早期胃癌の内視鏡的切除法―根治を目的として

Endoscopic Resection for Early Gastric Cancer: The Actual Procedure and Clinical Evaluation

要旨　早期胃癌に対する根治を目的とした内視鏡治療の適応は，多数の手術早期胃癌の病理組織学的検討から，リンパ節転移のない20mm未満・Ul（－），10mm未満・Ul（＋），深達度mの分化型腺癌と考えている．その治癒判定では回収組織の詳細な病理組織学的検索が必須であり，筆者らは高周波電流を用いた2チャンネルファイバースコープによる内視鏡的切除術を施行してきた．1978年から1989年までの12年間に247例256病変の早期胃癌に本法を施行，全症例に追跡調査がなされており，内視鏡的治療による最終治癒率は86.2％であった．一方，症例の蓄積と共に経過観察中11例で他部位に新たな癌病変を認めており，術後のfollow-up内視鏡検査では切除部位だけでなく，癌発生母地を考慮した胃全体の注意深い観察が不可欠であることを強調したい．

　We have already reported the applications for endoscopic treatment based on the results of histopathological studies of many cases of early gastric cancer surgically treated, and the usefulness of endoscopic resection (ER) with a two-channel fiberscope as a means of practical treatment.

　Procedure:

　1) Horizontal extension of the lesion was correctly evaluated by dye-endoscopy and biopsy (Fig. 2a).

　2) A two-channel fiberscope was used, and the site of the lesion was held tightly with forceps and suspended (Fig. 2b～d).

　3) The suspended base including the normal mucosa around the lesion was strangled by means of a snare (Fig. 2e, f).

　4) After the forceps had been removed, the site was resected with high-frequency current as usual (Fig. 2g, h).

　5) The resected tissues were recovered for histopathological study(Fig. 3a-d).

　Results:

　ER was undertaken for 256 lesions of early gastric cancer, including 5 of typeⅠ, 118 of Ⅱa, 13 of Ⅱa十Ⅱc and 120 of Ⅱc respectively among 247 patients. The percentage of patients who underwent this form of resection accounted for 19.5% of a total of 1,261 patients with early gastric cancer.

　The rate of residual lesions was 9.7% (24/247) and the recurrence rate was 12.9% (30/232). Moreover, in 11 cases we found new lesions of cancer in follow-up endoscopy. Repeated ER was tried in 26 of these cases (40%, 26/65) showing new lesions, and it resulted in complete cure. Surgical resection was performed in 35 cases. Four cases were excluded because of their poor general condition. The final cure rate of early gastric cancer by ER was 86.2% (213/247), and the maximum of the follow-up period was 10 years and 2 months.

　Conclusions:

　1) Cancers less than 2 cm (1 cm UI (＋)) in size, localized in the mucosa are suitable candidates for ER.

　2) Attention should be paid to the presence of multiple cancers both before ER and in follow-up endoscopy.