Practical aspects of the management of precancerous lesions of the colon
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概要
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The guiding premise in Western society is that intervention in the 30% of adenoma-bearing subjects will prevent the 3% who currently die of colorectal cancer (CRC). Only 1% of GRC occur from familial adenomatous polypusis (FAP), and probably around 10 or 15% CRC have identifiable genetic risk, although the situation will clarify with the clinical availability of gene-probes. Cancer in ulcerative colitis is only a small risk overall, although a considerable anxiety for the endoscopist managing an individual patient in view of the unpredictability of mucosal dysplasia as a marker for cancer and the limitations of biopsy sampling. Once identified, any adenoma-bearing subject should have a careful total colonoscopy with potypectomies. Even lmn polyps can be seen with video-endoscopes, the resolution being still further increased with dye-contrast techniques. Flat adenomas appear to be uncommon in 1Vestern subjects. Surveillance strategies for adenomas have been over-emphasized; those with only one or more small adenoma(s) may not justify follow-up at all and infrequent surveillance (3-5 yearly) will be sufficient for most of the remainder, probably stopping around the age of 75 years. Large, multiple polyps indicate extra care in surveillance.<BR>The smallest polyps are easily managed by the technique of "hot-biopsy", although delayed haemorrhage is a risk, especially for those taking aspirin. 5mm-2cm polyps are best managed by snaring but over this size pre-injection technique; snould be considered for safety (adrenaline only if sessile/short-stalked, adrenaline + sclerosant for large stalks). Bipolar and spiked snares have a place fur difficult sessile polyps, which may need piecemeal removal using a suction trap for specimen retrieval. Up to 100 polyps can be removed in a session if clinically indicated. Overall about 98% of polyps presenting at colonoscopy can be removed. The 1% of sessile polyps that are endoscopically too risky to remove may not justify surgery if the patient is elderly. Only the few malignant polyps that are poorly-differentiated or inadequately removed require subsequent operative resection. For the remainder, tattooing the polypectomy site and infrequent follow-up is all that is required.
- 日本大腸肛門病学会の論文