早期胃癌EMR/ESDの絶対適応病変を決定するための術前内視鏡診断と問題点—消化性潰瘍合併の診断

Preoperative Endoscopic Diagnosis and Issues in Determining Absolute Indication of Lesions for EMR/ESD for Early Gastric Cancer:Diagnosis of Peptic Ulcer Complications

要旨●潰瘍瘢痕併存（ULs）早期胃癌の診断能に関して，過去の報告から後述の4点がわかった．①ULs早期胃癌の潰瘍の有無に関する術前診断は感度とPPVが低く，術前にULsの有無の判断自体が難しいことが浮き彫りになった．②範囲診断に関する詳細なデータは得られなかった．ただし，ULs早期胃癌ではHM1が多く，その原因は技術的要因であると考えられた．③深達度診断も正診率は72〜85%でULsなしの早期胃癌より低い傾向がみられた．④ESDの難易度の予測にはEUSが有用と考えられ，当院のデータでは第3層の断裂距離が5mmを超えると標本に挫滅を残す場合が73%で認められた．このことから，EUSの第3層断裂距離が5mmを超える場合は技術的な適応を超えている可能性がある．ただし，ULs早期胃癌に対するESDは，線維化領域の部位や面積，瘢痕化の時期，個々の内視鏡技術により成績が左右されるため，これらの要素も加味して治療適応を決定すべきと考えた．

　This article describes diagnostic performance for early gastric cancer with ULs（ulcer scars）. Previous reports have highlighted that（1）the sensitivity and positive predictive value of preoperative diagnoses of the presence/absence of ulcers in early gastric cancer with ULs are low and it is difficult to determine the presence/absence of ULs preoperatively.（2）Detailed data on the extent of diagnoses were not obtained. However, HM1 was predominant in early gastric cancer with ULs, and the cause was considered to be technical. （3）The diagnostic accuracy for depth of invasion was 72%〜85%, which was lower than that for early gastric cancer without ULs. （4）EUS（endoscopic ultrasonography）appears to be useful for predicting the difficulty of ESD（endoscopic submucosal dissection）. Based on data from our institution, when the rupture distance of the 3rd layer exceeds 5mm, 73% of specimens were crushed. This suggests that EUS 3rd layer rupture distances of >5mm may be beyond technical indications. However, since the outcome of ESD for early gastric cancer with ULs is affected by the site and area of fibrosis, timing of scarring, and individual endoscopic techniques, therapeutic indications should be determined with due consideration of these factors.