Wehrmann T, Lange P, Nakamura M, Riphaus A, Stergiou N
Medizinische Klinik I (Gastroenterologie - interventionelle Endoskopie), Klinikum Hannover-Siloah, Hannover.
Z Gastroenterol. 2001 Nov;39(11):919-28. doi: 10.1055/s-2001-18538.
Surgical therapy of early malignancies of the upper gastrointestinal tract is associated with substantial morbidity and mortality, especially in elderly and co-morbid patients. In Japan endoscopic mucosal resection (EMR) has been proven to be safe and efficacious in this indication.
22 patients (68 +/- 14 years, 9 females) with high-grade dysplasia of the esophagus (n = 5), early carcinoma of the esophagus (T1N0M0, n = 11) or early gastric cancer (T1N0M0, n = 6) proven by high-resolution videoendoscopy (plus chromoendoscopy in most cases), miniprobe-endosonography (12-20 MHz) and biopsy were enrolled. The lesion size ranged from 7-40 mm in diameter. EMR was performed using a monofile snare, in almost all cases after submucosal injection of an attenuated epinephrine-solution (1:20,000) to effect a lifting sign. "En bloc" resection was possible in 17/22 cases (77 %), but in 5 patients piecemeal-resection had to be performed due to a larger lesion size.
Active bleeding occurred on 14 of 22 occasions (64 %), in another 5 patients secondary bleeding (within 24 h after EMR) were detected. All these events could be managed endoscopically (mainly by hemoclip application) and blood transfusion was not required. Other complications did not occur. A complete resection (R0) was achieved in 21/22 cases, however, one patient had to undergo a second EMR procedure because histology of the first resected specimen had revealed malignant infiltration of the resection margin (R1). After the second EMR procedure complete (R0)-resection was obtained. Compared to the histological findings after EMR the pre-procedural staging proved to be correct in all cases. The control examinations (clinical exam, lab data, endoscopy with multiple biopsies, endosonography and CT) after EMR revealed no local or systemic cancer recurrence in 21/22 patients (median follow-up 5 months, range 3-12 months). However, in one patient with adenocarcinoma and Barrett-esophagus another mucosal adenocarcinoma was detected 3 months after EMR (located in opposite to the initial carcinoma treated with EMR).
EMR seems to be a safe and effective (regarding local tumor control) therapy for high-grade dyplasia and early malignancies in the upper gastrointestinal tract. However, long-term follow-up in these patients has to be awaited.
上消化道早期恶性肿瘤的手术治疗会带来较高的发病率和死亡率，尤其是在老年及合并其他疾病的患者中。在日本，内镜黏膜切除术（EMR）已被证明在该适应症方面是安全有效的。
纳入22例患者（年龄68±14岁，女性9例），经高分辨率视频内镜检查（多数情况下联合染色内镜检查）、微型探头超声内镜检查（12 - 20 MHz）及活检证实患有食管高级别异型增生（n = 5）、早期食管癌（T1N0M0，n = 11）或早期胃癌（T1N0M0，n = 6）。病变直径范围为7 - 40 mm。几乎所有病例均在黏膜下注射稀释的肾上腺素溶液（1:20,000）以形成抬举征后，使用单丝圈套器进行EMR。17/22例（77%）实现了整块切除，但5例患者因病变较大不得不进行分片切除。
22例中有14例（64%）出现活动性出血，另有5例患者在EMR后24小时内检测到继发性出血。所有这些情况均可通过内镜处理（主要是应用止血夹），无需输血。未发生其他并发症。21/22例实现了完全切除（R0），然而，1例患者因首次切除标本的组织学检查显示切除边缘有恶性浸润（R1），不得不接受第二次EMR手术。第二次EMR手术后获得了完全（R0）切除。与EMR后的组织学结果相比，术前分期在所有病例中均被证明是正确的。EMR后的对照检查（临床检查、实验室数据、多次活检的内镜检查、超声内镜检查和CT）显示，21/22例患者（中位随访5个月，范围3 - 12个月）无局部或全身癌症复发。然而，1例腺癌合并巴雷特食管的患者在EMR后3个月检测到另一个黏膜腺癌（位于与接受EMR治疗的初始癌相对的位置）。
EMR似乎是治疗上消化道高级别异型增生和早期恶性肿瘤的一种安全有效的（关于局部肿瘤控制）治疗方法。然而，这些患者仍需长期随访。
