早期胃癌に対するESD切除成績と切除困難例の特徴

Curability and Safety of ESD for Gastric Cancer―Characteristics of Cases in Which ESD is Difficult to be Performed

要旨　ESD困難例で十分な根治性と安全性を維持してESDが実施できているか否か明らかにするために，当院でESDを行った胃癌181症例，182病変を対象に検討を行った．EMR相対適応である大きな病変や潰瘍瘢痕を有する病変，噴門部などESD操作困難部位の病変をESD困難例と想定し，ESD症例を層別化して比較検討した．切除粘膜径5cm以上群vs5cm未満群，ESD困難部位群vsESD容易部位群の比較では，一括切除率，水平断端陰性率，完全治癒切除率，粘膜下層浸潤率，穿孔発生率に有意差は認めなかった．潰瘍瘢痕群vs非瘢痕群では，潰瘍瘢痕群において有意差はないが水平断端癌陰性率が低い傾向にあった．適切な手技に基づけば困難症例でも十分なESD成績を得ることが可能であることが示された．穹窿部頂部病変やUL-IIIs以深の潰瘍瘢痕症例は今のところESDが不可能であるが，より振り幅の大きいmulti-bending scopeや内視鏡的全層切除手技の開発によって，将来内視鏡治療が可能となるものと推測される．

　In order to elucidate whether ESD can be carried out with appropriate curability and safety in cases with relative EMR indication for gastric cancer, we studied 182 gastric cancers resected by ESD. Factors considered obstructing ESD, such as ulceration, difficult position and size (diameter larger than 5cm), did not significantly affect the curative ability and safety of ESD. Therefore, appropriate training in ESD can result with the same levels of curability and safety as in cases with relative EMR indication for gastric cancer. Although we are not able to perform ESD for gastric cancers at the top portion of the fornix, or cancers with deep ulceration fibrosis in the proper muscle layer, further development such as full thickness resection might enable ESD even for such cases.