内镜下分片黏膜切除术治疗直肠无蒂型息肉52例

我院肛肠科采用内镜下分片黏膜切除术（endo—scopicpartial mucosal resection，EPMR）治疗直径≥2cm的无蒂型直肠息肉52例，取得满意疗效，总结报道如下。     

无痛胃镜下黏膜切除术治疗胃无蒂息肉45例分析

目的 探讨无痛胃镜下黏膜切除术(Endoscopic mucosal resection,EMR)治疗胃无蒂息肉的临床效果及并发症防治。方法 对45例胃无蒂息肉在丙泊酚静脉麻醉下行EMR,观察其疗效、麻醉效果,记录术中术后发生并发症及处理情况,对切除标本进行病理组织学观察,术后定期内镜随访,以评价切除效果。结果 45例患者52枚息肉均一次性切除,成功率100%。9月后复查1例复发,总有效率为97.8%。术中出血3例给予药物喷洒、高频电凝,止血夹夹闭成功止血,无1例出现迟发性出血、穿孔等严重并发症和麻醉意外。结论 无痛胃镜下EMR治疗胃无蒂息肉,是一种安全有效、操作简便、成功率高、患者易于接受的好方法,无痛胃镜是手术成功的重要保证。     

内镜下黏膜切除术治疗结直肠无蒂息肉52例

目前对结直肠息肉的治疗首选内镜下切除,但经内镜切除大的无蒂结直肠息肉比较困难,且容易发生结肠穿孔和出血。内镜黏膜切除术（endoscop-ic mucosal resection ,EMR）是近10年来发展起来的诊治消化道扁平病灶的一项新技术,自2009年1月-2012年5月,我院对52例结肠广基息肉行肠镜下EMR,取得良好疗效,现总结如下。     

内镜黏膜切除术(EMR)治疗结肠广基息肉的临床效果

目的探讨内镜黏膜切除术(EMR)治疗结肠广基息肉的临床效果。方法对32例(48枚)结肠广基息肉患者实施内镜下EMR治疗。结果 32例(48枚)广基结直肠息肉均经EMR手术一次顺利切除,一次切除率为97.92%。手术时间(79.30±18.28)min,切除息肉直径为(3.43±1.51) cm。其中腺瘤性息肉38枚,增生性息肉8枚,局灶癌变1例(病理证实并追加外科行根治性手术)。术后24 h出现延迟出血1例,经保守治疗痊愈。未发生术中大出血、穿孔等严重并发症。术后随访1 a,无病变残留和复发病例。结论 EMR治疗广基结肠息肉,创伤小,术后并发症少,临床效果可靠。     

内镜下微波治疗大肠息肉的临床体会

微波应用于临床治疗 ,已有多年的历史 ,但作为内镜下治疗手段 ,还是近几年的事。我院采用多功能微波治疗仪 ,在纤维结肠镜下治疗大肠息肉 15例 ,32枚 ,取得较好的临床效果 ,现报告如下。1　临床资料本组 15例 ,男 11例 ,女 4例 ;年龄最大 75岁 ,最小 14岁。大肠息肉 32枚中 ,降结肠 4枚 ,乙状结肠 17枚 ,直肠息肉 11枚。最多者 6枚。最大息肉直径 1 5ｃｍ左右 ,小者直径约 0 3ｃｍ。其中有蒂者 8枚 ,亚蒂者 9枚 ,无蒂者 15枚。病理诊断 :腺瘤样息肉 9例 ,其中绒毛状腺瘤 1例 ;增生性息肉 5例 ;幼年性息肉 1例。2　治疗方法治疗前 ,常规行肠…     

