内容紹介
Surgical Case of Ulcerative Colitis Accompanied with Rectal Cancer Combined with Transanal Minimally Invasive Surgery
Summary
A 46-year-old man developed ulcerative colitis at the age of 19 years. Although the colitis was medically treated, it relapsed and repeated over time. Periodic lower gastrointestinal endoscopy revealed lower rectal cancer, and he was referred to our department of surgery. Previous steroid therapy induced diabetes, and he was obese, with a height of 170.3 cm, weight of 89.6 kg, and BMI of 30.89 kg/m2, indicating that laparoscopic dissection near the anus would be difficult to perform. Therefore, the patient was scheduled for transanal minimally invasive surgery(TAMIS). The surgery involved as much laparoscopic rectal dissection as possible in the ventral to dorsal direction, followed by the TAMIS procedure. Dissection was started from the dentate line, and, after the closure of the anal stump, GelPOINT was placed, and made continuous with the previous dissection layer by applying the technique of down-to-up total mesorectal excision(TME)by TAMIS. The large intestine was excised through a small abdominal incision to create an ileal pouch, hand-sewn anastomosis was performed transanally to create a temporary colostomy, and the surgery was completed. Regarding TAMIS-TME several problems remain to be solved, including an understanding of its unique anatomy and the mastery of single-port surgical techniques. However, the herein reported patient with a high BMI had a definite indication for TAMIS-TME.
要旨
症例は46歳,男性。19歳で潰瘍性大腸炎を発症し内科治療を行うも,再発寛解を繰り返していた。定期検査の下部消化管内視鏡にて下部直腸癌を指摘され,外科紹介となった。これまでのステロイド投与にて糖尿病を併発し,身長170.3 cm,体重89.6 kg,BMI 30.89 kg/m2と肥満のため,腹腔鏡手術では肛門付近の剥離困難が予想された。このため経肛門式内視鏡下手術(transanal minimally invasive surgery: TAMIS)の併用を予定した。手術は腹腔鏡で直腸の剥離を腹側から肛門に向け可及的に剥離を行い,TAMIS操作に移る。歯状線より剥離を開始し,肛門側断端を閉鎖の後GelPOINTを装着,TAMISによるdown-to-up total mesorectal excision(TME)の手術手技を応用して先の剥離層と連続させた。腹部に作製した小開腹創より大腸を摘出し,回腸嚢を作製,経肛門操作にて手縫い吻合を行い,一時的人工肛門を作製し手術終了とした。TAMIS-TMEは,その独特の解剖理解・単孔手術手技の習熟などいくつかの課題が残されているが,本症例のようにBMIの高い肥満症例ではTAMIS-TMEのよい適応と思われた。
目次
Summary
A 46-year-old man developed ulcerative colitis at the age of 19 years. Although the colitis was medically treated, it relapsed and repeated over time. Periodic lower gastrointestinal endoscopy revealed lower rectal cancer, and he was referred to our department of surgery. Previous steroid therapy induced diabetes, and he was obese, with a height of 170.3 cm, weight of 89.6 kg, and BMI of 30.89 kg/m2, indicating that laparoscopic dissection near the anus would be difficult to perform. Therefore, the patient was scheduled for transanal minimally invasive surgery(TAMIS). The surgery involved as much laparoscopic rectal dissection as possible in the ventral to dorsal direction, followed by the TAMIS procedure. Dissection was started from the dentate line, and, after the closure of the anal stump, GelPOINT was placed, and made continuous with the previous dissection layer by applying the technique of down-to-up total mesorectal excision(TME)by TAMIS. The large intestine was excised through a small abdominal incision to create an ileal pouch, hand-sewn anastomosis was performed transanally to create a temporary colostomy, and the surgery was completed. Regarding TAMIS-TME several problems remain to be solved, including an understanding of its unique anatomy and the mastery of single-port surgical techniques. However, the herein reported patient with a high BMI had a definite indication for TAMIS-TME.
要旨
症例は46歳,男性。19歳で潰瘍性大腸炎を発症し内科治療を行うも,再発寛解を繰り返していた。定期検査の下部消化管内視鏡にて下部直腸癌を指摘され,外科紹介となった。これまでのステロイド投与にて糖尿病を併発し,身長170.3 cm,体重89.6 kg,BMI 30.89 kg/m2と肥満のため,腹腔鏡手術では肛門付近の剥離困難が予想された。このため経肛門式内視鏡下手術(transanal minimally invasive surgery: TAMIS)の併用を予定した。手術は腹腔鏡で直腸の剥離を腹側から肛門に向け可及的に剥離を行い,TAMIS操作に移る。歯状線より剥離を開始し,肛門側断端を閉鎖の後GelPOINTを装着,TAMISによるdown-to-up total mesorectal excision(TME)の手術手技を応用して先の剥離層と連続させた。腹部に作製した小開腹創より大腸を摘出し,回腸嚢を作製,経肛門操作にて手縫い吻合を行い,一時的人工肛門を作製し手術終了とした。TAMIS-TMEは,その独特の解剖理解・単孔手術手技の習熟などいくつかの課題が残されているが,本症例のようにBMIの高い肥満症例ではTAMIS-TMEのよい適応と思われた。