内镜经黏膜下隧道肿瘤切除术治疗直肠固有肌层肿瘤

目的评价内镜经黏膜下隧道肿瘤切除术（STER）治疗来源于固有肌层的直肠黏膜下肿瘤（SMT）的临床效果。方法回顾性分析2011年3月至2013年3月间在复旦大学附属中山医院内镜中心行STER术治疗的8例来源于固有肌层的直肠黏膜下肿瘤的临床病理资料。结果8例STER手术均获成功,肿瘤均一次性完整切除,肿块距肛缘5～15cm,切除标本最大直径1．0～3．5（平均1．8）cm,手术耗时40～70（平均51）min。术中黏膜穿孔1例,予以金属夹夹闭修补成功。术后出现下肢皮下气肿1例,对症支持治疗2周后完全消退。术后病理诊断：神经鞘瘤3例,平滑肌瘤2例,胃肠间质瘤1例,增生胶原纤维伴结节变性2例。术后随访6～30月未见病变残留或复发。结论采用STER技术切除直肠固有肌层来源的SMT是一种安全、可行、有效的治疗方法。     

内镜黏膜下剥离术治疗消化道黏膜下肿瘤

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗消化道黏膜下肿瘤(submucosal tumor,SMT)的疗效和安全性。方法对内镜发现的19例消化道SMT(食管6例,胃6例,十二指肠1例,乙状结肠1例,直肠5例)进行超声内镜检查(18例病变位于黏膜下层,1例位于固有肌层),应用头端弯曲的针形切开刀进行ESD治疗。黏膜下注射生理盐水抬高病变,使病变与肌层相分离,预切开病变周围黏膜,剥离病变下方黏膜下层结缔组织,完整切除病变。结果病变最大直径0.5～3.0cm(平均1.6cm)。18例成功完成ESD治疗,手术时间15～105min(平均45min)。2例ESD术中出现内镜难以控制的大出血,1例成功保守治疗(三腔管食管囊压迫),1例转开腹手术。无术后出血。ESD穿孔3例:2例术中消化道穿孔(十二指肠球部和胃底),应用金属夹缝合成功,未转开腹手术;1例直肠类癌剥离深至肌层,术后出现皮下气肿,保守治疗气肿减退。所有ESD剥离病变包膜完整,基底和切缘未见病变累及。结论ESD治疗消化道SMT安全、有效,可以完整切除消化道黏膜下层病变,提供完整的病理诊断资料。对于来源于固有肌层的SMT,应慎行ESD。     

食管胃交界部固有肌层来源黏膜下肿瘤内镜下切除方法的选择与评价

目的评价以内镜黏膜下剥离术（ESD）为基础的各种内镜切除技术在食管胃交界部（EGJ）固有肌层来源黏膜下肿瘤（SMT）治疗中的临床价值和适应证的选择。方法回顾性分析复旦大学附属中山医院内镜中心所有接受内镜下切除治疗的患者资料库．筛选出2007年3月至2011年6月间经内镜下超声或CT证实固有肌层来源的EGJ处SMT患者143例。详细记录患者的临床病理资料、内镜切除方法、完整切除率、并发症发生率及术后随访资料。结果143例患者中男74例,女69例,平均年龄49．1岁。135例（94-4％）病变成功完成内镜下整块切除,其中接受内镜黏膜下挖除术126例,无腹腔镜辅助的内镜全层切除术6例,内镜经黏膜下隧道肿瘤切除术3例：另外8例肿瘤于内镜下部分切除后,基底部尼龙绳套扎。肿瘤平均直径为17．6mm．平均手术时间45．1min．平均出血量50．0ml。术中穿孔6例,贲门黏膜撕裂1例。均通过内镜下处理及保守治疗好转。术后病理示,平滑肌瘤121例,胃肠间质瘤20例。颗粒细胞瘤1例．肌间脂肪瘤1例。术后经3。48个月的随访,未见局部复发和远处转移病例。结论在EGJ固有肌层来源SMT治疗中．各种内镜切除方法均安全有效．临床医师需根据肿瘤的临床特征具体选择．     

消化道黏膜下肿瘤内镜微创切除新技术的开展及评价

消化道黏膜下肿瘤（submucosal tumor,SMT）泛指一类来源于黏膜以下的消化道病变。内镜和超声内镜检查均无法定性诊断．长期随访会造成患者的巨大负担。我国学者在内镜黏膜下剥离术发展的基础上,大胆尝试内镜切除消化道黏膜下肿瘤．既能得到正确的诊断,又能起到治疗的目的．本文就各种内镜下切除消化道SMT的指征、方法以及疗效等作出评价。     