影响结直肠肿瘤内镜下黏膜切除术预后的多因素分析

目的研究内镜下黏膜切除术（EMR）治疗结直肠病变的并发症及危险因素。方法回顾性分析了南京中医药大学第三附属医院肛肠医疗中心2004年10月至2007年10月共进行EMR术84例94枚结直肠病变,对可能影响EMR术后并发症的因素进行Logistic回归分析。结果84例患者,男性56例、女性28例,平均年龄（57±13）岁（30—85岁）,术前病理检查诊断为结肠腺瘤69枚（73．4％）、绒毛状腺瘤4枚（4．3％）、管状绒毛状腺瘤17枚（18．1％）、结肠腺瘤癌变2枚（2．1％）、结直肠类癌2枚（2．1％）,息肉平均大小（15±7）mm（10～40mm）。平均随访时间（254-7）个月（3～36个月）。4例（4．3％）患者发生术中或术后出血、3例（3．2％）发生息肉复发,总并发症发生率为6．4％,并发症的发生与病变的大小、是否需要分次切除及是否为绒毛状腺瘤有关,多因素分析提示病变大于20mm是EMR术后并发症发生的独立的危险因素。结论结肠病变大于20mm是EMR术后并发症发生的独立的危险因素,对于大于20mm的结肠病变、特别不能整块切除的病变在进行EMR切除时需要慎重,术后要加强随访。     

19例结肠镜下治疗无蒂大息肉的临床体会

目的 探讨内镜下注射l：10000肾上腺素盐水摘除无蒂大息肉的安全性和有效性。方法 先在病变的基底部黏膜下层分点注射l：10000肾上腺素盐水，使病变部位隆起，然后在肠镜下应用圈套行高频电切除。结果 应用本法治疗无蒂大息肉19例，直径在2～3cm15例，3．1～4．0cm3例，4．5cml例，术后病理示17例为腺瘤，2例癌变，本治疗未出现出血、穿孔等并发症。结论 结肠镜下注射l：10000肾上腺盐水，高频电摘除无蒂大息肉是安全、有效的。     

内镜下高频电圈套法切除巨大大肠息肉32例

内镜下电凝切除是治疗大肠息肉的首选方法，但对于直径大于2．5cm的息肉，有术中或术后出血甚至穿孔的危险。为寻找安全有效的治疗方法，1996年-2004年，我院采用内镜下高频电圈套法成功切除有蒂或亚蒂的结肠巨大息肉32例(37枚)，总结报告如下。     

内镜下尼龙绳套扎或金属钛夹钳夹联合高频电凝切除治疗大肠巨大息肉的临床应用

为探讨内镜下尼龙绳套扎或金属钛夹钳夹联合高频电凝切除治疗大肠巨大息肉的疗效,对19例26枚大肠巨大息肉采用此方法治疗。结果显示,17枚亚蒂或有蒂息肉一次性尼龙绳套扎并切除成功,9枚长蒂息肉金属钛夹阻断血流后切除成功。术后无严重并发症发生。2周后内镜复查显示,14例创面愈合仅留瘢痕;3例创面处形成浅溃疡;1例创面处留有息肉样组织,追加热探头灼除;1例残端过长,追加尼龙绳套扎切除。结果表明,内镜下尼龙绳套扎或金属钛夹钳夹联合高频电凝切除治疗大肠巨大息肉安全有效,操作简单,并发症少。     

3种直肠类癌内镜治疗方法的比较研究

为探讨多种直肠类癌内镜下切除术的优缺点,Zhao等通过回顾性分析,比较了传统的内镜下黏膜切除术（EMR）、透明帽辅助内镜下黏膜切除术（EMR-C）及内镜下黏膜剥离术（ESD）的手术时间和并发症发生率。该研究共纳入了30例直肠类癌患者,3种方法各10例,肿瘤直径均小于1cm。研究结果：传统EMR组、EMR．C组及ESD组中各有8、8及10例的肿瘤被一次性完全切除;     

