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surgical removal of part of a structure or organ
of or relating to endoscopy
of or relating to mucous membranes

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(手術による器官や組織,特に骨の)切徐

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2017/07/19 00:44:35」(JST)

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Endoscopic mucosal resection (EMR) is a technique used to remove cancerous or other abnormal lesions found in the digestive tract.

For the esophagous

EMR has been advocated for early esophageal cancers (that is, those that are superficial and confined to the mucosa only) and has been shown to be a less invasive, safe, and effective nonsurgical therapy for early squamous-cell carcinoma.^[1] It has also been shown to have be safe and effective for early adenocarcinoma arising in Barrett’s esophagus. The prognosis after treatment with EMR is comparable to surgical resection. This technique can be attempted in patients, without evidence of nodal or distant metastases, with differentiated tumors that are slightly raised and less than 2 cm in diameter, or in differentiated tumors that are ulcerated and less than 1 cm in diameter. The most commonly employed modalities of EMR include strip biopsy, double-snare polypectomy, resection with combined use of highly concentrated saline and epinephrine, and resection using a cap.

The strip biopsy method for endoscopic mucosal resection of esophageal cancer is performed with a double-channel endoscope equipped with grasping forceps and snare. After marking the lesion border with an electric coagulator, saline is injected into the submucosa below the lesion to separate the lesion from the muscle layer and to force its protrusion. The grasping forceps are passed through the snare loop. The mucosa surrounding the lesion is grasped, lifted, and strangulated and resected by electrocautery. The endoscopic double-snare polypectomy method is indicated for protruding lesions. Using a double-channel scope, the lesion is grasped and lifted by the first snare and strangulated with the second snare for complete resection.

Endoscopic resection with injection of concentrated saline and epinephrine is carried out using a double-channel scope. The lesion borders are marked with a coagulator. Highly concentrated saline and epinephrine are injected (15–20 ml) into the submucosal layer to swell the area containing the lesion and elucidate the markings. The mucosa outside the demarcated border is excised using a high-frequency scalpel to the depth of the submucosal layer. The resected mucosa is lifted and grasped with forceps, trapping and strangulating the lesion with a snare, and then resected by electrocautery.

Another method of EMR employs the use of a clear cap and prelooped snare inside the cap. After insertion, the cap is placed on the lesion and the mucosa containing the lesion is drawn up inside the cap by aspiration. The mucosa is caught by the snare and strangulated, and finally resected by electrocautery. This is called the "band and snare" or "suck and cut" technique. The resected specimen is retrieved and submitted for microscopic examination for determination of tumor invasion depth, resection margin, and possible vascular involvement. The resulting "ulcer" heals within three weeks.

EMR can also be used to debulk or completely treat polypoid dysplastic or malignant lesions in Barrett’s esophagus, the known precursor lesion to esophageal adenocarcinoma. In a preliminary report from Germany, EMR was performed as primary treatment or adjunctive therapy following photodynamic therapy for early adenocarcinomas in Barrett's esophagus. The "suck and cut" technique (with and without prior saline injection) was used, as well as the "band and cut" technique. Although all tumors were resected without difficulty, 12.5% developed bleeding (which was managed successfully by endoscopic therapy). Eighty-one percent of the lesions were completely resected. The other lesions were also treated with other endoscopic techniques.

The major complications of endoscopic mucosal resection include postoperative bleeding, perforation, and stricture formation. During the procedure, an injection of 100,000 times diluted epinephrine into the muscular wall, along with high-frequency coagulation or clipping, can be applied to the bleeding point for hemostasis. It is important to administer acid-reducing medications to prevent postoperative hemorrhage. Perforation may be prevented with sufficient saline injection to raise the mucosa containing the lesion. The "nonlifting sign" and complaints of pain when the snare strangulates the lesion are contrainidications of EMR. When perforation is recognized immediately after a procedure, the perforation should be closed by clips. Surgery should be considered in cases of endoscopic closure failure. The incidence of complications ranges from 0–50% and recurrence of esophageal squamous-cell carcinoma range from 0–8%.

Notes

^ Wang, Prasad, and Tian

References

Wang KK, Prasad G, Tian J (September 2010). "Endoscopic mucosal resection and endoscopic submucosal dissection in esophageal and gastric cancers". Curr. Opin. Gastroenterol. 26 (5): 453–8. PMC 3215503 . PMID 20703112. doi:10.1097/MOG.0b013e32833e4712.

UpToDate Contents

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English Journal

Nasopharyngeal pleomorphic adenoma presenting as otitis media with effusion: Case report and literature review.

Maruyama A, Tsunoda A, Takahashi M, Kishimoto S, Suzuki M.SourceDepartment of Otolaryngology, Tokyo Medical and Dental University.
American journal of otolaryngology.Am J Otolaryngol.2014 Jan-Feb;35(1):73-6. doi: 10.1016/j.amjoto.2013.08.019. Epub 2013 Sep 16.
Most tumors arising in the nasopharynx are malignant and frequently develop otitis media with effusion (OME). On the contrary, benign nasopharyngeal tumors are very rare, and pleomorphic adenoma, which is a benign mixed tumor of the nasopharynx, is also rarely encountered. We herein report a case of
PMID 24051236

Advances in diagnostic and therapeutic colonoscopy.

Gómez V, Wallace MB.SourceDivision of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA.
Current opinion in gastroenterology.Curr Opin Gastroenterol.2014 Jan;30(1):63-8. doi: 10.1097/MOG.0000000000000026.
PURPOSE OF REVIEW: We review current studies on endoscopic and technologic advances for the detection and treatment of colorectal neoplasia.RECENT FINDINGS: Improvements in adenoma detection have been shown to be possible with the use of high definition white light as well as water-related methods s
PMID 24241243

Training for complex endoscopic procedures: how to incorporate endoscopic submucosal dissection skills in the West?

Draganov PV, Coman RM, Gotoda T.SourceDivision of Gastroenterology, Hepatology and Nutrition, University of Florida, 1600 Archer Rd, Gainesville, FL, USA.
Expert review of gastroenterology & hepatology.Expert Rev Gastroenterol Hepatol.2013 Dec 3. [Epub ahead of print]
Endoscopic submucosal dissection (ESD) has been employed for removal of early neoplastic gastrointestinal lesions and has well-documented higher en bloc and curative resection rates compared with endoscopic mucosal resection. Based on these advantages, ESD has gained widespread use in Asia but unfor
PMID 24308749