| 特集名 | 消化器内視鏡の技術革新―開発秘話と次世代内視鏡医療の構築に向けて | |
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| 題名 | 技術革新と開発秘話（6）大腸ESDの開発 | |
| 発刊年月 | 2016年 09月 | |
| 著者 | 矢作 直久 | 慶應義塾大学医学部腫瘍センター |
| 【 要旨 】 | ESDが確立する前に，まず確実にスネアを掛けるために病変の周囲を切開することから新しい手技が始まった．安全性を担保するためにさまざまなコンセプトで新たな処置具が開発されたが，徐々に対象病変が大きくなるにつれて切開だけではスネアが掛けられなくなったため，切開縁の粘膜下層を剝離するようになり，最終的にスネアを用いずに剝離だけで病変を一括切除する方法へとたどり着いた． 大腸でこの方法を用いた報告はなかったが，S状結腸の小型のLST‒NG‒PDを発見し，EMRでは確実な切除は難しいことから，われわれは十分な隆起を形成してから短い細径スネアの先端と手作りの先端透明フードを用いることにより安全に切除できると考え，1999年に初めてESDを行った．この成功の後に，徐々に対象病変のサイズを上げていった．さらに穿孔した症例や10cmを超える大型病変の切除後でも臨床経過はスムースであり，非常に綺麗に治ることを経験し，大腸ESDは非常に有用であることを確信した．大腸に適した処置具が開発され徐々に大腸ESDは普及してきている．大腸腫瘍の頻度は欧米諸国でも高いため，今後さらなる機器の開発により世界的に大腸ESDが普及すると思われる． |
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| Theme | Technological Innovation of Digestive Endoscopy -- Toward the Next Generation of Endoscopic Medicine | |
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| Title | Development of Colorectal Endoscopic Submucosal Dissection | |
| Author | Naohisa Yahagi | Cancer Center, Keio University School of Medicine |
| [ Summary ] | Before the endoscopic submucosal dissection (ESD) procedure had been established, circumferential mucosal incision was introduced as a new resection technique used to facilitate snaring. Several devices utilizing different concepts were then developed to ensure the safety of the procedure. As a result of the increase in the size of the target lesions, we started performing submucosal dissection of the surrounding tissue along the incision line to ensure the application of snare wires to the target lesions. Finally, we found that reliable en‒bloc resection was possible by dissecting submucosal tissue without using the snare. No opportunities were available to perform this procedure in the colon; however, we decided to apply this technique to a small LST‒NG‒PD (laterally spreading tumor non‒glanular pseudo‒depressed type) in the sigmoid colon in 1999 because endoscopic mucosal resection could not achieve complete resection, and our technique involving the use of the tip of a thin‒type snare and a hand‒made transparent hood after creating sufficient submucosal fluid cushion seemed relatively safe even for colonic lesions. The lesion was successfully removed using this technique, and we gradually targeted larger lesions. We are convinced of the efficacy of colonic ESD after experiencing uneventful clinical courses and excellent outcomes of the treated cases, even of those with perforation or very large resection (>10 cm in size). ESD has gradually become popular because of the development of specific devices for colonic procedures. The incidence of colorectal tumors is high in Western countries; therefore, colonic ESD will become more popular around the world with further advancement of new devices. |
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