结直肠腺瘤性息肉和早期癌的内镜治疗

目的 评价结直肠腺瘤性息肉和早期癌的内镜治疗效果.方法 自2006年1月至2007年10月对245例肠镜发现的腺瘤性息肉,局限于黏膜层、抬举征(+)的早期癌患者分别进行息肉圈套切除术、内镜黏膜切除术、内镜分片黏膜切除术和内镜黏膜下剥离术.结果 253枚病变,大小0.5～8.5 cm(平均2.3 cm),其中<2 cm 157枚,>2 cm 96枚.内镜下成功切除249枚,内镜切除成功率98.4%(249/253).内镜治疗中未出现无法控制的创面大出血,2例术后出现迟发出血.1例长蒂息肉治疗后出现少量膈下游离气体,2例直肠病变剥离治疗后出现皮下气肿,保守治疗后气肿减退;4例病变剥离过程中创面见裂口,3例金属夹成功缝合;1例治疗后出现腹胀和腹腔大量游离气体,急诊开腹手术修补创面.总的并发症发生率3.6%(9/253).内镜治疗后8例接受外科手术(病变局部抬举不良4例,分化不良腺癌1例,高级别瘤变2例,穿孔1例).术后随访231例,随访期3～22个月(平均14.3个月),内镜黏膜下剥离术后巨大人工溃疡创面3个月基本愈合;3例分片黏膜切除术后复发.结论 内镜治疗可以有效切除结直肠腺瘤性息肉和早期癌,提供准确的病理诊断资料,内镜治疗并发症发生率有待进一步降低.     

十二指肠Brunner腺瘤的内镜治疗

目的探讨十二指肠Brenner腺瘤内镜治疗的价值。方法回顾性分析2006年11月至2011年5月间复旦大学附属中山医院内镜中心行内镜治疗且经病理证实的29例十二指肠Brunner腺瘤患者的临床资料。结果29例患者中男性13例,女性16例,中位年龄为55（29-72）岁。病灶大小（1．7±0．1）cm,其中0．5-1．0cm17例。1．0-2．0cm6例,大于2．0cm6例。无蒂隆起性病灶18例;有蒂病灶11例,其中粗蒂3例,亚蒂2例。内镜治疗中采取圈套电切9例（其中3例外加尼龙绳结扎）,内镜黏膜切除术12例,内镜黏膜下剥离术8例,均获完整切除。术中出血1例约200ml,经多枚金属夹夹闭和尼龙绳圈套后成功止血;术中穿孔1例,予金属夹夹闭：术后第2天发生迟发性出血1例,行内镜止血。全组术后随访2。39（中位数13）个月,生活质量较好,未见任何远期并发症。术后1年复发1例。再次予内镜黏膜下剥离术治疗。结论内镜治疗对于Brunner腺瘤是一种安全、有效的治疗方法。     

胆囊隆起样病变的诊治探讨（附203例报告）

目的探讨胆囊隆起样病变的诊治原则。方法回顾分析203例手术切除胆囊隆起样病变病例的临床、病理特点。其中197例行术前B超检查，203例均行术后病理检查。结果胆囊良性病变共190例（胆固醇息肉128例，单纯腺瘤16例），98．0％的胆固醇息肉直径小于10mm，半数以上的胆固醇息肉为多发；腺瘤多为单发，平均直径为（6．0±3．4）mm；良性病变患者有症状者87．9％（167／190）。胆囊恶性病变13例（腺癌8例、乳头状腺癌5例），平均直径为（11．2±3．1）mm，年龄均大于55岁。结论对于B超提示的胆囊隆起样病变，胆固醇性息肉、腺瘤是最常见的良性病变，腺癌是最常见的恶性病变。对于有症状者应行手术治疗，年龄大于60岁、直径大于10mm以及合并结石的单发息肉是恶性病变的危险因素。对于无症状者，应综合分析，再决定是否手术。     

