食道癌手術における腹腔鏡補助下腸瘻造設術

Laparoscopic-assisted feeding jejunostomy in surgery for esophageal cancer

◆要旨：当科で施行している食道癌に対する胸腔鏡・腹腔鏡補助下食道亜全摘術時の腸瘻造設術は，手技を簡便化し，若手外科医師でも可能な手技としての定型化をコンセプトとしている．心窩部の小開腹創から腸瘻チューブの留置を行い，腹壁への固定を腹腔鏡下に行っている．腹壁固定の方法として，従来，小開腹創から直視できる範囲での限定的な固定や，腹腔鏡下での一定の技術を要する体腔内縫合結紮による固定が行われてきたが，いずれも様々な制限がかかる．今回，小開腹創操作時の前処置と工夫を行い壁外からの器具を利用することで，高い技術を要さず，造設部位の制限がなく，多様な術式で応用可能と思われる手技を紹介する．

Laparoscopic（or laparoscopy-assisted） jejunostomy has been performed widely since the 1990s, and no special complicated procedure is required. However, creation of the jejunostomy after thoracoscopic esophagectomy and laparoscopic-assisted gastric conduit reconstruction is cumbersome, especially for the young surgeons. The authors introduced the following method to simplify the procedure. Initially, the feeding tube is intubated into the jejunum by the Witzel technique using a jejunostomy kit（Nipro STJ Kit^Ⓡ）. After four stitches are applied and tied at the jejunal wall to surround the tube, two additional sutures are placed at the oral side of the jejunal wall from the jejunostomy site. Following this, six sutures are fixed using Lapa-Her-Closure^TM through the abdominal wall. We performed this procedure in 50 patients with esophageal cancer. Postoperative tube obstruction occurred in three patients, but re-opening of the tube with a guide wire was possible in two of the patients. The outcomes of this procedure were good. The authors found that the procedure is simplified and standardized and is applicable to various situations.