内镜黏膜下剥离术治疗结直肠病变的临床分析

目的 探讨内镜黏膜下剥离术（ESD）治疗结直肠病变的安全性和有效性。 方法 回顾性分析2012年6月至2016年6月在北京大学第一医院内镜中心接受ESD治疗的163例结直肠病变患者资料,对病变的临床病理特征、整块切除率、完全切除率、并发症发生率及复发率进行统计分析。 结果 163例病变中黏膜病变118例,包括隆起型病变31例,平坦型病变22例,侧向发育型肿瘤65例;黏膜下病变45例,均为隆起型病变。病变中位直径2.2（2.0）cm,手术时间42（53）min。整块切除率92.6％（151／163）,完全切除率86.5％（141／163）,病变大小与整块切除率及完全切除率相关（P＜0.05）。4例发生ESD相关并发症,其中2例为术中出血,1例为术后迟发出血,经内镜下确切止血后好转;1例术后迟发性穿孔,经外科手术治疗后好转。135例随访患者中4例出现复发,3例再次内镜下切除,1例手术切除。 结论 ESD治疗结直肠病变是安全有效的。达到整块切除及完全切除的患者可获得良好的长期预后。     

内镜黏膜下剥离术治疗食管早期癌及癌前病变

目的 探讨内镜黏膜下剥离术(ESD)治疗食管早期癌及癌前病变的应用价值.方法 对胃镜发现的食管早癌和上皮内瘤变、深度未超越黏膜卜层者15例进行ESD治疗:(1)黏膜下注射生理盐水抬高病变;(2)预切开病变周围黏膜;(3)沿病变下方黏膜下层完整剥离病变.结果 15例食管早癌和上皮内瘤变病变,最大卣径2.5～4.5 cm(平均3.2 cm).14例病变成功完成ESD治疗,ESD成功率93.3%(14/15).所有剥离病变全部得到病理确诊,基底和切缘未见病变累及.ESD手术时间(白黏膜下注射至完整剥离病变)45～150 min,(平均75 min).术中出血量平均30 ml,均经电凝、氙离子凝固术和止血夹成功止血,未出现需再次内镜下治疗的出血;ESD穿孔发生率0(0/15).术后随访14例,随访期6～18个月(平均11.5个月),创而完全愈合,无一例病变残留和复发.结论 ESD是治疗食管早癌和癌前病变的新方法,不仅能完整切除较大的病变,还能提供完整的病理学诊断资料.     

张氏剥离刀与远视距法在食管内镜黏膜下剥离术中的应用

回顾性分析2016年5月至2017年3月用张氏剥离刀采用远视距法ESD治疗的20例患者资料,病例均符合食管ESD治疗适应证。病变均完成了整块切除,切除标本大小3.0～11.0 cm;手术时间13～67 min。所有病例术中出血情况与常规方法相同,均可通过电凝或止血钳成功止血;术后无迟发性出血及穿孔病例发生。术后食管狭窄3例,但均为轻度狭窄不影响进食。无其他严重并发症及死亡病例发生。张氏剥离刀初步应用效果满意。     

剪状刀在复杂病变内镜黏膜下剥离术中的应用

目的评价剪状刀在内镜黏膜下剥离术（ESD）应用中的疗效及安全性。方法对2010年5月至2012年5月间34例患者的36次复杂ESD治疗中应用剪状刀进行黏膜剥离,观察疗效及并发症发生情况。结果36次ESD均完整剥离病变,完全切除率为91．7％,发生延迟出血2例（占5．6％）,给予内镜下止血后出血停止,无穿孔发生。患者平均住院5d,6例患者于术后6个月、12个月术后复查,创面愈合良好,未见肿瘤复发及残余,其余患者均在随访中。结论剪状刀的应用使得复杂病变内镜黏膜下剥离术易于操作、便于剥离,提高手术安全性、有效性的同时无需其他手术器械辅助,可降低手术费用,值得推广应用。     

内镜黏膜下剥离术治疗胃肠道黏膜及黏膜下病变的疗效及安全性分析

内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）是一项新兴的内镜治疗技术,目前广泛应用于消化遭息肉、早期癌和黏膜下肿瘤等的治疗。现回顾分析我院一年多来采用ESD治疗的胃肠道黏膜及黏膜下层病灶的临床资料,评价其疗效及安全性。     

