内镜黏膜下剥离术治疗食管、胃壁病变46例报告

目的探讨内镜下黏膜剥离术（endoscopic submucosal dissection,ESD）处理食管、胃壁病灶的疗效和安全性。方法 2009年1月～8月胃镜发现的食管、胃壁大小0.5～4.0 cm的黏膜病变25例及大小0.5～3.0 cm的黏膜下病变21例作为入选对象,通过超声内镜和（或）活检病理检查明确病灶大小、位置、性质进行ESD：胃镜及黏膜染色确定病灶,针刀或氩气刀标记病灶;黏膜下注射含亚甲蓝及肾上腺素的生理盐水抬高病变;预切开病变周围黏膜;自病变黏膜下层完整剥离病灶;创面处理。结果黏膜病变25例：均切除病灶;1例穿孔约0.3 cm×0.3 cm,钛夹夹闭后保守治疗愈合;1例术后12 h出血行内镜下紧急止血;随访1～6个月,平均2.5月,术后2个月20例溃疡创面愈合,4例创面大部分愈合,1例术后3个月复发,后转外科手术切除。黏膜下病灶21例：均完整剥离黏膜下肿瘤;1例穿孔0.5 cm×0.5 cm,钛夹夹闭后保守治疗愈合;21例随访1～4个月,平均2个月,1例术后2个月复发再行ESD,其余20例无复发。结论 ESD对于食管、胃壁黏膜病变及黏膜下病变具有整块切除率高、复发率较低、并发症少等优点,值得推广。

Endoscopic Submucosal Dissection for the Lesions in the Esophageal and Gastric Wall: Report of 46 Cases

Objective To assess the effectiveness and safety of endoscopic submucosal dissection（ESD） for the treatment of lesions in the esophageal and gastric wall. Methods Patients with 0.5-4.0 cm mucosal or 0.5-3.0 cm submucosal lesions in the esophageal or gastric wall that were detected by gastroscopy from January 2009 to August 2009 were enrolled in this study.Endoscopic ultrasonography and/or biopsy were applied to confirm the size,location,and nature of the lesions.The patients then received ESD following this procedure： After being identified by gastroscopy or mucosal staining,the lesions were marked with needle knife or argon plasma coagulation（APC）;Then,the submucosa was raised through submucosal injection of methylthioninium chloride and diluted epinephrine so that to pre-cut the circumferential mucosa of the target lesion;finally the lesion was completely removed along the submucosal layer,and the wound surfaces was handled afterwards. Results In our patients,25 showed mucosal lesions,which were all dissected by endoscopy.One patient received conservative therapy with titanium clips afterwards because of a 0.3 cm × 0.3 cm perforation.Postoperative massive hemorrhage was detected in one patients in 12 hours after the surgery,hemostasis was then carried out immediately by endoscopy and achieved a good result.The patients were followed up for 1 to 6 months（mean,2.5 months）.During the period,20 cases had the ulcer been healed completely,4 were healed incompletely,and the other showed recurrence in 3 months,who was then converted to open surgery for resection.Submuocsal lesion were detected in 21 patients;in all of these cases,submucosal tumors were removed completely.In one of them,a perforation of 0.5 cm × 0.5 cm was detected,and then was cured by titanium clips.These cases were followed up for 1 to 4 months with a mean of 2 months;only one of them showed recurrence in 2 months,and thus received a second ESD.Conclusion ESD has a high en bloc resection rate,low residual rate and few complications for mucosal lesions and submucosal tumors,and thus we recommend to widely use this technique.