内镜精查对胃低级别上皮内瘤变早癌筛查的价值

背景:普通白光内镜检查及其指导的活检存在局限性,可能造成早癌漏诊或误诊。目的:探讨内镜精查对胃低级别上皮内瘤变(LGIN)患者早癌筛查的价值。方法:选取2016年8月—2019年2月在常州市中医医院经普通内镜活检病理诊断为胃LGIN的患者50例,于3个月后进行复查,对其中30例有典型Ⅱa、Ⅱc或Ⅱa+Ⅱc形态改变者行放大内镜联合窄带成像(ME-NBI)精查和内镜黏膜下剥离术(ESD)治疗。结果:根据VS分类标准,30例行内镜精查者中15例提示早癌,15例提示非癌病变。精查活检病理提示高级别上皮内瘤变(HGIN)或胃癌10例,LGIN或慢性炎症改变20例。最终ESD病理显示14例为HGIN或胃癌,16例为LGIN或慢性炎症改变。以ESD病理结果为金标准,内镜精查诊断胃早癌的敏感性和阴性预测值均为100%,显著高于普通内镜活检病理和精查活检病理(P0.05)。结论:对于普通内镜活检病理提示胃LGIN者,ME-NBI精查可提高早癌检出率,防止漏诊。     

十二指肠降部非壶腹部散发型腺瘤内镜下的 高危征象识别及治疗效果

目的评估内镜治疗十二指肠降部非壶腹部散发型腺瘤的安全性和有效性,并分析总结其内镜下高危征象。方法回顾性分析2012年11月—2019年9月于南京鼓楼医院病理确诊的十二指肠降部非壶腹部散发型腺瘤患者54例,依据病理分级将患者分为高级别上皮内瘤变（high grade intraepithelial neoplasia,HGIN）/癌变（adenocarcinoma,AC）组以及低级别上皮内瘤变（low grade intraepithelial neoplasia,LGIN）组,记录并比较2组患者性别、年龄、病变长径、病变形态、病变色泽、治疗方式、手术并发症以及术后随访等临床资料,并评估内镜下治疗效果。结果54例患者中HGIN/AC组12例,LGIN组42例,2组间病变长径以及病变色泽差异均有统计学意义（P均＜0.05）。54例患者接受相应内镜下治疗,8例较小病变予活检钳除,32例行内镜黏膜切除术治疗,14例行内镜黏膜下剥离术治疗。术中小穿孔1例,内镜下钛夹封闭,内科治疗后无并发症;2例出现术后迟发性出血,均经内镜下治疗后出血控制。术后随访2~58个月,无一例复发。结论内镜治疗十二指肠降部非壶腹部散发型腺瘤是一种安全有效的方法,病变长径>10 mm以及色泽发红时,应警惕病变恶变倾向。     

窄带光成像联合放大内镜在活检病理提示胃低级别上皮内瘤变中的应用

目的 评价窄带光成像联合放大内镜（narrow band imaging-magnifying endoscopy,NBI-ME）对活检病理提示胃低级别上皮内瘤变（low-grade intraepithelial neoplasia, LGIN）的进一步评估价值。方法 2017年1月—2020年10月,因胃镜活检病理提示胃LGIN在苏州大学附属第一医院行内镜黏膜下剥离术（endoscopic submucosal dissection, ESD）治疗,且ESD术前予NBI-ME再次评估的180处病灶纳入回顾性分析。以ESD术后病理结果为金标准,计算NBI-ME预测胃镜活检病理提示胃LGIN病灶ESD术后发生病理升级的敏感度、特异度、阳性预测值、阴性预测值和准确率,并绘制NBI-ME预测胃镜活检病理提示胃LGIN病灶ESD术后发生病理升级的ROC曲线。结果 180处胃镜活检病理提示胃LGIN病灶中,ESD术后病理升级115处（63.89%）、非升级65处（36.11%）。ESD术前NBI-ME检查漏诊10处、误诊19处、正确151处,NBI-ME预测胃镜活检病理提示胃LGIN病灶ESD术后发生病理升级的敏感度、特异度、阳性预测值、阴性预测值和准确率分别为91.3%（105/115）、70.8%（46/65）、84.7%（105/124）、82.1%（46/56）和83.9%（151/180）,NBI-ME预测活检病理提示LGIN发生ESD术后病理升级的ROC曲线下面积为0.810（95%CI：0.737~0.883）。结论 对于活检病理提示胃LGIN的病灶,通过进一步行NBI-ME检查可以较为准确地预测病灶是否发生ESD术后病理升级,对活检病理提示胃LGIN的患者是进一步随访或内镜下切除的治疗策略选择具有重要指导意义。     

