CAJ | 학술논문

目的：探讨内镜黏膜下剥离术（Endoscopic submucosal dissection, ESD）治疗和诊断高度可疑或早期结直肠癌和癌前病变的有效性和安全性，比较整块活检病理与内镜活检病理对早期癌诊断意义及共聚焦激光显微内镜在随访中的价值。方法对于内镜下高度可疑早期结直肠癌或早期结直肠癌及癌前病变的19例患者行ESD治疗，术后评价ESD治疗相关的一次性整块切除率、组织学治愈性切除率、手术并发症；比较术后整块病理与术前内镜活检诊断符合率；在术后随访时用共聚焦激光显微内镜检查（1、3个月）以指导活检并观察局部复发情况。结果19处病灶一次性整块切除率为94.7%（18/19），组织学治愈性切除率为84.2%（16/19）；病变平均大小（2.3±0.5）cm，平均手术时间（70±19.4）min；术后腹痛2例，延迟性出血1例，内镜下钛夹止血成功，其余病例未发生急性或延迟性出血以及穿孔；术后病理：黏膜内癌7例，癌前病变10例，黏膜下癌2例，其中2例黏膜下癌均进一步补充开腹手术，术后切除病变肠段未发现癌组织残留和周边淋巴结转移；所有病例术后平均随访（24.6±8.0）个月，局部未见残留、复发及异时病灶发生；其中7例黏膜内癌ESD术后1、3个月采用共聚焦激光显微内镜检查以指导活检进行随访未见癌组织残留及复发。19处病灶ESD术后大块组织病理诊断符合率为100%，而术前活检病理诊断符合率仅为57.9%，有统计学意义（P<0.01）。结论 ESD具有较高一次性整块切除率和组织学治愈性切除率，是一种治疗和诊断高度可疑或早期结直肠癌病变或癌前病变的安全有效的方法。共聚焦激光显微内镜可能对早期结直肠癌的术后随访具有一定的价值。
목적：탐토내경점막하박리술（Endoscopic submucosal dissection, ESD）치료화진단고도가의혹조기결직장암화암전병변적유효성화안전성，비교정괴활검병리여내경활검병리대조기암진단의의급공취초격광현미내경재수방중적개치。방법대우내경하고도가의조기결직장암혹조기결직장암급암전병변적19례환자행ESD치료，술후평개ESD치료상관적일차성정괴절제솔、조직학치유성절제솔、수술병발증；비교술후정괴병리여술전내경활검진단부합솔；재술후수방시용공취초격광현미내경검사（1、3개월）이지도활검병관찰국부복발정황。결과19처병조일차성정괴절제솔위94.7%（18/19），조직학치유성절제솔위84.2%（16/19）；병변평균대소（2.3±0.5）cm，평균수술시간（70±19.4）min；술후복통2례，연지성출혈1례，내경하태협지혈성공，기여병례미발생급성혹연지성출혈이급천공；술후병리：점막내암7례，암전병변10례，점막하암2례，기중2례점막하암균진일보보충개복수술，술후절제병변장단미발현암조직잔류화주변림파결전이；소유병례술후평균수방（24.6±8.0）개월，국부미견잔류、복발급이시병조발생；기중7례점막내암ESD술후1、3개월채용공취초격광현미내경검사이지도활검진행수방미견암조직잔류급복발。19처병조ESD술후대괴조직병리진단부합솔위100%，이술전활검병리진단부합솔부위57.9%，유통계학의의（P<0.01）。결론 ESD구유교고일차성정괴절제솔화조직학치유성절제솔，시일충치료화진단고도가의혹조기결직장암병변혹암전병변적안전유효적방법。공취초격광현미내경가능대조기결직장암적술후수방구유일정적개치。
Objective The aim of this study was to explore the efficacy and safety of endoscopic sub-mucosal dissection(ESD)for treatment and diagnosis of highly suspicious or early colorectal cancer(ECC)and precancerous lesions, and to evaluate the diagnostic significance of en bloc resection and the value of confocal laser endomicroscopy in the follow-up. Methods Nineteen patients underwent ESD for endoscopic highly suspicious or clear ECCs and precancerous lesions. For these patients, en bloc resection rate, histological cura-tive resection rate, complications were evaluated, relevant detection rate of postoperative en bloc resection rate with preoperative endoscopic biopsy were compared, and the follow-up by confocal laser microscopy was conducted 1 month and 3 month after operation. Results En bloc resection rate of 19 lesions was 94.7%(18/19), histological curative resection rate was 84.2%(16/19). The mean size was (2.3 ± 0.5)cm, and the mean op-erative time was (70 ± 19.4)minutes. Two cases suffered abdominal pain, and 1 case developed delayed bleed-ing which was successfully stopped by endoscopic hemostatic clip. Postoperative histopathological examina-tions confirmed that the lesions included 7 intramucosal carcinomas, 10 precancerous lesions, and 2 submucos-al carcinoma. Submucosal carcinomas were resected by surgery operation, and both the lateral and basal mar-gins of the specimens were free of tumor cells, and no surrounding lymph node metastasis was noted. The aver-age follow-up time was (24.6 ± 8.0)months, and no residual local recurrence and metachronous lesions oc-curred. Seven cases of intramucosal cancer were guided to have a recheck by confocal laser microscopy en-doscopy in 1, 3 months after operation which confirmed no residual or recurrence lesions. Histopathological diagnosis of en bloc tissues by ESD in 19 lesions was 100%, significantly higher than 57.9%of the preopera-tive biopsy ( P<0.01). Conclusion ESD is a safe and effective method for diagnosis and treatment of highly suspicious or early colorectal cancer and precancerous lesions. Confocal laser endomicroscopy might have an important role in the postoperative follow-up of early colorectal cancer.