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DOI: 10.1055/s-2001-18538
Endoskopische Mukosaresektion von (prä-)malignen Veränderungen im oberen Gastrointestinaltrakt
Endoscopic mucosal resection of premalignant lesions of the upper gastrointestinal tractPublication History
15.5.2001
6.8.2001
Publication Date:
21 November 2001 (online)

Fragestellung
Die operative Therapie frühmaligner Veränderungen am oberen Gastrointestinaltrakt ist mit einer substanziellen Morbidität und Letalität behaftet, die insbesondere bei multimorbiden Patienten bedeutsam ist. Im asiatischen Raum wurden hier mit der endoskopischen Mukosaresektion (EMR) exzellente Resultate erzielt.
Patienten und Methodik: Bei 22 Patienten (68 ± 14 J., 9 weiblich) wurde mittels hochauflösender Videoendoskopie (partiell als Chromoendoskopie), Minisonden-Endosonographie (12-20 MHz) und Biopsie die Diagnose einer hochgradigen Dysplasie (n = 5), eines T1N0M0-Ösophaguskarzinoms (n = 11) bzw. -Magenkarzinoms (n = 6) gestellt. Die Läsionen hatten einen max. Diameter von 7-40 mm. Die EMR erfolgte mittels monofiler Schlinge, überwiegend nach vorheriger Abhebung der Läsion von der Submukosa durch Umspritzung mit verdünnter Adrenalinlösung. Eine „En-Bloc”-Resektion gelang in 17 Fällen, bei 5 Läsionen war aufgrund der Größe eine Abtragung in 2-3 Portionen erforderlich („Piecemeal”-Resektion).
Ergebnisse: Unmittelbar nach EMR wurde bei 14/22 Patienten eine Nachblutung detektiert, sekundäre Nachblutungen (bis 24 h nach EMR) wurden in 5 Fällen beobachtet. Alle Blutungen konnten endoskopisch (zumeist Klippapplikation) beherrscht werden (keine Transfusion erforderlich), weitere Komplikationen traten nicht auf. Eine R0-Resektion konnte in 21/22 Fällen dokumentiert werden, bei einem Patienten mit histologischer Infiltration des Resektionsrandes (R1) erfolgte eine zweite EMR-Behandlung (hierbei R0-Resektion erzielt). Die präoperative Tumorklassifikation erwies sich in allen Fällen als korrekt. Eine endoskopisch-makroskopische Abheilung der Wundflächen konnte bei allen Patienten binnen 4 Wochen beobachtet werden. Klinische, endoskopische, endosonographische und bioptische Kontrolluntersuchungen ergaben in 21/22 Fällen keinen Hinweis für ein lokoregionäres Rezidiv während einer medianen Nachbeobachtung von 5 Monaten (Streubreite: 2-12 Monate). Bei einem Patienten mit Barrett-Karzinom wurde 3 Monate nach EMR ein mukosales Zweitkarzinom an anderer Lokalisation im Barrett-Epithel nachgewiesen.
Folgerung: Bei sorgfältiger Indikationsstellung ist die EMR von hochgradigen Dysplasien und Frühkarzinomen am oberen GI-Trakt nebenwirkungsarm und effizient (vollständige Resektion im Gesunden) durchführbar. Die Langzeitergebnisse bleiben jedoch abzuwarten.
Endoscopic mucosal resection of premalignant lesions of the upper gastrointestinal tract
Background: 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.
Patients and methods: 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.
Results: 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).
Conclusion: 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.
Schlüsselwörter
Ösophaguskarzinom - Magenkarzinom - Mukosaresektion - Endosonographie - Barrett - Ösophagus
Key words
Esophageal Carcinoma - Gastric Cancer - Endoscopic Mucosal Resection - Endosonography
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Anschrift für die Verfasser
Priv.-Doz. Dr. Till Wehrmann
Medizinische Klinik I
Klinikum Hannover-Siloah
Roesebeckstraße 15
30449 Hannover
Email: twehrmann@hotmail.com