超声内镜辅助下皮圈套扎术对胃间质瘤的治疗价值

目的探讨超声内镜辅助下橡皮圈套扎术对胃间质瘤的治疗价值。方法回顾性分析郑州大学人民医院(河南省人民医院)内镜中心自2011年10月至2013年12月收治胃固有肌层源性间质瘤患者120例(间质瘤大小5~12 mm),行内镜下橡皮圈套扎治疗。治愈标准为病变完全脱落,如未脱落或仅有部分脱落则认为无效,给予重复治疗。术前、术中和术后行常规内镜及超声内镜(EUS)检查、随访。结果一次套扎成功116例(96.7%),2例二次套扎成功,2例放弃内镜治疗。7例患者术后3 d内出现一过性少量黑便,未经特殊处理症状消失,无穿孔、大出血等严重并发症发生。120例患者全部进行3~49个月的随访,2例患者术后2年局部息肉样增生,再次内镜下切除;118例患者完全治愈,未见复发。结论超声内镜辅助下橡皮圈套扎术治疗胃固有肌层间质瘤(大小5~12 mm)安全有效,临床可行性好。     

内镜下黏膜切除术治疗食管平滑肌瘤42例的临床观察

目的探讨内镜下黏膜切除术(EMR)治疗食管平滑肌瘤的疗效和应用价值。方法回顾性分析2009年1月-2011年1月我院消化内镜中心行EMR治疗且经病理证实的42例食管平滑肌瘤患者的临床资料。结果 42例患者均经微探头超声内镜检查确定其食管病变的解剖层次及起源后,行EMR完整切除病变组织。3例手术中出血患者经金属夹夹闭出血点后成功止血,1例手术后迟发性出血患者经内镜下氩离子血浆凝固术(APC)止血成功。无穿孔、感染等严重并发症发生,术后随访6个月,无瘢痕狭窄等术后并发症发生。结论 EMR治疗食管平滑肌瘤是一种安全、有效的微创治疗方法,具有重要的临床应用价值。     

超声内镜辅助内镜黏膜切除术治疗食管黏膜肌层病变的临床分析

目的回顾分析内镜下黏膜切除术(endoscopic mucosal resection,EMR)对食管黏膜肌层病变的治疗效果,并讨论其并发症和随访结果。方法 40例经超声内镜小探头证实的食管黏膜肌层病变,以注射法行黏膜切除治疗,记录病变大小、超声所见、操作方法、并发症、术后病理类型及随访情况。结果 40处病变经EMR完整切除,一次性完整切除率95.0%(38/40)。并发症:术中创面少许渗血7例(17.5%),均以氩气刀止血成功,无搏动性出血及穿孔发生。无迟发性出血及穿孔发生。术后病理:平滑肌瘤32例,间质瘤3例,炎性肉芽肿3例,血管瘤2例。随访1～12个月,未见病变残留或复发。结论超声内镜联合内镜黏膜切除术,术后常规行免疫组化检查,可完整切除食管黏膜肌层病变,方法安全有效。     