内镜黏膜剥离术治疗消化道黏膜及黏膜下病变

目的探讨内镜下黏膜剥离术(endoscopic gubmucosal disseetion,ESD)治疗消化道黏膜及黏膜下病变的疗效、安全性及并发症防治。方法回顾性分析ESD方法治疗37例消化道黏膜及黏膜下病变的内镜下手术情况、并发症及治疗、预后情况。结果术中出血3例,术后出血2例,均内镜下成功止血;术中穿孔2例,均予内镜下金属夹夹闭后内科保守治疗成功,未有中转外科手术;l例直肠类癌及1例食管重度异型增生术后切缘病变组织残留,2~6月后复查未见明显复发迹象。结论 ESD治疗消化道黏膜及黏膜下病变安全、有效,可以一次性完整切除较大病变,提供完整的病理学资料,且术后不易复发。     

内镜黏膜下剥离术治疗Ⅰ型胃神经内分泌肿瘤的安全性、有效性分析

目的探究内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗Ⅰ型胃神经内分泌肿瘤(gastric neuroendocrine tumors,GNETs)的安全性及有效性。方法回顾性分析2012年1月至2018年12月接受ESD治疗并病理确诊的Ⅰ型GNETs患者,收集临床及病理资料进行分析,门诊及电话随访术后情况。结果共纳入61例Ⅰ型GNETs病例,总病灶数143个,多发病灶2~5个36例(59.0%),病灶≥6个5例(8.2%)。病灶分布在胃体128个(89.5%),胃底10个(7.0%),胃窦5个(3.5%)。所有病变均为整块切除(100%),病灶直径平均为7.9 mm(4~30 mm),115个病灶(80.4%)直径<10 mm,病灶直径>20 mm 4例(2.8%)。ESD平均手术时间为19 min(10~60 min),全组病例未出现术中和术后穿孔、出血等并发症。ESD术后病理显示G₁级99个(69.2%)病灶,G₂级44个(30.8%)病灶。2例病灶垂直切缘阳性,完整切除率98.6%(141/143),1例切缘阳性患者追加补救性外科手术。术后中位随访38.3个月(10~93个月),1例患者意外死亡,死因与GNETs无关。随访中无患者出现原位复发。10例患者ESD术后异位再发,再发率为16.4%(10/61),中位再发时间为12.8个月。再发病例中,有6例G₁级和1例G₂级患者再次接受ESD治疗;2例G₁级患者拒绝再次手术,密切随访;1例G₂级患者发现复发后意外死亡。5例患者病灶数目≥6个,其中4例G₁级,1例G₂级,ESD术后均密切随访,异位再发率40.0%(2/5)。4例患者病灶直径>20 mm,其中1例G₂级病例为前述因切缘阳性追加补救性外科手术;其余3例术后病理评估为1例G₁级,2例G₂级,水平切缘和垂直切缘均阴性、无脉管侵犯,随访无原位复发或异位再发。结论ESD是Ⅰ型GNETs安全、有效的治疗选择。     

内镜黏膜下剥离术治疗十二指肠病变的临床疗效分析

目的评价内镜黏膜下剥离术(ESD)治疗十二指肠病变的临床疗效及安全性。方法回顾性分析2011年1月至2019年5月在中南大学湘雅二医院消化内科行ESD治疗的45例十二指肠病变患者(共46个病变)的临床资料,对病变特点、整块切除率、完整切除率、手术并发症、术后病理和复发情况进行统计分析。结果45例患者中男20例、女25例,年龄(52.0±11.8)岁。46个病变中位于十二指肠球部31个(67.4%),降部12个(26.1%),球降交界部3个(6.5%)。病变直径(2.4±1.9)cm。病变起源于黏膜层14个(30.4%),黏膜下层29个(63.1%),固有肌层3个(6.5%)。术后病理:Brunner腺瘤11个(23.9%),神经内分泌肿瘤9个(19.6%),异位胰腺5个(10.9%),脂肪瘤5个(10.9%),其他16个(34.8%)。45例患者46个病变均顺利完成ESD,病变整块切除率100.0%(46/46),完整切除率为91.3%(42/46)。术中出血1例(2.2%),内镜下成功止血;迟发性穿孔1例(2.2%),行急诊外科手术治疗;电凝综合征1例(2.2%),内科保守治疗好转。术后2例患者追加外科手术治疗。患者平均住院时间6.2 d(2~21 d),无一例死亡。随访41例,平均随访时间30个月(1~78个月),随访期间1例(2.4%)复发。结论ESD治疗十二指肠病变安全、有效,具有较好的临床应用价值。     

