当教室におけるTEMの現状と問題点について

〔目的〕当教室におけるtrans anal endoscopic microsurgery(TEM)の現状とその問題点を明らかにし,TEMの今後の位置付けを検討する.〔対象と方法〕当教室で1990年1月～2005年3月までに経肛門的に局所切除を施行したIS0例を対象とした.その内訳は従来法6S例(52.3%),minimal invasive trans anal surgery(MITAS)20例(15.4%),TEM42例(32.3%)である.(A)従来法,MITAS,TEMについて,(1)対象疾患,(2)肛門縁から腫瘍までの距離,(3)腫瘍最大径,(4)水平断端陽性率,(5)手術時間の各5項目について比較,検討した.さらにTEMの問題点として手術時間に影響を与える因子である器材セット時間,腫瘍径,手術時期による手術時間の変化についても検討した.〔結果〕肛門縁から腫瘍までの距離は,従来法41.8±25.4mm,TEM 68.2±44.8mmで,TEMは肛門より遠い病変への適応が可能であった(p=0.0004).手術時間は従来法50.7±35.9分,TEM 84.8±49.6分で,TEMは従来法と比べ有意に長時間を要した(p=0.0002).水平断端陽性率は従来法12.5%,MITAS25.0%,TEM 9.5%とTEMが最も低率で,TEMは病巣の境界の識別に優れた手技と思われた.器材セット時間は前期39.9±2.5分,後期41.8±14.0分で有意差を認めなかった.同一術者,腫瘍径30mm未満に統一し,手術時間を前期,後期で比較すると,前期79.6±38.1分,後期66.8±25.0分で有意差はなく,手術手技習得に時間を要すると思われた.〔結語〕TEMは手術手技習得に時間を要する,器材セット時間も必要という問題点はあるものの,肛門より遠い病変に適応が可能で,病巣の境界の識別に優れているという長所もあり,経肛門的手術手技の一つとして習得しておくことは有用である.[Purpose] The authors investigated to assess the current status and problems in trans anal endoscopic microsurgery (TEM). [Subjects and Methods] The subjects of this study consisted of 130 patients that underwent trans anal local resection in this department from January 1990 to March 2005 (consisting of 68 cases (52.3%) that underwent a conventional procedure, 20 cases (15.4%) that underwent minimal invasive trans anal surgery (MITAS) and 42 cases (32.3%) that underwent TEM). Study (A) consisted of a comparative study of the conventional procedure, MITAS and TEM for five parameters consisting of (1) disease, (2) distance from the edge of the anus to the tumor, (3) maximum tumor diameter, (4) operation time and (5) lateral margin positive rate. Study (B) consisted of an assessment of problems with TEM for three parameters consisting of (6) indication of TEM, (7) required setup time, (8) time required to learn procedure. [Results] The average distances from the edge of the anus to the tumor were 41.8 ± 25.4 mm for the conventional procedure and 68.2 ± 44.8 mm for TEM, indicating that TEM was useful for treatment of distal lesions (p=0.004). The operation time were 50.7 ± 35.9 minutes for the conventional procedure, and 84.8 ± 49.6 minutes for TEM, thus indicating that TEM requires a significantly longer operation time as compared with the conventional procedure (p=0.0002). The lateral margin positive rates were 12.5% for the conventional procedure, 25.0% for MITAS and 9.5% for TEM, with the margin positive rate for TEM being the lowest. The required setup times were 39.9 ± 2.5 minutes for an early period and 41.8 ± 14.0 minutes for a late period, and there were no significant differences observed. The times required to learn the procedure of parameter (8) based on being performed by the same surgeon for a unified tumor diameter of less than 30 mm were 79.6 ± 38.1 for the early period and 66.8 ± 25.0 minutes for the late period, and there were no significant differences observed. [Conclusion] Although TEM has problems with respect to the time required to learn the procedure, setup time, indicated cases and so forth, since it is superior with respect to the ability to treat distal lesions and identifying the boundary of a focus, it is useful to learn TEM as a trans anal surgical procedure

潰瘍性大腸炎の経過中に虫垂出血を来した1例

医学部外科学(第2)講座　亀岡信悟教授退任記念特別号