内镜下十二指肠乳头切除术联合胆管内射频消融术治疗十二指肠乳头肿瘤合并胆管内浸润的价值

目的　评估内镜下十二指肠乳头切除术（endoscopic papillectomy,EP）联合胆管内射频消融术（radio frequency ablation, RFA）治疗十二指肠乳头肿瘤合并胆管内浸润的有效性与安全性。方法　纳入2013年2月—2019年2月采用EP联合胆管内RFA治疗经病理组织学证实的十二指肠乳头肿瘤伴胆管内浸润的12例患者资料。总结患者的临床特征、内镜表现、内镜治疗效果和术后并发症发生情况,并随访分析复发率。结果　内镜超声检查测量病变中位大小为18.5 mm×15.5 mm,胆管内侵犯长度为（14.1±5.8） mm。12例患者均成功行ER+RFA,技术成功率100%;术后病理示腺癌5例,腺瘤伴高级上皮内瘤变6例,腺瘤伴低级别上皮内瘤变1例。术后随访（28.5±10.4）个月,接受（4.1±1.6）次ERCP和胆管内活检,分别有2例患者在14个月和20个月时复发（均为腺癌）。结论　EP联合胆管内RFA治疗十二指肠乳头肿瘤伴胆管内浸润是安全有效的,但考虑到复发的风险,术后需要严密随访观察。     

肝动脉化疗栓塞术后行经皮射频消融术治疗高危部位原发性肝癌的效果和安全性分析

目的探讨在肝动脉化疗栓塞术(TACE)基础上行经皮射频消融术(RFA)治疗高危部位肝癌病灶的临床疗效及安全性。方法收集2011年1月-2015年12月首都医科大学附属北京地坛医院收治的高危部位原发性肝癌患者64例。所有患者首先行TACE治疗,术后3~5 d行RFA治疗。RFA治疗均在CT引导下完成。主要观察治疗效果及不良反应发生情况。结果 64例患者中共包含76个病灶,均完成TACE及RFA治疗。术后1个月肿瘤完全消融率为81.5%(62/76)。术后随访6~64个月,至随访结束,肿瘤局部进展率为28.9%(22/76);1、2、3年生存率分别为90.6%、78.1%、64.1%。随访期间手术严重并发症发生率为3.1%(1例出现肝脓肿、1例出现胆道出血),分别在内科治疗和介入治疗后缓解且无后遗症。结论在TACE基础上行CT引导下经皮RFA治疗高危部位原发性肝癌是一种安全可行的治疗方案。     

内镜下黏膜剥离术治疗消化道早癌及癌前病变24例临床分析

目的观察内镜下黏膜剥离术(ESD)对消化道病变的治疗效果。方法2006年11月至2008年6月,中国人民解放军总医院消化科内镜中心ESD治疗消化道病变24例。观察其疗效及并发症发生情况。结果24例患者病变全部切除成功,操作时间36～165 min,平均75.7 min。其中,胃窦体病变操作时间41～81 min,平均60.1 min;2个胃底部病变耗时分别为114 min和118 min,平均116.0 min;食管病变操作时间39～102 min,平均63.7 min;大肠病变36～165 min,平均83.8 min。无术中出血、穿孔并发症发生,术后迟发出血1例,内镜下止血成功,出血率为4.1%。患者住院天数5～19 d,平均8.8 d。所有病例均纳入内镜随访计划,随访时间最长12个月,最短1个月。随访结果,复发1例,复发残留率4.2%。结论ESD虽然有操作过程复杂、操作技巧难度大等缺点,但对于消化道早期肿瘤以及黏膜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。     

