胃EMRの適応拡大：大きさからみて―一括切除を目指した手技の工夫と成績：Hookingナイフ法with intra-gastric lesion lifting method

Endoscopic Mucosal Resection Using a Hooking Knife (Hooking EMR)

要旨　Hookingナイフ法は病変周囲粘膜を切開した後に，Hookingナイフを用いて粘膜下層の線維や血管を切離することで，大きく正確な一括切除を可能とした新たなEMR手技である．今回紹介したingra-gastric lesion lifting methodを併用することで粘膜下層の剥離が容易となる．また，切開前血管凝固法を用いると出血を予防することができ，良い視野で切離を続けることができる．これらの手技を用いると占居部位，大きさにかかわらず一括切除が可能であるが，初心者は2cm以下の病変切除から開始することをお勧めする．

　Lymph nodal metastasis of gastric mucosal cancer is very rare, so, endoscopic mucosal resection (EMR) was selected for the treatment of such lesions instead of gastrectomy. However, the size of endoscopically resected specimens was 10～20 mm, so piece-meal resection was performed for larger lesions. Histological examination for the piecemeal-resected specimens was difficult compared with that of en-bloc resected specimens, so we developed a new EMR method, Hooking EMR, to resect larger en-bloc specimens.

　Firstly, we placed marks around the lesion using a coagulation needle. next, glycerol-diluted epinephrine solution was injected into the submucosal layer to separate the mucosal lesion from the proper muscular layer. Then, we cut the mucosa using a needle knife. Finally, we cut the submucosal fibers using a hooking knife and resected the lesion without using a snare.

　A large en-bloc resection, 70 mm or over in size, was possible with this new method. Because of this, the histological examination for both the range of lateral spreading and depth of invasion can be made more precisely. Hooking EMR is a new useful EMR method for resection of large lesions which until now, have required piece-meal resection.