Chung Ii-Kwun, Lee Jun Haeng, Lee Suck-Ho, Kim Sun-Joo, Cho Joo Young, Cho Won Young, Hwangbo Young, Keum Bo Ra, Park Jong Jae, Chun Hoon-Jai, Kim Hoi Jin, Kim Jae J, Ji Sam-Ryong, Seol Sang Young
Department of Internal Medicine, Soonchunhyang University, Cheonan, Korea.
Gastrointest Endosc. 2009 Jun;69(7):1228-35. doi: 10.1016/j.gie.2008.09.027. Epub 2009 Feb 27.
The technique of endoscopic submucosal dissection (ESD) was introduced to be able to obtain en bloc specimens of large early GI neoplasms. The drawback of ESD is its technical difficulty, which, consequently, is associated with a higher rate of complication and which requires advanced endoscopic techniques and a long procedure time.
To assess the therapeutic outcome of ESD by expert endoscopists who have at least 3 years' experience of EMR in Korea.
A retrospective, multicenter study.
From January 2006 to June 2007, 1000 early gastric cancers in 952 patients (502 men, 450 women; mean age 62.1 years, range 43-90 years) were treated by using ESD at 6 Korean ESD study group (KESG)-related university hospitals in Korea.
We performed ESD procedures with typical sequences (marking, incision, and submucosal dissection).
The rate of en bloc resection, incidence of complication, and length of procedure. Predetermined factors (various endoscopic and final pathologic features) for these outcomes.
The rates of en bloc resection, complete en bloc resection, vertical incomplete resection, and piecemeal resection were 95.3%, 87.7%, 1.8%, and 4.1%, respectively. The rates of delayed bleeding, significant bleeding, perforation, and surgery related to complication were 15.6%, 0.6%, 1.2%, and 0.2%, respectively. The mean procedure time was 47.8 +/- 38.3 minutes. The rates of en bloc resection differed significantly in relation to the location of the lesions (upper portion vs middle portion vs lower portion of the stomach, 88.6% vs 95.2% vs 96.0%, respectively; P = .02), presence of a scar (no vs yes, 96.0% vs 89.5%, respectively; P = .002), and histologic type (low-grade adenoma vs high-grade adenoma vs differentiated early gastric cancer vs undifferentiated early gastric cancer, 95.8% vs 94.6% vs 96.2% vs 83.8%, respectively; P = .007). The rates of delayed bleeding differed significantly in relation to location (upper portion vs lower portion of the stomach, 28.6% vs 13.8%, respectively; P = .003), the size of the tumor (>40 mm vs <20 mm, 28.6% vs 13.7%, respectively; P = .009), recurrent lesion (29.4% vs 15.1%, respectively; P = .024), and macroscopic type (flat vs elevated, 18.8% vs 12.4%, respectively; P = .047). Factors related to the longer procedure time were location (upper portion vs lower portion of the stomach, 64.8 vs 44.1 minutes, respectively; P < .001), the size of the tumor (>40 mm vs < 20 mm, 67.1 vs 42.0 minutes, respectively; P < .001), the presence of ulcer (54.6 vs 46.8 minutes; P < .045), and the presence of a scar (69.2 vs 45.0 minutes; P < .001).
ESD is an effective and safe therapy in the management of early gastric neoplasms. Endoscopists have to accept the need for advanced endoscopic techniques for performing ESD in the case of large lesions, scar lesions, undifferentiated cancers, or for the lesions in the upper portion of the stomach. Endoscopists require more experience to decrease complications in patients who have a large or recurrent lesion in the upper portion of the stomach; these lesions also take more time to complete the ESD procedure.
内镜黏膜下剥离术（ESD）技术被引入用于获取大型早期胃肠道肿瘤的整块标本。ESD的缺点是其技术难度大，因此并发症发生率较高，且需要先进的内镜技术和较长的手术时间。
评估韩国至少有3年内镜黏膜切除术（EMR）经验的专家内镜医师进行ESD的治疗效果。
一项回顾性多中心研究。
2006年1月至2007年6月，韩国6个与韩国ESD研究组（KESG）相关的大学医院对952例患者（502例男性，450例女性；平均年龄62.1岁，范围43 - 90岁）的1000例早期胃癌进行了ESD治疗。
我们采用典型步骤（标记、切开和黏膜下剥离）进行ESD手术。
整块切除率、并发症发生率和手术时间。这些结果的预定因素（各种内镜和最终病理特征）。
整块切除率、完全整块切除率、垂直不完全切除率和碎块切除率分别为95.3%、87.7%、1.8%和4.1%。延迟出血、严重出血、穿孔及与并发症相关的手术发生率分别为15.6%、0.6%、1.2%和0.2%。平均手术时间为47.8±38.3分钟。整块切除率在病变部位（胃上部与中部与下部，分别为88.6% vs 95.2% vs 96.0%；P = 0.02）、瘢痕存在情况（无 vs 有，分别为96.0% vs 89.5%；P = 0.002）以及组织学类型（低级别腺瘤 vs 高级别腺瘤 vs 分化型早期胃癌 vs 未分化型早期胃癌，分别为95.8% vs 94.6% vs 96.2% vs 83.8%；P = 0.007）方面存在显著差异。延迟出血率在病变部位（胃上部与下部，分别为28.6% vs 13.8%；P = 0.003）、肿瘤大小（>40 mm vs <20 mm，分别为28.6% vs 13.7%；P = 0.009）、复发病变（分别为29.4% vs 15.1%；P = 0.024）以及大体类型（平坦型 vs 隆起型，分别为18.8% vs 12.4%；P = 0.047）方面存在显著差异。与较长手术时间相关的因素包括病变部位（胃上部与下部，分别为64.8分钟 vs 44.1分钟；P < 0.001）、肿瘤大小（>40 mm vs <20 mm，分别为67.1分钟 vs 42.0分钟；P < 0.001）、溃疡存在情况（54.6分钟 vs 46.8分钟；P < 0.045）以及瘢痕存在情况（69.2分钟 vs 45.0分钟；P < 0.001）。
ESD是治疗早期胃肿瘤的一种有效且安全的方法。对于大病变、瘢痕病变、未分化癌或胃上部病变，内镜医师必须接受采用先进内镜技术进行ESD的必要性。对于胃上部有大病变或复发病变的患者，内镜医师需要更多经验以减少并发症；这些病变完成ESD手术也需要更多时间。
