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Stomach and Intestine(Tokyo) Volume 42, Issue 7 （June 2007）

胃と腸 42巻7号（2007年6月発行）

Japanese English

今月の主題大腸ESDの現況と将来展望

主題

大腸ESDの技術習得とそのための必要条件 ESD for Colorectal Tumors and Its Training System in Order to Obtain a Safe Procedure 為我井芳郎 ^1,2 , 斉藤幸夫 ³ , 正木尚彦 ⁴ , 大嶋隆夫 ⁴ , 長沖祐子 ⁴ , 矢郷祐三 ⁴ , 上村直実 ⁴ , 竹下恵美子 ³ , 三宅大 ³ , 清水利夫 ³ Yoshiro Tamegai ^1,2 , Yukio Saito ³ , Naohiko Masaki ⁴ , Takao Oshima ⁴ , Yuko Nagaoki ⁴ , Yuzo Yago ⁴ , Naomi Uemura ⁴ , Emiko Takeshita ³ , Ohki Miyake ³ , Toshio Shimizu ³ ¹聖隷横浜病院内視鏡センター ²前 : 国立国際医療センター消化器科 ³国立国際医療センター外科 ⁴国立国際医療センター消化器科 ¹Department of Gastroenterology, Seirei Yokohama Hospital, Yokohama, Japan ³Department of Surgery, International Medical Center of Japan, Tokyo ⁴Department of Gastroenterology, International Medical Center of Japan, Tokyo キーワード：内視鏡的粘膜下層剥離術 , ESD , 大腸腫瘍 Keyword: 内視鏡的粘膜下層剥離術 , ESD , 大腸腫瘍 pp.1115-1126

発行日 2007年6月25日 Published Date 2007/6/25

DOI https://doi.org/10.11477/mf.1403101139

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要旨　ESDは，全周性腫瘍を除き内視鏡的に一括切除の可能な大きさの限界を払拭しつつある．大腸ESDは食道・胃ESDに比べ解剖学的・組織学的特性から難度が高い．その技術習得は診断学と並行して胃のESDトレーニングシステムのうえに位置付けられる．また偶発症の頻度は高く，高度な手技やリスクマネージメントのみならず倫理的要素も問われる．大腸ESDの適応は，①大きさは20mm以上，②IIIs，III_L，IV，V_I型pit patternを示す推定深達度mないしsm微小浸潤癌，③V_N型pit patternを認めず，明らかなnon lifting sign陰性，の病変と位置付けられる．以上の基準で大腸腫瘍127例（男76例，女51例，平均65.9歳）130病変に対しHook knifeによるESDを行った．一括切除は126病変（96.9％）で腫瘍の遺残・再発例はない．1病変（0.77％）で小穿孔を認めたがクリップにより閉鎖し完治した．大腸ESDの安全性と根治性は徐々に確立されてきた．今後その標準化に向け機器の開発や技術習得を目指した教育システムの構築が急務である．

　Endoscopic submucosal dissection (ESD) has made possible en-bloc resection of colorectal tumors regardless of size, except entirely circumferential lesions. The ESD technique for colorectal tumors is more difficult than that for gastro-esophageal tumors because of the anatomical and histological characteristics of the colorectal wall. For these reasons, its learning system is more advanced than the ESD technique for gastric tumors, and is accompanied with diagnostic training for colorectal tumors. Furthermore, this procedure has so high a rate of potential complications that surgeons have to be experts in endoscopic examination, risk management, and ethical judgement.

　The indications for ESD are as follows : First, tumors larger than 20mm in diameter. Secondly, pit patterns of type III_L, IIIs, IV or V_I tumors (mucosal or minimally submucosal invasive cancers). Thirdly, tumors without V_N pit pattern or non-lifting signs. ESD was performed for 130 colorectal tumors (adenomas and early cancers) in 127 patients (76 male, 51 female, mean age of 65.9 years old) by using a Hook-knife. Among these lesions, 126 lesions (96.9％) were resected by the en bloc method. One case with complications due to perforation (0.77％) was seen, and was treated using endoclips. All cases were followed up after resection by colonoscopic examinations. Neither residual tumors nor recurrences were found. The safety of ESD for colorectal tumor has gradually increased. With the development of this device and the learning system, ESD will play an important role in therapeutic strategy for colorectal tumors.