Hurlstone D P, Sanders D S, Thomson M, Cross S S
Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom.
Endoscopy. 2006 Sep;38(9):902-6. doi: 10.1055/s-2006-944733.
Endoscopic mucosal resection and submucosal dissection can provide curative endoscopic therapy for Paris type I/II adenomas and node-negative early cancer. No studies have addressed the technical feasibility of retroflexion endoscopic dissection methods for luminal "salvage" therapy in patients considered unresectable using conventional forward-viewing resection.
Colonoscopy using an Olympus GIF-XQ240 gastroscope was carried out in 76 patients with Paris type I/II adenomas, early colorectal cancer (CRC), or laterally spreading tumors (LSTs) when the index endoscopist considered the lesion to be unresectable due to retrograde fold involvement. Endoscopic mucosal resection (EMR) and submucosal dissection were carried out using a complete retroflexion technique. Endoscopic and miniprobe 20-MHz or 12.5-MHz ultrasound follow-up data were collected prospectively up to 24 months after the index resection.
Cecal intubation or cannulation to the neoterminal ileum was achieved in 76 (100 %) cases. Forty lesions (53 %) were classified in accordance with the Paris criteria as Is; 16 (21 %) as type II; 10 (13.5 %) as LST-G; and 10 (13.5 %) as LST-NG. Eight lesions (10 %) were excluded from EMR on the basis of endoscopic ultrasound criteria, with 68 of the 76 lesions (89 %) meeting the criteria for endoluminal resection. The median intubation time was 16 min (range 3-32 min). The median resection times were 98 min (range 30 - 242 min), 36 min (range 10-60 min), 172 min (range 20 - 240 min), and 60 min (range 10-116 min) for Paris Is, II, LST-G, and LST-NG lesions, respectively. LST-G morphology was associated with a high median submucosal injection volume in comparison with all other Paris types ( P < 0.05) and with a prolonged resection time ( P < 0.01). Sixty-one patients (94 %) completed the surveillance protocol. Higaki recurrence criteria were met in seven patients (11 %), with six undergoing successful adjunctive endoluminal resection. After 24 months of follow-up, the "cure" rate with endoscopic resection was 60 out of 61 (98 %).
This is the first prospective study to address the safety and medium-term efficacy of retroflexion endoscopic resection in the colon. When appropriate exclusion criteria are applied, selected patients can receive curative resection using the retroflexion technique. "Salvage" endoluminal therapy may therefore be possible in such cases when surgical resection would otherwise have been required.
内镜黏膜切除术和黏膜下剥离术可为巴黎I/II型腺瘤和无淋巴结转移的早期癌症提供根治性内镜治疗。对于那些被认为无法使用传统前视式切除术切除的患者，尚未有研究探讨反转内镜剥离方法用于腔内“挽救性”治疗的技术可行性。
对76例巴黎I/II型腺瘤、早期结直肠癌（CRC）或侧向扩散肿瘤（LST）患者进行结肠镜检查，使用奥林巴斯GIF-XQ240胃镜，当主检内镜医师认为病变因逆行皱襞受累而无法切除时进行检查。采用完全反转技术进行内镜黏膜切除术（EMR）和黏膜下剥离术。前瞻性收集索引切除术后长达24个月的内镜和微型探头20MHz或12.5MHz超声随访数据。
76例（100%）患者成功完成盲肠插管或新末端回肠插管。40个病变（53%）根据巴黎标准分类为Is型；16个（21%）为II型；10个（13.5%）为LST-G型；10个（13.5%）为LST-NG型。根据内镜超声标准，8个病变（10%）被排除在EMR之外，76个病变中的68个（89%）符合腔内切除标准。中位插管时间为16分钟（范围3 - 32分钟）。巴黎Is型、II型、LST-G型和LST-NG型病变的中位切除时间分别为98分钟（范围30 - 242分钟）、36分钟（范围10 - 60分钟）、172分钟（范围20 - 240分钟）和60分钟（范围10 - 116分钟）。与所有其他巴黎类型相比，LST-G形态与较高的中位黏膜下注射量相关（P < 0.05），且切除时间延长（P < 0.01）。61例患者（94%）完成了监测方案。7例患者（11%）符合Higaki复发标准，其中6例成功接受了辅助腔内切除术。随访24个月后，内镜切除的“治愈”率为61例中的60例（98%）。
这是第一项探讨结肠反转内镜切除术安全性和中期疗效的前瞻性研究。当应用适当的排除标准时，选定的患者可以使用反转技术接受根治性切除。因此，在原本需要手术切除的此类病例中，“挽救性”腔内治疗可能是可行的。
