潰瘍合併早期胃癌のESD―潰瘍合併早期胃癌ESDの治療成績

Treatment Outcomes of Endoscopic Submucosal Dissection for Early Gastric Cancer with Ulceration Findings

要旨　2002年9月～2010年12月の間に，当施設において，早期胃癌に対してESDを施行した2,143病変（1,874症例）を，潰瘍合併早期胃癌〔UL（＋）群〕428病変と潰瘍非合併早期胃癌〔UL（－）群〕1,715病変に分類し，治療成績についてretrospectiveに比較検討を行った．両群で，一括切除率，後出血率に有意差は認めなかったが，UL（＋）群ではUL（－）群と比して有意に，一括断端陰性切除率が低く，治療時間が長く，術中穿孔率が高いという結果であった．潰瘍合併早期胃癌に対するESDの難易度はいまだ高く，今後さらなる工夫が求められる．また，潰瘍合併早期胃癌に対するESDは長期エビデンスに乏しく，臨床研究の位置づけであり，内視鏡医の技量によっては，熟練施設への紹介や，最初から外科手術も考慮するべきである．長期治療成績に関しては，現在進行中の多施設前向き試験の結果が期待される．

　A total of 2,143 cases of early gastric cancer that underwent ESD（endoscopic submucosal dissection）at our facility between September 2002 and December 2010 were classified into 428cases of early gastric cancer complicated with ulcer〔UL（＋）group〕and 1,715 cases of early gastric cancer not complicated with ulcer〔UL（－）group〕, and a retrospective comparative study was performed. There were no significant differences between the two groups in en bloc resection rate or postoperative hemorrhage rate, but the UL（＋）group had a significantly lower rate in en bloc margin-negative resection compared to the UL（－）group, with longer treatment time and a high rate of perforation during surgery. ESD remains difficult for early gastric cancer complicated with ulcer, and further improvements are required. In addition, there is a paucity of long-term ESD observations for early gastric cancer complicated with ulcer, and thus the procedure is often regarded as being in the clinical research stage. Depending on the skill level of the physician carrying out endoscopy, referring the patient to another facility with more experience or performing a surgical procedure without ESD may be considered. With regard to the long-term outcome, it will be necessary to wait for the results from an ongoing multicenter prospective study.