内镜黏膜下剥离术治疗20例胃肠道间质瘤

目的探讨内镜黏膜下剥离术（ESD）治疗胃肠道间质瘤（GIST）的疗效和安全性。方法对来源于肌层、内镜超声（EUS）诊断GIST的20例患者应用头端弯曲的针形切开刀进行ESD治疗：（1）黏膜下注射生理盐水；（2）预切开病变周围黏膜；（3）剥离黏膜下层组织显露肌层GIST，一次性完整切除病变。结果共计20例来源于肌层的GIST，其中12例位于胃底，1例位于胃窦，3例位于胃体，4例位于直肠。病变直径0．5—3．2（平均1．6）cm。19例（95．0％）患者的病变全部完整剥离，1例ESD剥离病变后创面仍有肿瘤残留，后行外科手术扩大切除治疗。ESD手术时间60－150（平均87．5）min。全组未出现ESD术后出血。3例（15．0％）ESD治疗中发生穿孔，应用金属夹成功闭合裂孔，均未中转开腹手术修补。术后随访期2—12个月，19例病变完整剥离者未见肿瘤复发。结论ESD治疗小的、来源于肌层的GIST安全、有效，病变可以被完整切除并提供完整的病理学诊断资料。     

内镜黏膜下挖除术在黏膜下肿瘤中的应用

目的探讨内镜黏膜下挖除术（endoscopic submucosal excavation,ESE）处理消化道黏膜下肿瘤（submucosaltumor,SMT）的疗效和安全性。方法 2009年1~11月内镜发现的22例黏膜下病灶（食管11例、贲门2例、胃8例、结肠1例）作为入选对象,通过内镜超声（endoscopic ultrasonography,EUS）检查明确病灶大小、位置、性质,进行ESE治疗,观察其疗效和并发症情况。结果 20例（91%）完整挖除,2例ESE术后创面仍有肿瘤残留且病理报告低度恶性,转外科手术扩大切除治疗。病灶直径0.5~3.5 cm（平均1.5 cm）,手术时间20~220 min（平均75 min）。3例穿孔均保守治愈。术后随访1~12个月（平均6.5月）,20例完整挖除者均未见复发。结论 ESE对消化道的SMT具有可完整挖除病灶、创伤小、术后恢复快等优点,值得推广。     

治疗胃固有肌层肿瘤中改良内镜下黏膜结扎剥离术临床分析

目的探讨改良内镜下肿瘤结扎剥离术(ESD—L)运用于胃固有肌层肿瘤切除术临床分析。方法对44例胃固有肌层肿瘤患者均行ESD—L术切除胃部肿瘤,观察并分析术中和术后相关情况,术后均随访观察治疗效果。结果 44例患者病变部位均完整切除,7例出现穿孔,及时行全层切除并金属夹止血,术后无其他并发症出现。44例均获完整随访观察,未见复发及严重并发症发生。结论改良内镜下黏膜结扎剥离术运用于胃固有肌层肿瘤的切除可以达到完整切除病变部位,剥离病灶,减少术中出血和创面,从而降低因直视下全层切除导致的手术风险,改善治疗效果,提高生活质量。     

内镜下全层切除术治疗结直肠黏膜下肿瘤的价值

目的探讨内镜下全层切除术（EFTR）治疗结直肠黏膜下肿瘤（SMT）的可行性和安全性。方法回顾性分析2009年9月至2012年3月间复旦大学附属中山医院内镜中心实施EPTR切除的4例结直肠SMT患者的临床资料。结果4例患者中男性1例,女性3例,年龄33。78岁;肿瘤位于上段直肠2例,升结肠1例．降结肠1例。4例EFTR手术均获成功并完整切除肿瘤．手术时间24-80（平均48．0）min,切除肿瘤最大径为0.8．2．0（平均1．45）cm。术后病理结果提示分别为神经鞘瘤、囊样积气症、子宫内膜异位症和黏膜肌层平滑肌轻度增生。术中及术后均未出现出血和穿孔,有2例患者术后出现腹痛、发热,其中1例出现局限性腹膜炎体征,均经禁食、静脉抗炎补液等保守治疗后好转,未行外科干预。术后随访1-30个月,未发现肿瘤残留或复发。结论EPTR治疗结直肠SMT安全、有效。     

内镜黏膜下挖除术治疗胃固有肌层肿瘤116例临床分析

目的探讨内镜黏膜下挖除术（ESE）治疗胃固有肌层肿瘤的安全性及疗效。方法以2006年7月至2011年3月期间浙江省台州医院对起源于胃固有肌层的黏膜下肿瘤而行ESE治疗的116例患者为研究对象,分析术中、术后并发症及相应治疗情况,术后对上述病例进行胃镜随访。结果成功挖除肿瘤112例（96．6％）,手术时间（51．9±16.3）min。术中出血9例（7．8％）,术中穿孔20例（17．2％）。术后出血3例（2．6％）,需外科干预5例（4．3％）,其中术中4例,术后1例。术后未出现腹腔脓肿。腹膜炎等其他并发症;ESE术后平均住院6．1d;中位随访时间12个月,随访期内未发现肿瘤残留及复发。结论ESE治疗胃固有肌层肿瘤是安全可行的,近期疗效确切。     