内镜黏膜下剥离术治疗胃食管广基病变的临床研究

目的 探讨内镜黏膜下剥离术（ESD）治疗胃食管广基底病变的疗效及安全性.方法 回顾性分析2012年1月～ 2014年1月我院应用电子食管胃镜发现的直径≥2.0 cm胃食管广基病变（息肉、癌前病变、早期局限性肿瘤）患者的临床资料,经超声内镜检查位于黏膜肌层以下（包括黏膜肌层）的病灶纳入选择,并行ESD治疗.结果 本组研究共64例患者,54例病灶位于胃内,10例病灶位于食管内,所有病变经ESD完整剥离,术后经病理证实标本基底及边缘均无病变组织残留.胃组：5例（9.26％）发生术中少量渗血,出血量2～10ml,予以电热活检钳电凝成功止血;1例（1.85％）患者术后8小时出现呕血,鲜红色,Hb从132g/L降至100 g/L,急诊胃镜止血成功.食管：病灶内均未见出血、穿孔、皮下气肿等并发症.随访58例,术后l,3,6个月复查胃镜,创面愈合良好,未见病变残留和复发.结论 ESD治疗胃食管广基病变安全、有效,并发症发生率低,能维持正常的生理结构.     

内镜黏膜下隧道法剥离术治疗胃角巨大黏膜病变的多中心回顾性研究

目的 评估内镜黏膜下隧道法剥离术（ESTD）在治疗胃角巨大黏膜病变中的应用价值。 方法 回顾性分析2014年7月至2016年7月在6家中心接受ESTD或内镜黏膜下剥离术（ESD）治疗的87例胃角大面积黏膜病变患者资料,其中ESTD组32例,ESD组55例。比较2组剥离时间、剥离速度、整块切除率、治愈性切除率、并发症及复发情况。 结果 ESTD组剥离时间较ESD组短［（87.3±32.6）min比（136.7±64.5）min,P＜0.01］,剥离速度明显快于ESD组［（0.18±0.07）cm2／min比（0.08±0.05）cm2／min,P＜0.01］,ESTD组较ESD组整块切除率［100％（32／32）比87.3％（48／55）,P=0.035］及治愈性切除率［100％（32／32）比85.5％（47／55）,P=0.024］高。ESD组术中均有出血发生,有8例出现肌层损伤;而ESTD组术中出血率仅59.4％（19／32）,且无肌层损伤发生（P均＜0.05）。2组复发率比较差异无统计学意义［0（0／32）比1.9％（1／54）,P=0.443］。 结论 ESTD在治疗胃角巨大黏膜病变时具有更高的剥除效率,同时可有效降低手术风险,减少并发症的出现,值得临床推广。     

Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma and precancerous lesions

AIM To evaluate the clinical outcomes of patients who underwent endoscopic submucosal tunnel dissection(ESTD) for esophageal squamous cell carcinoma(ESCC) and precancerous lesions.METHODS ESTD was performed in 289 patients. The clinical outcomes of the patients and pathological features of the lesions were retrospectively reviewed.RESULTS A total of 311 lesions were included in the analysis. The en bloc rate, complete resection rate, and curative resection rate were 99.04%, 81.28%, and 78.46%, respectively. The ESTD procedure time was 102.4 ± 35.1 min, the mean hospitalization time was 10.3 ± 2.8 d, and the average expenditure was 3766.5 ± 846.5 dollars. The intraoperative bleeding rate was 6.43%, the postoperative bleeding rate was 1.61%, the perforation rate was 1.93%, and the postoperative infection rate was 9.65%. Esophageal stricture and positive margin were severe adverse events, with an incidence rate of 14.79% and 15.76%, respectively. No tumor recurrence occurred during the follow-up period. CONCLUSION ESTD for ESCC and precancerous lesions is feasible and relatively safe, but for large mucosal lesions, the rate of esophageal stricture and positive margin is high.     

