大腸ESDのコツとピットフォール―切除手順の刷新と困難例への対処

Tips and Pitfalls in Colorectal Endoscopic Submucosal Dissection―Procedural Improvement and Handling of Difficult Cases

要旨　大腸においても，適切なデバイス選択と切除手順により安全にESDを施行することが可能になった．しかし，対処すべき局面が多々あり難易度は依然として高い．大腸ESD最大のポイントはいち早く順方向からのアプローチ経路を確保することである．われわれはこの認識に至り，最初に遠位（口）側の粘膜切開およびトリミングを終了しておく手順から，病変の近位（肛門）側の粘膜切開と剥離を先に行う手順に変更した．本稿では大腸ESDの手技の実際と困難状況への対処法を詳述した．

　While the appropriate choice of device and dissection procedure has enabled safer endoscopic submucosal dissection (ESD) in the large intestine, as well as other sites, this methodology remains challenging, since it involves a number of aspects that require technical and other skills. The crucial point in colorectal ESD is to secure timely access to the lesion from the forward direction. The recognition of this fact has prompted us to alter our procedure: we now engage first in mucosal incision and submucosal dissection of the distal (anal) side of the lesion, instead of mucosal incision and trimming of the proximal (oral) side. This report describes in detail the techniques employed in colorectal ESD and the management of difficult situations possibly encountered in the procedure.