胸腔镜辅助下隧道内镜切除食管固有肌层肿瘤

近年来．在内镜诊治技术基础上发展起来的内镜黏膜切除术（endoscopie mucosal resection,EMR）和内镜黏膜下剥离术（endoscopic submucosal dissection．ESD）逐渐在我同开展．广泛应用于消化道黏膜病变、黏膜下肿瘤（submucosal tumor．SMT）等．患者避免了常规开腹和开胸手术的创伤。但该手术的技术难度大．且内镜所见局限于腔内．故对于消化道壁巨大的或者向腔外生长的SMT,治疗价值有限。     

Submucosal tunneling endoscopic resection for submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a feasibility study (with videos)

Background

The esophagogastric junction (EGJ) is a difficult location for endoscopic resection due to its narrow lumen and sharp angle. Potential increased risks of perforation and mediastinal infection exist, especially for submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. We previously demonstrated the safety and efficacy of submucosal tunneling endoscopic resection (STER) for upper gastrointestinal SMTs, but the feasibility of STER for the removal of SMTs at the EGJ requires systematic investigation. The aim of the investigation was to evaluate the clinical impact of STER on the removal of SMTs at the EGJ.

Methods

A prospective study was carried out which included a consecutive cohort of 57 patients who underwent STER for 57 SMTs of the EGJ originating from the MP layer between July 2010 and August 2012 in a single academic medical center. Adverse events, en bloc resection rate, and local recurrence were evaluated.

Results

The average maximum diameter of the lesions was 21.5 mm (range 6–35 mm). The en bloc resection rate was 100 % (57/57). No delayed hemorrhage or severe adverse events occurred in any of the 57 patients following STER. No local recurrence and distant metastasis occurred during 24 months’ follow-up. Less subcutaneous emphysema and pneumomediastinum absorption time (p = 0.005) occurred with CO₂ versus air insufflations.

Conclusions

Our study showed that STER was safe and effective, provided accurate histopathologic evaluation, and was curative for SMTs of the deep MP layers at the EGJ. CO₂ gas insufflation is recommended.     

Submucosal tunneling endoscopic resection for small upper gastrointestinal subepithelial tumors originating from the muscularis propria layer

Background

This prospective study was designed to evaluate the safety and efficacy of submucosal tunneling endoscopic resection (STER) for small (≤3 cm) upper gastrointestinal (GI) subepithelial tumors (SETs) originating from the muscularis propria (MP) layer.

Methods

Between August 2011 and February 2013, a total of 85 patients with upper GI SETs originating from the MP layer were treated with STER. The key steps were as follows: (1) locating the tumor by injection of methylene blue or indigo carmine and then creating a submucosal tunnel from 5 cm above the tumor between the submucosal and muscular layers; (2) resecting the tumor by endoscopic resection techniques; (3) closing the mucosal incision site with several clips after the tumor is removed.

Results

Of the 85 SETs, 60 were located in the esophagus, 16 in the cardia, and 9 in the stomach. STER was successfully performed in all cases (success rate: 100 %). The mean tumor size was 19.2 mm. The mean procedure time was 57.2 min. The average hospital stay after the procedure was 5.9 days. Pathological diagnosis of the tumors were leiomyoma (65/85), gastrointestinal stromal tumor (GIST) (19/85), and calcifying fibrous tumor (1/85). During the procedure, eight patients developed pneumothorax, subcutaneous emphysema, and/or pneumoperitoneum. These patients recovered after conservative treatment. The rate of all complications was significantly higher for lesions originating in the deeper MP layer (70 %) than in the superficial MP layer (1.3 %; p < 0.001). The total complication rate for different histological diagnoses was also significantly different (26.3 % for GISTs, 4.6 % for leiomyomas, 0 % for calcifying fibrous tumors, p < 0.05). No residual or recurrent tumors were detected during the follow-up period (median: 8 months).

Conclusions

Submucosal tunneling endoscopic resection appears to be a feasible, safe, and effective procedure for treatment of small (≤3 cm) upper GI SETs originating from the MP layer.     

