を有した8例を除外し，肝圧排群36例と肝脱転群19例の計55例で検討した．［結果］肝脱転法は肝圧排法と比較して術後肝酵素が低い傾向を認めた．肝脱転法は良好な術野の確保に加え手技的にも安全であり，術後肝機能の観点からも有用な方法と考える．

　In laparoscopic surgery for upper gastric cancer, it is important to ensure a safe view around the esophageal hiatus. Since the left hepatic segment obstructed the view of the operative field when the liver was elevated by liver retractor, we introduced the lateral segment displacement（LD）method, in which we inverted the left lateral hepatic segment. In this study, we evaluated the effectiveness of this method.

　We compared the surgical outcomes for 55 patients who underwent laparoscopic or robotic total gastrectomy（L/RTG）and proximal gastrectomy（L/RPG）between April 2018 and November 2020 in our hospital. Of the 55 patients, 36 underwent gastrectomy with the liver retractor（LR）method, and 19 underwent the LD method.

　No significant differences were seen in age, height, weight, and sex between the two groups. Operating time was longer in the LD group（335 min versus 305 min, P＝0.014）. No significant difference was observed in bleeding, however, lesser bleeding reported in the LD group（42 mL versus 48.5 mL, P＝0.152）. Complications such as anastomotic stenosis and suture failure were not observed. There was no difference in the transition in postoperative liver function. However, postoperative serum aspartate transaminase and alanine transaminase tended to be lower in the LD group.

　In addition, in terms of ensuring a safe view around the esophageal hiatus, the LD method is technically safe and helpful from the viewpoint of postoperative liver enzyme level. Future studies examining a larger number of cases are needed.