胃上皮下病変の内視鏡下粘膜下掘出における縦切開の有効性の評価
April 28th, 2026
本プロトコルは、胃上皮下病変の切除と欠損閉合を促進するために設計された縦切開内視鏡下粘膜下掘出術を説明しています。
本研究では、内視鏡による粘膜下掘りにおける縦切開と円形切開を比較し、どちらがより速く安全かを明らかにします。円形切開は大きな欠損を生み、閉じるのが難しいです。縦切開は閉鎖を簡素化し、手術時間を短縮します。
この技術は、2センチメートル以下の小さな胃上皮下病変の内視鏡的切除に理想的です。まず、使い捨ての電気外科ナイフを使い、病変の縁から3〜5ミリメートル外に円形にいくつかの点を描き、切除境界を定義します。インディゴルージュの粘膜下注射では、針を組織の奥深くまで差し込みます。
注射しながらゆっくりと抽出し、先端が中粘膜下層内に留まることを確認します。粘膜表面が急速かつ均一かつ持続的に上昇し、滑らかでドーム状の粘膜隆起を形成していることを確認しましょう。次に、使い捨ての電気外科ナイフを使い、病変の中心軸に沿って粘膜と粘膜下を縦方向に切開し、病変の縦方向全体を超えるようにします。
電気外科ナイフを使って病変の下の粘膜下結合組織を慎重に切り離し、分離します。次に、病変を完全に露出させ、下の筋肉層をできるだけ保存しながら付着部から完全に解放します。分離過程で出血が検出された場合は、電気外科ナイフで軽度の出血血管を凝固させてください。
切除欠損部を活発な出血や血管の有無を徹底的に検査してください。出血点や高リスク血管は、一度使いの電気外科的止血鉗子で治療し、遅延出血を防ぎます。欠損を閉じるために、まず中程度に胃内ガスを吸引して欠損の縁を近似し、組織間の隙間を狭めてクリッピングを行います。
クリップの片方の顎で欠損の近位側の粘膜縁を握ります。次に、反対側の顎で遠位粘膜の縁をフックします。連続吸引を維持しながらクリップを閉じます。
次に、クリップを順次に貼り付けて粘膜の縁を近似し、欠損全体が完全に逆転するまで続けます。改善群と従来グループの間で、ほとんどのベースラインの人口統計学的および臨床変数において統計的に有意な差は認められませんでした。改良型群は従来型群に比べて平均運用時間が大幅に短かった。
いずれのグループでも、穿孔、腹部膿瘍、発熱、重度の腹痛などの重篤な術後合併症は認められませんでした。主要な合併症の発生率は両群とも0%であり、統計的に有意な差は認められませんでした。このプロトコルにより、手術時間、成功率、合併症を正確に測定できます。
主な課題は、縦切開が病変の長軸の真上に正確に位置することである。
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Overview
This article details a protocol for longitudinal incision endoscopic submucosal excavation (ESE) as an improved method for removing small gastric subepithelial lesions (SELs ≤ 2 cm). The longitudinal incision technique is compared to the conventional circular incision, demonstrating advantages in operative efficiency, defect closure, and safety.
Key Study Components
Area of Science
- Gastroenterology
- Endoscopic surgery
- Minimally invasive procedures
Background
- Endoscopic submucosal excavation (ESE) is used to manage gastric subepithelial lesions.
- Traditional circular incisions can create large defects that are difficult to close.
- Efficient closure and reduced operative time are important for patient outcomes.
- There is a need for improved techniques to optimize ESE for small gastric SELs.
Purpose of Study
- To present a detailed protocol for longitudinal incision ESE.
- To compare the longitudinal incision technique with the conventional circular incision in terms of procedural success, operative time, and safety.
- To assess the feasibility and technical outcomes of the new approach.
Methods Used
- Marking the lesion margin with dots in a circular pattern, 3–5 mm outside the lesion edge.
- Submucosal injection of indigo rouge to elevate the mucosa.
- Making a longitudinal incision along the central axis of the lesion using an electrosurgical knife.
- Dissecting and separating submucosal tissue to fully expose and free the lesion.
- Hemostasis using electrosurgical knife and hemostatic forceps as needed.
- Primary closure of the defect with sequential application of metal clips under suction.
- Retrospective comparison of outcomes between longitudinal (n=21) and circular (n=31) incision groups.
Main Results
- The longitudinal incision group achieved a 100% procedural success rate.
- Mean operation time was significantly shorter for the longitudinal group (51.43 ± 5.56 min) compared to the circular group (70.00 ± 6.96 min, P=0.0179).
- Reduced need for advanced closure devices in the longitudinal group (5% vs. 28%).
- Low complication rates in both groups, with no serious postoperative events.
Conclusions
- The longitudinal incision ESE technique is safe, effective, and feasible for gastric SELs ≤ 2 cm.
- This method offers practical advantages in operative efficiency and defect management.
- It may reduce the need for additional closure devices and consumables.
Frequently Asked Questions
Executive Industry Relevance
Efficient and reproducible tissue resection methods are critical for translational research models and preclinical tool development in gastrointestinal disease. The longitudinal incision protocol for endoscopic submucosal excavation (ESE) offers improved operative efficiency and defect management, supporting standardized workflows for small gastric subepithelial lesion removal. This technique enables precise measurement of procedural variables, facilitating robust comparison and optimization in discovery-stage tool validation.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables controlled hypothesis testing of tissue resection strategies in disease-relevant gastric models.
- Supports mechanistic de-risking by reducing procedural variability and improving closure outcomes.
- Facilitates functional validation of endoscopic tools and closure devices in preclinical settings.
Screening & Assay Development
- Provides a standardized protocol for generating reproducible tissue defects for device or biomarker assay development.
- Improves assay readiness by minimizing closure complexity and consumable variability.
- Enables quantitative measurement of operative time, success rates, and complication profiles for comparative studies.
Translational & Preclinical Research
- Aligns with translational models requiring precise, low-complication tissue manipulation.
- Supports continuity from discovery through preclinical validation by enabling consistent procedural endpoints.
- Reduces risk in advancing new endoscopic technologies or closure devices toward clinical evaluation.
Pipeline & Workflow Integration
This protocol fits within the continuum from early discovery tool validation to preclinical model optimization for gastrointestinal research and device development.
- Discovery Biology: Supports hypothesis-driven comparison of incision and closure strategies in gastric tissue models.
- Screening: Provides reproducible, quantitative outputs for evaluating device performance and closure efficacy.
- Analytics: Enables direct measurement of operative time, procedural success, and complication rates for robust statistical analysis.
- Translational Research: Facilitates risk-adjusted advancement of endoscopic techniques and closure devices in preclinical pipelines.
- Enterprise Reuse: Establishes a reusable protocol for standardized tissue resection and closure studies across research teams.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence in procedural outcomes and reduces mechanistic ambiguity in tissue resection studies.
- Operational Value: Enhances standardization, reproducibility, and scalability of endoscopic protocols for research and development.
- Strategic Value: Supports better go/no-go decisions for device and technique advancement, improving capital efficiency.
- Portfolio Impact: Enables risk-adjusted prioritization of endoscopic technologies and closure solutions in translational pipelines.
Implementation Considerations
- Requires expertise in endoscopic technique and precise lesion localization.
- Needs access to electrosurgical knives, hemostatic forceps, and standardized closure devices.
- Demands cross-team protocol standardization for reproducible outcomes.
- Adaptation may be needed for lesions larger than 2 cm or in non-gastric tissues.
- Centering the incision over the lesion's long axis is a key technical challenge.