Laparoscopic surgery for submucosal tumors located at the esophagogastric junction and the prepylorus

Background  Laparoscopic partial gastric resection is widely accepted as a treatment for gastric submucosal tumors (SMTs). However, SMTs of either end of the stomach are generally managed by subtotal gastrectomies or total gastrectomies. This study was conducted to evaluate surgical techniques for management of SMTs located at the ends of the stomach. Methods  Among 63 patients who were diagnosed and underwent laparoscopic surgery for gastric SMTs at Seoul National University Bundang Hospital from May 2003 to May 2007, 11 SMTs located at the ends of the stomach were identified. The clinicopathologic results of these 11 SMTs were analyzed. Results  Laparoscopic partial wedge resections or tumor excisions were successfully performed on all patients except for those who had prepyloric tumors. Six men and five women had SMTs at the ends of the stomach. The patients ranged in age from 21–63 years (mean 43.4 ± 13.5 years). Of six esophagogastric junctional tumors that showed low, homogeneous contrast enhancement on computed tomography (CT) scans, five were treated by laparoscopic transgastric enucleation and one by tumor-everting resection. One esophagogastric junctional tumor that leaned toward the fundus and showed a 6-cm-diameter endophytic mass with heterogeneous enhancement on CT scan was resected by laparoscopic wedge resection. The mean operation time was 100 min (range 60–210 min). Three laparoscopy-assisted distal gastrectomies and one laparoscopic wedge resection were performed on SMTs located near the prepyloric antrum. There were no intra- or postoperative complications. Duration of postoperative hospital stay ranged from 4–7 days. Conclusion  Laparoscopic local resection is an effective treatment for SMTs located at the esophagogastric junction and can be used instead of a total or proximal gastrectomy. However, gastrectomies should be considered for SMTs located near the pylorus because of the small volume of the lower third of the stomach.     

Tailored-approach of laparoscopic wedge resection for treatment of submucosal tumor near the esophagogastric junction

Background Laparoscopic wedge resection (LWR) of the stomach cannot easily be applied to tumors that are located near the esophagogastric junction (EGJ). To define the tailored approach for this type of tumors, we evaluated our laparoscopic surgical technique and clinical outcomes. Methods We successfully performed 10 LWRs for patients with submucosal tumor (SMT) located 3 cm or less from the esophagogastric junction. A presumptive diagnosis of gastrointestinal stromal tumor (GIST) was made in all the cases, based on endoscopic and radiologic examinations. The patient demographics, perioperative parameters and outcomes of 10 patients were assessed. Results Neither intraoperative complications nor conversion to open surgery was required, and we were able to perform complete tumor excision with negative surgical margins for all the patients. The laparoscopic approaches of resection included the transgastric method (n = 5) and the exogastric method (n = 5). The mean operation time was 92.5 minutes (range 60–125 minutes). No blood transfusion was given for all cases in the perioperative period. The patients’ oral intake was restored on the third postoperative day. The hospital stay ranged from three to seven days (mean: 4.9 days). Pathologic analysis of the resected specimens showed six GISTs, three leiomyomas, and one lipoma. Conclusions Laparoscopic resection of gastric SMTs located near the EGJ is a feasible and safe procedure. The laparoscopic approaches to this area should be tailored, based on the location, size and expanding pattern of the tumor. This work was supported partly by the Catholic Cancer Center     

Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor

Background and objective  Laparoscopic wedge resection using a linear stapler is widely accepted as a treatment for gastric submucosal tumor (SMT). Although this surgery is simple, it can lead to excessive normal tissue removal. To avoid the latter, we have introduced endoscopic full-thickness resection with laparoscopic assistance, known as laparoscopy-assisted endoscopic full-thickness resection (LAEFR). Herein, we present the preliminary results of LAEFR for gastric SMT patients. Methods  Four patients with gastric SMT underwent LAEFR. LAEFR consists of four major procedures: (1) a circumferential incision as deep as the submucosal layer around the lesion by the endoscopic submucosal dissection technique, (2) endoscopic full-thickness (from the muscle layer to the serosal layer) incision around the three-fourths or two-thirds circumference on the above-mentioned submucosal incision under laparoscopic supervision, (3) completion of the full-thickness incision laparoscopically from inside the peritoneal cavity, and (4) handsewn closure of the gastric-wall defect. Results  LAEFR was successfully carried out without any intraoperative or postoperative adverse events. Mean operating time and estimated blood loss were 201 min and 27 mL, respectively. Contrast roentgenography on postoperative day 3 showed neither gastric deformity nor disturbance of gastric emptying in all the patients. Conclusions  LAEFR may be considered one of the so-called hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques because a peroral endoscope advances into the peritoneal cavity. LAEFR enabled whole-layer excision as small as possible with an adequate margin. LAEFR is a safe and minimally invasive treatment for patients with gastric SMT, and could be a more reasonable and economical alternative to other laparoscopic procedures.