Microsoft PowerPoint - 印刷用 2013K-net 大腸癌 小島.ppt
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1 もっと知りたい 大腸がん外科治療 広島市民病院外科 小島康知
2 プレゼンテーションマップ 1. 本邦における腹腔鏡下大腸切除の現況 2. 当科における腹腔鏡下大腸切除の現況 3. Robot 手術
3 腹腔鏡下大腸切除 ( 全国統計 ) その他肉腫カルチノイド進行大腸癌早期大腸癌 進行がんにも保険適応 日本内視鏡外科学会アンケートより
4 100% 腹腔鏡下大腸切除 ( 全国統計 ) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 早期大腸癌 進行大腸癌 2012 日本内視鏡外科学会アンケートより
5 結腸がん腹腔鏡手術適応 2010 年 2012 年 良性疾患に のみ行う, 2% 良性疾患と早期がんに行う, 14% 漿膜浸潤のある進行がんにも行う, 49% 漿膜浸潤のない進行がんにも行う, 35% 2012 日本内視鏡外科学会アンケートより
6 直腸がん腹腔鏡手術適応 2010 年 2012 年 良性疾患にのみ行う 3% 漿膜浸潤のある進行がんまで 36% 良性疾患 + 早期がん 21% 漿膜浸潤のない進行がんまで 40% 2012 日本内視鏡外科学会アンケートより
7 腹腔鏡下大腸切除 ( 全国統計 ) 早期直腸癌早期結腸癌進行直腸癌進行結腸癌 2012 日本内視鏡外科学会アンケートより
8 腹腔鏡下大腸切除と開腹術 ( 癌のみ ) 直腸がん手術 結腸がん手術 腹腔鏡直腸がん切除 腹腔鏡結腸がん切除 2012 日本内視鏡外科学会アンケートより
9 腹腔鏡下大腸切除と開腹術 ( 癌のみ ) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 直腸がん手術結腸がん手術腹腔鏡直腸がん切除腹腔鏡結腸がん切除 2012 日本内視鏡外科学会アンケートより
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11 CQ 3: 大腸癌に対する腹腔鏡下手術推奨カテゴリー B 腹腔鏡下手術には, 開腹手術とは異なる手術技術の習得と局所解剖の理解が不可欠であり, 手術チームの習熟度に応じた適応基準を個々に決定すべきである 腹腔鏡下手術は, 結腸癌および RS 癌に対する D2 以下の腸切除に適しており,cStage 0 cstage I がよい適応である D3 を伴う腹腔鏡下結腸切除術は難度が高いので,cStage II cstage III に対しては習熟度を十分に考慮して適応を決定すべきである また, 横行結腸癌, 高度肥満例, 高度癒着例も高難度である 直腸癌に対する腹腔鏡下手術の有効性と安全性は十分に確立されていない 2010 大腸癌治療ガイドライン
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13 発表者, グループ ( 国, 地域, 年度 ) Lacy (Spain) (2002) COST(USA) (2004) Lueng(HK) (2004) CLASICC(UK) (2005) 解析症例数 219( 単一施設 ) 863( 多施設 ) 403( 単一 ) 737 ( 多施設 ) 結果 stageiii において LAP 群が生存率が良好 全生存率では差なし 短期では差なし 問題点 Stage III の OP 群の成績が不良 (5 年生存率 50%) 全生存率では差なし開腹移行率 21% 補助療法規定なし 開腹移行率 23% 補助療法規定なし 開腹移行率 29% 補助療法規定なし在院死 5% COLOR(Eur) 1049 ( 多施設 ) (2005) JCOG0404(Jpn) 1057( 多施設 ) 短期では差なし 2009 年 3 月症例登録終了 開腹移行率 17% 補助療法規定なし Quality control 重視補助療法規定
14 Short-term clinical outcomes from a randomized controlled trial to evaluate laparoscopic and open surgery for stage II-III colorectal cancer: Japan Clinical Oncology Group study JCOG 0404 (NCT ). Seiichiro Yamamoto, Masafumi Inomata, Seigo Kitano, Hiroshi Katayama, Junki Mizusawa, Fumio Konishi, Kenichi Sugihara, Masahiko Watanabe, Yasuhiro Shimada, Yoshihiro Moriya and Colorectal Cancer Study Group of Japan Clinical Oncology Group National Cancer Center Hospital, Tokyo, Japan; Oita University Faculty of Medicine, Oita, Japan; JCOG Operations Office, National Cancer Center, Tokyo, Japan; JCOG Data Center, National Cancer Center, Tokyo, Japan; Jichi Medical School Saitama Medical Center, Saitama, Japan; Department of Surgical Oncology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan; Department of