臨牀消化器内科 Vol.13 No.8(11)


特集名 安全な内視鏡的粘膜切除術
題名 結節集簇様病変に対する粘膜切除
発刊年月 1998年 07月
著者 渡 二郎 旭川医科大学第三内科
【 要旨 】 大腸結節集籏様病変186病変を対象に,その内視鏡治療の適応と限界(一括切除と分割切除)を検討した.内視鏡治療の適応はリンパ節転移のない腺腫と粘膜内癌,sm1癌であり,これらの平均腫瘍径はそれぞれ18.0mmと25.8mmであった.また,内視鏡切除において一括切除できた病変の平均腫瘍径は16.4mmで,分割切除となったものは26.1mmであった.一括切除できた病変でも腫瘍径が20~26mmで組織学的切除断端陽性率は63.4%であり,26mm以上の病変では全例が切除断端陽性であった分割切除となった.ものでは10~15mmの大きさでもすでに過半数が断端陽性であった.切除断端陽性例77病変のうち経過観察中に局所再発を認めたものは11病変(14.3%)であり,このうち外科的手術が必要であったものは3病変だけであった.以上の結果から,内視鏡的な一括切除で治療可能な腫瘍径は20mm以下であることがわかった.術者の技量が伴えばそれ以上の腫瘍径でも分割切除による治療も可能であるが,十分なsafety marginをもった切除が必要である.しかし,内視鏡切除にあたる消化器内科医は,近年,進歩の著しいminimum invasive surgeryにゆだねる勇気をもつことも重要であろう.
Theme Safety Procedures in Endoscopic Mucosectomy
Title Endoscopic Resection for Nodule Aggregating Tumors of the Colorectum
Author Jiro Watari Third Department of Internal Medicine, Asahikawa Medical College
[ Summary ] To clarify the indications for and limitations of endoscopic resection (EMR) of nodule aggregating tumors, i.e. en bloc or piecemeal resection, 186 lesions were analyzed clinicopathologically. These tumors consisted of adenomas, intramucosal carcinomas and carcinomas with sm1 invasions. The average size of adenomas and carcinomas was 18.0mm and 25.8mm, respectively. The average size of the tumors treated with an en bloc EMR and with piecemeal EMR was 16.4mm and 26.1mm, respectively. The pathologically positive rates of the cut ends was between 63.4% and 100%, when an en bloc EMR was performed on a tumor of 20 to 25mm in size and over 26mm in diameter, respectively. In tumors treated with piecemeal EMR, most cases showed the cut ends to be pathologically positive even when their diameters ranged from 10 to 15mm. Local recurrence was found in 11 (14.3%) of 77 pathologically cut positive end cases, during a follow-up examination. Surgery was performed in 3 out of 11recurrent cases. These results suggest that when tumor size is less than 20mm in diameter, an en bloc EMR could achieve complete removal with a pathologically free cut end. Although the skill of en-doscopists may enable them to treat large tumors(of more than 20mm in size) with piecemeal EMR, they should be cautioned to take adequate safety measures. More important thing for endoscopists is not to hesitate to put patients in the hands of surgeons who can manage to treat such tumors with minimal invasive surgery, which has made remarkable progress in recent years.
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