内镜黏膜下剥离术治疗消化道黏膜下肿瘤的疗效分析

目的探讨内镜黏膜下剥离术(ESD)治疗消化道黏膜下肿瘤(submucosal tumor,SMT)的疗效及安全性。方法选取我院2008年3月-2011年6月经胃肠镜检查发现消化道黏膜下肿瘤48例,回顾性分析48例患者资料,包括患者的基本情况、病变部位、大小、治疗经过以及病理结果等,统计并发症发生情况及术后随访结果。结果病灶直径为0.8～5.8 cm,平均(3.3±0.75)cm,ESD手术时间为27～167 min,平均(71.0±22.6)min,ESD完整切除病灶45例(45/48,93.75%),穿孔3例(3/48,6.25%),其中1例大出血,1例食管患者ESD术后出现食管狭窄,经内镜下球囊扩张食管狭窄消失。所有病人均完成了术后6个月的内镜随访,1例患者见肿瘤复发。结论 ESD技术对较大病变可以整块切除,并提供完整的病理诊断资料;消化道SMT行ESD术是安全、有效的。     

A prospective study on radiofrequency ablation locally advanced pancreatic cancer

BACKGROUND:Radiofrequency ablation(RFA)has been suggested as a new treatment option for patients with locally advanced cancer.This study aimed to prospectively evaluate the efficacy and safety of intraoperative RFA in patients with unresectable,locally advanced,non-metastatic carcinoma of the pancreatic head.METHODS:RFA was the first step of the surgical procedure and was carried out on the mobilized pancreatic head followed by biliary by-pass and gastrojejunal-anastomosis.Intra-and post-operative morbidity and mortality,performance status, pain control,quality of life,and survival at 24 months were evaluated.RESULTS:Seven patients(3 men and 4 women;median age 66 years,range 47-80 years)were studied and 4 were eligible for treatment.The RFA procedure was carried out in 3 of the 4 patients;in one patient it was not carried out because of the upstaging of the neoplasm.In all 3 patients RFA achieved complete necrosis of the lesion.A biliary fistula developed 7 days after the procedure in one patient;all 3 patients developed ascites 8.6 days(range 7-9 days)on average after RFA.All patients died respectively,at 3,4,and 5 months after the treatment.CONCLUSIONS:In our experience,RFA is a feasible procedure, but it presents a very high rate of postoperative complications.Moreover,pain control,life quality and survival rate are poor.The few data suggest no impact on survival.     

胃上皮内瘤变术前活检与内镜黏膜下剥离术后病理差异性的探讨

目的对胃黏膜上皮内瘤变术前活检与内镜黏膜下剥离术(ESD)后出现病理差异这一现象进行探讨,并分析导致这种差异的原因以及相关影响因素。 方法回顾性分析了2016年7月至2019年6月经江苏省中医院住院行ESD治疗、术前活检为低级别上皮内瘤变(LGIN)/高级别上皮内瘤变(HGIN)的342例患者资料,运用统计学方法分析导致差异的影响因素。 结果342例患者中,187例为LGIN、155例为HGIN。LGIN组中病理一致者占61.5%,升级为HGIN、早期胃癌及以上者分别为21.4%、12.8%,总升级率34.2%,降级为慢性炎症者4.3%。HGIN组病理维持一致者占40.6%,升级为早期胃癌及以上者占52.9%,降级为LGIN者6.5%。多因素回归分析结果显示：病灶位于胃上1/3、表面充血、结节、放大内镜下DL(＋)、MV(＋)是LGIN组病理升级的危险因素;病灶表面结节是HGIN病理升级的危险因素。 结论白光内镜下活检与ESD后病理存在差异,病灶在胃上1/3、表面充血、结节、DL(＋)、MV(＋)是LGIN病理升级的危险因素;病灶表面结节是HGIN病理升级的危险因素。     

经导管动脉化疗栓塞后联合CT引导射频消融肝癌的初步应用

目的 探讨经导管动脉化疗栓塞(TALE)后联合CT引导射频消融(RFA)治疗肝癌的治疗效果并探讨相关介入技术.方法 14例肝癌患者共21个病灶,Child-Pugh分级A级或B级,分别TACE联合CT引导下(RFA)治疗,治疗术前术后均行CT、MRI等影像学检查,并定期随访21个月.结果 14例患者21个病灶的联...     