Surgery, Kitasato University School of Medicine, Kanagawa, Japan Background: The benefits of laparoscopic surgery (LAP) in comparison with open surgery (OP) have been suggested; however, the long-term survival after LAP for advanced colorectal cancer (CRC) requiring complete mesocolic excision is still unclear. We conducted a study to confirm the non-inferiority of LAP to OP in terms of overall survival with less frequent post-operative morbidity. The primary analysis is planned in 2014, and short-term outcomes including post-operative complications are presented here. Methods: Only accredited surgeons from 30 Japanese institutions participated. Eligibility criteria included histologically proven CRC; tumor located in the cecum, ascending, sigmoid or rectosigmoid colon; T3 or deeper lesion without involvement of other organs; N0 2 and M0; tumor size =<8 cm; patient age years. Patients were randomized preoperatively by the minimization method. Patients with pathological stage III received adjuvant chemotherapy with fluorouracil plus leucovorin. The primary endpoint is overall survival, and the planned sample size was Results: A total of 1057 patients were randomized (OP: 528, LAP: 529) between October 2004 and March Patients assigned to LAP had less blood loss than those assigned to OP (median 30 ml vs 85 ml, p<0.001), although LAP lasted 52 minutes longer than OP (p<0.001). Radicality of resection, as assessed by the number of resected lymph nodes, did not differ between the two groups. LAP was associated with earlier recovery of bowel function (p<0.001), and with a shorter hospital stay (p<0.0001) than OP. Morbidity and mortality until discharge did not differ between the two groups, except for fewer wound-related complications in LAP (p=0.007). Conclusions: Short-term clinical benefits of LAP were demonstrated, and laparoscopic surgery for advanced CRC can be performed safely by experienced surgeons. If the non-inferiority of LAP in overall survival is demonstrated in the primary analysis planned in 2014, LAP will be the new standard surgical procedure for CRC. J.Clin.Oncol., 30(Suppl):abstr.538,2012
15 Results: A total of 1057 patients were randomized (OP: 528, LAP: 529) between October 2004 and March Patients assigned to LAP had less blood loss than those assigned to OP (median 30 ml vs 85 ml, p<0.001), although LAP lasted 52 minutes longer than OP (p<0.001). Radicality of resection, as assessed by the number of resected lymph nodes, did not differ between the two groups. LAP was associated with earlier recovery of bowel function (p<0.001), and with a shorter hospital stay (p<0.0001) than OP. Morbidity and mortality until discharge did not differ between the two groups, except for fewer wound-related complications in LAP (p=0.007). 結果 1. 腹腔鏡群が出血量が少なく 手術時間が長く 初回排カ スまでの時間 在院日数が短かった 2. 在院中の合併症は創関連合併症は腹腔鏡群ですくなかったが 縫合不全 術後腸閉塞には差を認めなかった 3. 郭清リンパ節個数は差がなかった