Endoscopic submucosal dissection for early esophageal neoplasms using the stag beetle knife

AIM To determine short-and long-term outcomes of endoscopic submucosal dissection(ESD) using the stag beetle(SB) knife, a scissor-shaped device.METHODS Seventy consecutive patients with 96 early esophageal neoplasms, who underwent ESD using a SB knife at Kure Medical Center and Chugoku Cancer Center, Japan, between April 2010 and August 2016, were retrospectively evaluated. Clinicopathological characteristics of lesions and procedural adverse events were assessed. Therapeutic success was evaluated on the basis of en bloc, histologically complete, and curative or non-curative resection rates. Overall and tumor-specific survival, local or distant recurrence, and 3-and 5-year cumulative overall metachronous cancer rates were also assessed.RESULTS Eligible patients had dysplasia/intraepithelial neoplasia(22%) or early cancers(squamous cell carcinoma, 78%). The median procedural time was 60 min and on average, the lesions measured 24 mm in diameter, yielding 33-mm tissue defects. The en bloc resection rate was 100%, with 95% and 81% of dissections deemed histologically complete and curative, respectively. All procedures were completed without accidental incisions/perforations or delayed bleeding. During follow-up(mean, 35 ± 23 mo), no local recurrences or metastases were observed. The 3-and 5-year survival rates were 83% and 70%, respectively, with corresponding rates of 85% and 75% for curative resections and 74% and 49% for noncurative resections. The 3-and 5-year cumulative rates of metachronous cancer in the patients with curative resections were 14% and 26%, respectively.CONCLUSION ESD procedures using the SB knife are feasible, safe, and effective for treating early esophageal neoplasms, yielding favorable short-and long-term outcomes.     

长节段早期食管癌及癌前病变内镜治疗的有效性及安全性评价

目的 分析病灶长度超过5 cm的早期食管癌及癌前病变行内镜黏膜下剥离术(ESD)与内镜分片黏膜切除术(EPMR)的疗效及安全性。方法 回顾性分析2012年1月至2017 年7月在福建省食管癌早诊早治促进联盟治疗的85例病灶长度超过5 cm的早期食管癌及癌前病变患者临床资料。根据术式不同,分为ESD组（52例）及EPMR组（33例）,对比两组疗效、并发症及随访情况。结果 ESD组与EPMR组的完整切除率相比差异无统计学意义[86.5%（45/52）比87.9%（29/33）,P>0.05],ESD组的手术时间[（58.53±30.50）min比（32.06±9.12）min]、术后禁食时间[（4.18±1.30）d比（3.67±0.96）d]、住院时间[（7.45±2.44）d比（6.54±1.73）d]及抗生素使用时间[（3.48±2.33）d比（1.96±2.20）d]明显长于EPMR组（P均<0.05）。ESD组与EPMR组的术中并发症发生率比较差异无统计学意义（P>0.05）;发热、胸痛、术后出血等近期术后并发症发生率对比差异亦无统计学意义（P>0.05）。ESD组术后狭窄发生率较EPMR组高[23.1%（12/52）比6.1%（2/33）,P<0.05]。术后随访3~63个月,ESD组复发5例,EPMR组1例,两者对比差异无统计学意义（P>0.05）。结论 EPMR与ESD治疗病灶长度超过5 cm的早期食管癌及癌前病变具有相同的有效性及安全性,而EPMR操作时间短,术后狭窄并发症少,且术式相对简单,易于掌握。     

Endoscopic submucosal dissection vs endoscopic mucosal resection for superficial esophageal cancer

AIM:To investigate the effectiveness of endoscopic submucosal dissection(ESD)and endoscopic mucosal resection(EMR)in treating superficial esophageal cancer(SEC).METHODS:Studies investigating the safety and efficacy of ESD and EMR for SEC were searched from the databases of Pubmed,Web of Science,EMBASE and the Cochrane Library.Primary end points included the en bloc resection rate and the curative resection rate.Secondary end points included operative time,rates of perforation,postoperative esophageal stricture,bleeding and local recurrence.The random-effect model and the fixed-effect model were used for statistical analysis.RESULTS:Eight studies were identified and included in the meta-analysis.As shown by the pooled analysis,ESD had significantly higher en bloc and curative resection rates than EMR.Local recurrence rate in the ESD group was remarkably lower than that in the EMR group.However,operative time and perforation rate for ESD were significantly higher than those for EMR.As for the rate of postoperative esophageal stricture and procedure-related bleeding,no significant difference was found between the two techniques.CONCLUSION:ESD seems superior to EMR in the treatment of SEC as evidenced by significantly higher en bloc and curative resection rates and by obviously lower local recurrence rate.     

