Endoskopische Resektion früher kolorektaler Neoplasien – EMR oder ESD?

Zusammenfassung

In der Behandlung sessiler und flacher kolorektaler Adenome hat sich die endoskopische Mukosaresektion (EMR) als effektives und sicheres Verfahren etabliert. Als Nachteil werden residuale Adenomanteile in etwa jedem fünften Fall angesehen, die aus einer meist stückweisen Abtragung resultieren. Durch eine technisch einfache Nachbehandlung im Rahmen einer Kontrollkoloskopie wird jedoch nahezu immer eine definitive lokale Remission erzielt. Im Vergleich zur EMR ist die endoskopische Submukosaresektion (ESD) technisch anspruchsvoller und zeitaufwändiger. Effektiv und sicher ist sie nur, wenn sie von ausgewiesenen Experten durchgeführt wird. Unter diesen Bedingungen gelingt dann häufig eine En-bloc-Resektion früher kolorektaler Neoplasien. Die hiermit verbundene niedrige Rate an Residuen erfordert im Gegensatz zur EMR nur selten eine Nachbehandlung. Es ergeben sich jedoch keine belegten Vorteile, wenn die definitive lokale Neoplasiefreiheit als primäres Therapieziel angesehen wird. Demgegenüber sollte die ESD der EMR vorgezogen werden, wenn der Verdacht auf ein Frühkarzinom mit geringer Infiltrationstiefe (< 1000 µm der Submukosa) besteht. Die ESD erhöht in diesen Fällen die Wahrscheinlichkeit einer histologisch dokumentierbaren vollständigen Resektion (R0). Nach westlichen Studien wird dieses Ziel jedoch nur selten erreicht.

Abstract

Endoscopic mucosal resection (EMR) has been established as an effective and safe procedure for the treatment of sessile and flat colorectal adenomas. Piecemeal resection is common and considered to be disadvantegeous because it results in residual adenomatous lesions in approximately every fifth case. However a technically easy re-treatment at a follow-up colonoscopy nearly always achieves a definitive complete local remission. In comparison to EMR, endoscopic submucosal dissection (ESD) is technically more demanding and time consuming. It is only effective and safe if performed by specialized experts. Under these conditions an en-bloc resection of early colorectal neoplasia can be frequently achieved. The resulting low rate of residuals rarely requires re-treatment in contrast to EMR. However there are no proven advantages if definitive local freedom from neoplasia is considered as the primary aim of treatment. On the other hand ESD should be preferred over EMR for suspected early cancer with a low infiltration depth (< 1000 µm of the submucosa). In these cases ESD increases the probability of a histologically documented complete resection (R0). According to Western studies this aim can be only rarely achieved.

Schlüsselwörter

kolorektales Adenom - frühe kolorektale Neoplasie - endoskopische Resektion - EMR - ESD

Key words

colorectal adenoma - colorectal early neoplasia - endoscopic resection - EMR - ESD

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