早期胃癌に対するESDによる偶発症の現状とその対策―全身管理，循環動態も含めて

Current Status and Countermeasures of Complications Associated with Endoscopic Submucosal Dissection (ESD)

要旨　内視鏡的粘膜下層剝離術(以下ESD)による偶発症の現状と対策について述べた．術中出血は必発であるが，視野を確保しながら地道に血管処理を行うことにより治療時間の短縮が図れる．術後出血は，切除後の潰瘍底を細い血管までくまなく止血することで予防が可能である．穿孔は適応病変0.9％，適応拡大病変1.6％と低率であるのに対して，適応外病変18.8％と有意に高率であった．また，precutによる穿孔例もあり，十分な注意が必要である．ESDでは治療に長時間を必要とするため，鎮静剤と鎮痛剤を併用した注意深い術中管理が要求される．長時間の鎮静による合併症(誤嚥性肺炎，褥創，深部静脈血栓症)の予防として，低反発マットの使用，頻回な口腔内分泌物の吸引，治療時間が2時間を超えた時点で体位変換，下肢マッサージ，膀胱カテーテルの留置を行っている．ESD施行医は十分かつ安全な鎮静を行うための知識と配慮が必要とされる．

　We examined the current status of complications associated with endoscopic submucosal dissection (ESD) and countermeasures against such complications. Intraoperative bleeding is unavoidable, but the treatment time can be shortened by the control of bleeding vessels, while securing an adequate field of view. Postoperative bleeding can be prevented by the control of bleeding from small vessels at the ulcer floor after resection. The rate of perforation was significantly higher for non-indicated lesions (18.8％) than for indicated lesions (0.9％) and indication-expanded lesions (1.6％). Some patients had perforation after precutting, so caution is required. Because ESD requires a long treatment time, patients should receive sedatives and analgesics and be closely monitored during the procedure. To prevent complications caused by prolonged treatment with sedatives (i.e., aspiration pneumonia, decubitus ulcers, deep-vein thrombosis), patients were placed on a low repulsion mattress, and oral secretion was frequently aspirated. When the treatment time exceeded 2 hours, complications were controlled by changing the patient's body position, massaging the lower extremities, and using an indwelling bladder catheter. The successful outcome of ESD requires knowledge and attention to ensure that sedation is adequate and safe during the procedure.