進化してきた各領域のコラボレーション手術

Collaborative surgeries: evolution in various fields

要旨

2008年にHikiらによって開発されたLECSは当初，胃粘膜下腫瘍の過不足のない切除を目的とした胃局所切除術の一亜型であった。その後，より低侵襲な胃局所切除法として 2014年に保険適用となり，腹腔鏡下手術の適応となる胃粘膜下腫瘍をおもな対象として国内外に普及してきた。また，目的を同じくする種々のコラボレーション手術（NEWSやCLEAN-NET，closed LECSなど）が次々と開発され，これらはLECS関連手技として認知が広がり，腫瘍の大きさや発育形式，delleの有無など，胃粘膜下腫瘍の特徴に応じて適切な術式を選択することが可能となってきた。最近では，胃癌や他臓器への応用が進み，LECS のさらなる適応拡大が期待されている。本稿では，LECSのコンセプトが対象となる胃粘膜下腫瘍に対する胃局所切除術を中心に，変貌･進化してきた消化管疾患に対する消化器内視鏡医と外科系医師とのさまざまなコラボレーション手術の現状を整理しながら概説する。

　In 2008, Hiki et al. reported the successful use of an ESD technique to assist in the laparoscopic local resection of the stomach in patients with gastric submucosal tumor. This technique, namely laparoscopic and endoscopic cooperative surgery (LECS), is a procedure in which tumor observations are made laparoscopically and endoscopically in order to determine the overall appearance of the tumor. The resection range is decided by performing incisions around the tumor with endoscopic procedures; minimal resection is carried out under laparoscopic guidance, and the gastric wall defect is sutured laparoscopically. Using this technique, the target area can be kept as small as possible. LECS for removal of gastric submucosal tumor has been covered by Japan’s national health insurance since 2014, and since then, it has been widely practiced throughout Japan and other countries. Various forms of LECS-related procedures have been developed: non-exposed endoscopic wall-inversion surgery (NEWS), a combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique (CLEAN-NET) and closed LECS. These has led to a recent increase in the indication of modified LECS to include patients with gastric cancer. The LECS concept has been applied to tumor excision in other organs, such as the duodenum, colon and rectum. Further evolution of LECS procedures is expected in the future.