16 Conclusions: Short-term clinical benefits of LAP were demonstrated, and laparoscopic surgery for advanced CRC can be performed safely by experienced surgeons. If the non-inferiority of LAP in overall survival is demonstrated in the primary analysis planned in 2014, LAP will be the new standard surgical procedure for CRC. 結語腹腔鏡手術はStageII/IIIの結腸癌において 2014 年に解析予定の全生存期間において非劣性が示されれば 標準治療をなり得るだろう
17 プレゼンテーションマップ 1. 本邦における腹腔鏡下大腸切除の現況 2. 当科における腹腔鏡下大腸切除の現況 3. Robot 手術
18 初発大腸癌手術症例数の推移
19 CQ 3: 大腸癌に対する腹腔鏡下手術 推奨カテゴリー B 腹腔鏡下手術には, 開腹手術とは異なる手術技術の習得と局所解剖の理解が不可欠であり, 手術チームの習熟度に応じた適応基準を個々に決定すべきである 腹腔鏡下手術は, 結腸癌および RS 癌に対する D2 以下の腸切除に適しており,cStage 0 cstage I がよい適応である D3 を伴う腹腔鏡下結腸切除術は難度が高いので,cStage II cstage III に対しては習熟度を十分に考慮して適応を決定すべきである また, 横行結腸癌, 高度肥満例, 高度癒着例も高難度である 直腸癌に対する腹腔鏡下手術の有効性と安全性は十分に確立されていない 2010 大腸癌治療ガイドライン
20 2007 年までの腹腔鏡手術の適応 盲腸から直腸 S 状部 (RS) までは cstage I まで 上部直腸 下部直腸は cstage I まで Dep of Surgery, Hiroshima City Hosp
21 2007 年以降腹腔鏡手術の適応 盲腸から直腸 S 状部 (RS) までは cstage II まで 上部直腸 下部直腸は cstage I まで Dep of Surgery, Hiroshima City Hosp
22 対象 2007 年 1 月から 2011 年 12 月まで 原発性大腸癌症例 878 例中 盲腸から直腸 S 状部 577 例 Dep of Surgery, Hiroshima City Hosp
23 対象 腹腔鏡下手術 (LAP): 163 例 (28.2%) 開腹手術 (OPEN): 414 例 (71.8%) Dep of Surgery, Hiroshima City Hosp
24 LAP 症 例 OPEN 症例数 性別 (M:F) 85:78 206:208 年齢 ( 中央値 ) 占拠部位 右側結腸 (V/C/A/T) 1/15/39/11 5/41/73/43 左側結腸 (D/S/RS) 10/55/32 27/127/96 Dep of Surgery, Hiroshima City Hosp
25 LAP 症 例 OPEN pstage I II IIIa IIIb 5 36 IV 7 82 Dep of Surgery, Hiroshima City Hosp
26 (%) pstage I の全生存期間 100% 97.3% LAP (N=83) OPEN (N=37) (day)
27 (%) pstage II の全生存期間 93.9% 83.4% LAP (N=42) OPEN (N=165) (day)
28 (%) pstage IIIa の全生存期間 90.0% 84.4% LAP (N=19) OPEN (N=90)
29 2012 年 4 月以降腹腔鏡手術の適応 盲腸から直腸 S 状部 (RS) までは cstage III まで 上部直腸は cstage III まで 下部直腸は cstage I まで Dep of Surgery, Hiroshima City Hosp
30 結腸切除術 (D3 郭清 ) 癌の部分とリンパ節を扇状に切除
31 tumor tumor
32 初発大腸癌手術症例数の推移
33 200 手術アプローチ別症例数 OPEN LAP
34 プレゼンテーションマップ 1. 本邦における腹腔鏡下大腸切除の現況 2. 当科における腹腔鏡下大腸切除の現況 3. Robot 手術
35 da Vinci Surgical System サージョンコンソール ペイシェントカート ヴィジョンカート
36 da Vinci Surgical System 全世界で 1600 台以上導入 利点 3D による立体視 術者手振れの補正機能 問題点 臨床的な手技が未確立で evidence が不足 保険診療が認められず 自費診療である
37 da Vinci Surgical System 手術の現場
38 da Vinci Surgical System 術者
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