内镜黏膜下剥离术治疗结直肠侧向发育型肿瘤的疗效

目的探讨直径〉2em的结直肠侧向发育型肿瘤（LST）的病理特点,评估内镜黏膜下剥离术（ESD）治疗结直肠LST的疗效及安全性。方法回顾性分析2007年12月至2011年4月复旦大学附属中山医院收治的151例结直肠LST患者的临床资料。根据内镜下表面形态将151例LST进行分型,统计各型LST的部位、大小、形态特征,然后对LST的临床病理特点以及ESD治疗的切除率、手术时问、并发症和复发情况进行分析。采用K系数检验分析LST亚型一致性。结果151例患者中,结直肠LST分布依次为：直肠58例、升结肠47例、盲肠15例、横结肠14例、乙状结肠13例、降结肠4例。病变直径为（3．4±1．2）em。颗粒型结直肠LST105例,其中结节混合型75例,颗粒均一型30例;非颗粒型结直肠LST46例,其中扁平隆起型31例,假凹陷型15例。两型分型一致系数K为0．87,四亚型分型一致系数K为0．80。腺瘤伴有低级别瘤变96例、高级别上皮内瘤变44例、黏膜下癌11例。腺瘤中管状绒毛状腺瘤58例、管状腺瘤33例、绒毛状腺瘤3例、锯齿状腺瘤2例。整块切除率为98．01％（148／151）,完整切除率为94．70％（143／151）,完整治愈切除率为90．73％（137／151）。手术时间为（52±31）min,ESD术后出血发生率为3．97％（6／151）,穿孔发生率为3．31％（5／151）。平均随访时间为28．6个月,复发率为0．66％（1／151）。结论直径〉2cm的结直肠LST病变存在较高的恶变潜能。ESD治疗LST病变整块切除率高,复发率较低,是结直肠LST病变安全且有效的治疗方法。     

Prognostic significance of high‐grade dysplasia in colorectal adenomas

Aim Colonoscopy to detect and remove polyps has contributed to a reduction in colorectal carcinoma. Three‐year follow up is recommended for patients considered to be at high risk (at least three adenomas, adenoma ≥ 1 cm, villous or high‐grade features). Our study focused on patients diagnosed with high‐grade dysplasia with regard to initial management and follow up. Method A search of patients who had had endoscopic removal of a high‐grade adenoma was carried out. Patients with the following were excluded: follow up of < 1 year, polyposis syndromes, prior colon cancer and a diagnosis of adenocarcinoma within 6 months following initial diagnosis. Results Eighty‐three patients treated between 1999 and 2007 for high‐grade dysplasia (HGD) in a colorectal adenoma were identified. Over a median follow‐up period of 4 years, 53 (64%) developed further adenomatous polyps. Among these, 7% had an adenoma with HGD or an adenocarcinoma. In all these patients, the initial high‐grade adenoma was > 1 cm in diameter. Initial follow‐up colonoscopy was performed on average 7 months following the initial diagnosis. Ten per cent of patients underwent prophylactic segmental resection, and 6% received argon laser therapy. Conclusion The study demonstrates that patients who have a colorectal adenoma > 1 cm with HGD may be at high risk of developing further adenomas with HGD or carcinoma. Close follow up is warranted.     

Role of laparoscopic cholecystectomy in the management of polypoid lesions of the gallbladder

This retrospective clinicohistopathologic study was performed to delineate the role of laparoscopic cholecystectomy in the management of polypoid lesions of the gallbladder. One hundred forty-three consecutive patients who had a preoperative sonographic diagnosis of polypoid lesions of the gallbladder with a diameter less than 1.5 cm and who underwent laparoscopic cholecystectomy at Cathay General Hospital were included in the analysis. Histopathologic study showed that 22 (15.4%) patients had true tumors, including adenoma (16), adenoma with focal adenocarcinoma (2), adenocarcinoma (3), and carcinoid tumor (1). Tumorlike lesions were found in 121 (84.6%) patients and included cholesterol polyp (106), adenomyomatous hyperplasia (10), inflammatory polyp (3), and papillary hyperplasia (2). The mean diameter of malignant polypoid lesions of the gallbladder was 1.35 +/- 0.42 cm, which was significantly larger than that of cholesterol polyps (0.66 +/- 0.40 cm, P = 0.0001) but not significantly larger than that of adenomyomatous hyperplasias (1.12 +/- 0.42 cm) and adenomas (1.08 +/- 0.47 cm). The mean age of patients with malignant polypoid lesions of the gallbladder (61.2 +/- 13.3 years old) was significantly older than that of patients with adenomyomatous hyperplasia (46.6 +/- 13.4 years, P = 0.03), cholesterol polyps (44.5 +/- 10.5 years, P = 0.0003), and adenomas (41.4 +/- 9.4 years, P = 0.0008). Clinical follow-up showed that most (98.6%) patients benefited from the minimal invasiveness of laparoscopic cholecystectomy with satisfactory surgical results. We conclude that laparoscopic cholecystectomy is a reliable, safe, and minimally invasive biopsy procedure and definite management of polypoid lesions of the gallbladder with a diameter less than 1.5 cm.     

