腹腔鏡下大腸全摘1期再建・肝切除を同時に行った横行結腸癌併発家族性大腸腺腫症の1例

Laparoscopic restorative proctocolectomy and simultaneous resection of synchronous liver metastases for familial adenomatous polyposis with stage Ⅳ transverse colon cancer

◆要旨：患者は18歳，女性．家族歴に家族性大腸腺腫症があり，腹痛を主訴に前医を受診した．検査で，全大腸に無数のポリープと横行結腸右側に2型進行癌，多発リンパ節転移および肝S4に2個の転移が認められた．D3リンパ節郭清を伴う大腸全摘および肝S4部分切除を腹腔鏡補助下に施行し，直腸粘膜切除と回腸囊肛門吻合を経肛門的に行った．一時的な人工肛門は作製しなかった．手術時間は671分，出血量は50ml，術後経過は良好で術後26日目に退院した．横行結腸進行癌に対する腹腔鏡下手術は難度の高い手術とされ，大腸全摘回腸囊肛門吻合と肝切除を同時に行った報告はない．適切なポート配置とエネルギーデバイスを用いることで，1期的な切除再建が可能であった．

　We present our experience of simultaneous laparoscopic surgery for an 18-year-old female patient affected by familial adenomatous polyposis with advanced transverse colon cancer, multiple lymph node involvement and two liver metastases. Colonoscopy demonstrated an ulcerating tumor at transverse colon and numerous polyps in colon and rectum. CT scan and MR revealed multiple lymph node swellings in the transverse mesocolon and two small nodules in the medial segment of the liver. Total proctocolectomy, D3 lymph node dissection and liver resection were performed under laparoscopy. A 13-cm ileal J pouch was constructed extracorporeally and the pouch anal anastomosis was performed transanally. Diverting ileostomy was not conducted. The operating time was 671 minutes. Blood loss was 50ml and the postoperative hospital stay was 26 days without any complication. Laparoscopic surgery is feasible for this complex clinical setting and a restorative proctocolectomy without diverting ileostomy may eventually bring a good cosmetic outcome.