经食管黏膜下隧道内镜治疗大面积食管黏膜病变的价值

目的探讨经食管黏膜下隧道内镜治疗大面积食管黏膜病变的应用价值。 方法徐州医科大学附属淮安医院2015年1月至2017年7月经胃镜及病理诊断大面积食管高级别上皮内瘤变18例,采用随机数字表法分为传统内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)法及经食管黏膜下隧道法切除病变,对比及随访观察治疗效果。 结果隧道组均于术中一次性完整剥离切除,一次性整块切除率均为100%,经典ESD组1例圈套器辅助分片切除,一次性整块切除率均为88.9%,术后病理结果提示所有切除标本的侧切缘和基底切缘无肿瘤累及。病变切除的平均直径隧道组为(7.5±3.2)cm,经典ESD组为(8.3±1.4)cm,2组在病变切除面积差异无统计学意义(P>0.05);平均手术时间隧道组为(50.4±28.0)min,经典ESD组为手术时间(82.5±29.7)min,2组在一次性整块切除率、平均手术时间方面,差异有统计学意义(P<0.05)。隧道技术组术中无1例皮下气肿;剥离过程无环形肌受伤害;经典ESD组术中出现纵隔、皮下气肿2例,其中小穿孔的1例应用钛夹缝合,术后3 d气肿均自行消失,术后24 h内出现发热1例,伴有白细胞升高,抗炎对症处理后第2天完全缓解,差异有统计学意义(P<0.05)。 结论内镜经食管黏膜下隧道技术是大面积食管黏膜病变切除安全有效的方法,能有效降低内镜下病变切除的难度,缩短手术时间,减少并发症发生。     

Endoscopic submucosal tunnel dissection for large superficial esophageal squamous cell neoplasms

Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial esophageal squamous cell neoplasms (SESCNs) with no risk of lymphatic metastasis. However, for large SESCNs, especially when exceeding two-thirds of the esophageal circumference, conventional ESD is time-consuming and has an increased risk of adverse events. Based on the submucosal tunnel conception, endoscopic submucosal tunnel dissection (ESTD) was first introduced by us to remove large SESCNs, with excellent results. Studies from different centers also reported favorable results. Compared with conventional ESD, ESTD has a more rapid dissection speed and R0 resection rate. Currently in China, ESTD for large SESCNs is an important part of the digestive endoscopic tunnel technique, as is peroral endoscopic myotomy for achalasia and submucosal tunnel endoscopic resection for submucosal tumors of the muscularis propria. However, not all patients with SESCNs are candidates for ESTD, and postoperative esophageal strictures should also be taken into consideration, especially for lesions with a circumference greater than three-quarters. In this article, we describe our experience, review the literature of ESTD, and provide detailed information on indications, standard procedures, outcomes, and complications of ESTD.     

Endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms

Endoscopic resection is an effective treatment for noninvasive esophageal squamous cell neoplasms(ESCNs).Endoscopic mucosal resection(EMR)has been developed for small localized ESCNs as an alternative to surgical therapy because it shows similar effectiveness and is less invasive than esophagectomy.However,EMR is limited in resection size and therefore piecemeal resection is performed for large lesions,resulting in an imprecise histological evaluation and a high frequency of local recurrence.Endoscopic submucosal dissection(ESD)has been developed in Japan as one of the standard endoscopic resection techniques for ESCNs.ESD enables esophageal lesions,regardless of their size,to be removed en bloc and thus has a lower local recurrence rate than EMR.The development of new devices and the establishment of optimal strategies for esophageal ESD have resulted in fewer complications such as perforation than expected.However,esophageal stricture after ESD may occur when the resected area is larger than three-quarters of the esophageal lumen or particularly when it encompasses the entire circumference;such a stricture requires multiple sessions of endoscopic balloon dilatation.Recently,oral prednisolone has been reported to be useful in preventing post-ESD stricture.In addition,a combination of chemoradiotherapy(CRT)and ESD might be an alternative therapy for submucosal esophageal cancer that has a risk of lymph node metastasis because esophagectomy is extremely invasive;CRT has a higher local recurrence rate than esophagectomy but is less invasive.ESD is likely to play a central role in the treatment of superficial esophageal squamous cell neoplasms in the future.     

2020年日本食管癌内镜黏膜下剥离术和内镜黏膜切除术指南的解读：食管鳞癌部分

2020年日本胃肠内镜学会制定并发布了食管癌内镜黏膜下剥离术/内镜黏膜切除术指南。该指南基于已发表的大量临床研究证据,针对18个临床问题提出建议,问题涉及食管癌的术前诊断、内镜切除适应证、内镜切除方案、可治愈性评估以及术后监测5个方面,旨在解决实际工作中的问题并提高临床实践质量,主要内容包括食管鳞癌和食管腺癌2个部分,本文主要就食管鳞癌部分的指南内容进行解读。