Honjo Kumpei, Kure Kazumasa, Ichikawa Ryosuke, Ro Hisashi, Takahashi Rina, Niwa Koichiro, Ishiyama Shun, Sugimoto Kiichi, Kamiyama Hirohiko, Takahashi Makoto, Kojima Yutaka, Goto Michitoshi, Tomiki Yuichi, Sakamoto Kazuhiro, Fukumura Yuki, Yao Takashi
Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan.
Department of Human Pathology, Juntendo University Faculty of Medicine, Tokyo, Japan.
Case Rep Gastroenterol. 2016 Nov 21;10(3):693-700. doi: 10.1159/000452758. eCollection 2016 Sep-Dec.
Generally, lesions of rectal neuroendocrine tumors (NETs) 10 mm or smaller are less malignant and are indicated for endoscopic therapy. However, the vertical margin may remain positive after conventional endoscopic mucosal resection (EMR) because NETs develop in a way similar to submucosal tumors (SMTs). The usefulness of EMR with a ligation device, which is modified EMR, and endoscopic submucosal dissection (ESD) was reported, but no standard treatment has been established. We encountered 2 patients in whom rectal NETs were completely resected by combined dissection and resection of the circular muscle layer using the ESD technique. Case 1 was an 8-mm NET of the lower rectum. Case 2 was NET of the lower rectum treated with additional resection for a positive vertical margin after EMR. In both cases, the circular muscle layer was dissected applying the conventional ESD technique, followed by en bloc resection while conserving the longitudinal muscle layer. No problems occurred in the postoperative course in either case. Rectal NETs are observed in the lower rectum in many cases, and it is less likely that intestinal perforation by endoscopic therapy causes peritonitis. The method employed in these cases, namely combined dissection and resection of the circular muscle layer using the ESD technique, can be performed relatively safely, and it is possible to ensure negativity of the vertical margin. In addition, it may also be useful for additional treatment of cases with a positive vertical margin after EMR.
一般来说，直径10毫米及以下的直肠神经内分泌肿瘤（NETs）恶性程度较低，适合内镜治疗。然而，由于NETs的生长方式与黏膜下肿瘤（SMTs）相似，传统内镜黏膜切除术（EMR）后垂直切缘可能仍为阳性。有报道称改良EMR即带结扎装置的EMR以及内镜黏膜下剥离术（ESD）的有效性，但尚未确立标准治疗方法。我们遇到2例患者，通过使用ESD技术联合环形肌层剥离和切除术将直肠NETs完全切除。病例1是一名位于直肠下段的8毫米NET。病例2是直肠下段NET，在EMR后因垂直切缘阳性而进行了额外切除。在这两个病例中，均采用传统ESD技术剥离环形肌层，然后在保留纵肌层的同时整块切除。两个病例术后过程均未出现问题。直肠NETs在很多情况下位于直肠下段，内镜治疗导致肠穿孔引起腹膜炎的可能性较小。这些病例所采用的方法，即使用ESD技术联合环形肌层剥离和切除术，相对安全可行，并且能够确保垂直切缘为阴性。此外，它对于EMR后垂直切缘阳性病例的额外治疗可能也有用。