Mixed hyperplastic adenomatous polyps/serrated adenomas. A distinct form of colorectal neoplasia

We present the clinicopathologic characteristics of 110 colorectal mixed hyperplastic adenomatous polyps (MHAP) that exhibited the architectural but not the cytologic features of a hyperplastic polyp. They are compared with 60 traditional adenomas, 40 hyperplastic polyps, and five colonic polyps that contained admixed but well-defined hyperplastic and adenomatous glands (HP/AD). The patients with MHAP ranged in age from 15 to 88 years (mean, 63 years). Five patients had two or more (up to seven) lesions. MHAP measured 0.2-7.5 cm in diameter. They were distributed throughout the colorectum, but a slight preponderance of large lesions (more than 1.0 cm) occurred in the cecum and appendix. All MHAP were characterized by a serrated glandular pattern simulating that seen in hyperplasia (27% of MHAP were initially diagnosed as hyperplastic polyps). However, MHAP were distinguished by the presence of goblet cell immaturity, upper zone mitoses, prominence of nucleoli, and the absence of a thickened collagen table. Although surface mitotic activity, nuclear pseudostratification, and nuclear cytoplasmic ratio were greater in MHAP than in hyperplastic polyps, they were slightly less than in traditional adenomas. Thirty-seven percent of MHAP contained foci of significant dysplasia; 11% contained areas of intramucosal carcinoma. We conclude that these lesions reflect a morphologically unique variant of adenoma and suggest that they be termed "serrated adenoma" in order to emphasize their neoplastic nature. We further offer the hypothesis that MHAP may arise from the neoplastic transformation of a more differentiated cell in the crypt than the traditional adenoma.     

结直肠无蒂锯齿状病变的特征和临床问题

无蒂锯齿状息肉/腺瘤（SSL）曾经被认为是良性病变,而现有研究表明,通过锯齿状瘤变途径,约15%～30%的SSL最终发展为结直肠癌。锯齿状息肉分为增生性息肉、无蒂锯齿状病变、伴发育不良的无蒂锯齿性病变、传统锯齿状腺瘤和未分类锯齿状腺瘤,每一种都具有不同的形态学和分子特征。尽管对SSL的理解有所提高,但由于频繁的病理错误分类、结肠内镜检测不足和不完全切除率高,SSL仍然是内镜和病理医生面临的诸多临床挑战。本文总结了目前对锯齿状息肉的新认识和诊断问题。     

Endoscopic mucosal resection for advanced non-polypoid colorectal adenoma and early stage carcinoma

Purpose: Endoscopic mucosal resection (EMR) techniques were evaluated in the treatment of flat and sessile colorectal neoplasm. Patients and methods: Fifty-seven patients (32 female, 25 male) with non-polypoid colorectal lesions (n = 71, size ? 10 mm) were included in the study. Tumor location, shape, size, and depth (in malignant lesions) were determined by endoscopy and endoscopic ultrasound. EMR was performed using snare resection, endoscopic aspiration mucosectomy, or EMR using a cap-fitted endoscope. Results: Lesion size ranged from 10 to 50 mm. Complete resection was achieved in 59 of 61 benign and 6 of 8 malignant tumors. Thirty-five tumors were excised in one segment and 34 tumors in piecemeal technique. Pathological examination of neoplasm treated by EMR showed adenoma in 61 and early-stage carcinoma in 8 cases. Because of the non-lifting sign, 2 of 71 tumors were not treated endoscopically and referred to surgical resection revealing a T2 adenocarcinoma in both cases. Resection was incomplete in 2 of 61 adenomas with histological positive resection margin. Complications occurred in 2 patients, with 1 bleeding treated endoscopically and 1 perforation treated by surgery. Local recurrence was observed in 2 of 59 completely resected adenomas and in none of 6 early-stage carcinomas during a mean follow-up of 18 months (range 6 to 30 months). Conclusion: Advanced non-polypoid colorectal adenomas and early-stage carcinomas can be safely and effectively resected by endoscopic mucosal resection.