大腸pSM癌に対する内視鏡治療根治基準の拡大―根治基準拡大の是非について─非の立場から

Expansion of Indication for Endoscopic Treatment for Submucosal Invasive Colorectal Carcinoma from the Standpoint of Negation

要旨　大腸pSM癌に対する内視鏡治療根治基準の拡大について，否定的な立場から自験例を中心に検討した．外科切除を行った380例中リンパ節転移を39例（10％）に認め，ガイドラインの規約を満たさなかったのは1例であった．ガイドライン普及以後，内視鏡摘除後追加腸切除の施行比率は有意に増加した．内視鏡摘除後経過観察になった250例中5例に再発を認め，リンパ節再発を認めた3例はいずれも追加腸切除の適応を満たしていた．外科手術の合併症は，再手術例，術死例および入院死亡例も認めなかった．大腸pSM癌のリンパ節転移の頻度は低率でありover surgeryの可能性は否定できないが，ガイドラインの規約を満たさないリンパ節転移が存在すること，外科手術の少ない合併症および腹腔鏡手術の普及などによる術後QOLの向上，経過観察例の再発死亡例の存在を考えると容認できる部分も多く，大腸pSM癌を確実に救命するという観点からも，内視鏡治療根治基準の拡大は慎重にすべきである．

　We analyzed submucosal invasive colorectal carcinoma in order to evaluate the indication for endoscopic treatment of submucosal invasive colorectal carcinoma from the standpoint of negation. In 380 patients who had undergone surgical resection, 39 patients（10％）had lymph node metastasis and only one patient had not met the terms of the guidelines. After the dissemination of guidelines, the rate of additional bowel resection significantly Increased. Recurrence was seen in 5 of 250 patients who were followed-up after endscopic treatment and 3 patients who had lymph node recurrence met the indication for additional bowel resection. In the reoperation, surgical deaths and hospital deaths were seen in patients who had undergone surgical resection. The frequency of lymph node metastasis of colorectal submucosal invasive carcinoma was low and the possibility of over-surgery could not be denied. However, expansion of the indication for endoscopic treatment should be approached carefully, because of the presence of lymph node metastasis that did not meet the terms of the guidelines, fewer complications after surgical resection and improvement of QOL by the use of Laparoscopic surgery, the presence of recurrence and death cases that have followed after endoscopic treatment alone.