Major complications after radiofrequency ablation for liver tumors： Analysis of 255 patients

AIM： To investigate the major complications after radiofrequency ablation （RFA） for the treatment of liver tumors and analyze possible risk factors that precipitate these complications.
METHODS： From March 2001 to April 2008, 255 patients with liver tumors （205 male, 50 female; age range, 18-89 years; mean age, 56.0 years） who received RFA were enrolled in this study. Of these patients, 212 had hepatocellular carcinoma, 39 had metastatic liver tumors and four had cholangiocellular carcinoma. One hundred and forty eight patients had a single tumor, and 107 had multiple tumors. Maximum diameter of the tumors ranged 1.3-20 cm （mean, 5.1 cm）. All patients were treated with a cooledtip perfusion electrode attached to a radiofrequency generator （Radionics, Burlington, MA, USA）. RFA was performed via the percutaneous approach （n = 257）, laparoscopy （n = 7）, or open surgical treatment （n = 86）. The major complications related to RFA were recorded. The resultant data were analyzed to determine risk factors associated these complications.
RESULTS： Among the 255 patients, 425 liver tumors were treated and 350 RFA sessions were performed. Thirty-seven （10%） major complications were observed which included 13 cases of liver failure, 10 cases of hydrothorax requiring drainage, three cases of tumor seeding, one case of upper gastrointestinal bleeding, one case of intrahepatic abscess, one case of bile duct injury, one case of cardiac arrest, and five cases of hyperglycemia. Seven patients had more than two complications. Liver failure was the most severe complication and was associated with the highest mortality. Eleven patients died due to worsening liver decompensation. Child-Pugh classification （P = 0.001） and choice of approach （P = 0.045） were related to post-treatment liver failure, whereas patient age, tumor size and number were not significant factors precipitating this complication.
CONCLUSION： RFA can be accepted as a relatively safe procedure for the treatment of liver tumors. However, attention should be paid to possible complications even though the incidences of these complications are rare. Careful patient selection and the best approach choice （percutaneous, laparoscopy, or laparotomy） will help to minimize the incidence and morbidity rate of complications which occur after RFA.     

Clinical short—term results of radiofrequency ablation in l;iver cancers

AIM：To study local therapeutic efficacy,side effects,and complications of radiofrequency ablation(RFA),which is emerging as a new method for the treatment of patients with hepatocellular carcinoma(HCC)with cirrhosi or tchronic hepatitis and metastatic liver cencer.METHODS:Thirty-six patients with primary and secondary liver cancers(21with primary hepatocellular carcinoma,12with colorectal cancer liver metastases and 3with other malignant liver metastases),which were considered not suitable for curative resection,were include in this study.They were treated either with RFA(RITA2000,Mountain View.California,UAS)pecutaneously(n=20)or intraoperatively(n=16).The procedures were performed using the ultrasound guidance.The quality of RFAwere based on monitoring of equipments and subiect feeling of the practitioners.Patients treated withRFA was followed according to clinical findings,radiographic images.and tumor markers.RESULTS:Thirty-six patients underwent RFAfor48nodules.RFAwas used to treat an average1.3lesions per patient,and the median size of treated lesions was2.5cm(range,0.5-9cm),The average hospital stay was5.6days overall(2.8days for percutaneous cases and7.9days for open operations).Sevn patients underwent a second RFA procedure(sequential ablations).Sixteen HCCpatients with a high level of alpha fetoprotein(AFP)and 9colorectal cancer liver metastases patients with a high level of serum carcinoembryonic antigen(CEA)have a great reduction benefited from RFA.Four(11.1%)patients had complications;one skin burn;one postoperativa hemorrhage;one cholecystitis and one hepatic abscess associated with percutaneous ablations of a large lesion.There were 4deaths;3patients died from local and system diseases(1at7month,1at9month,and 1at 12month),1patients died from cardivascular shck,but no RFA-related death.At a median follow-up of 10months(range,1-24months),6patients(16.7%)had recurrences at an RFAsite,and 20patients(56.7%)remained clinically freeof diseas.     

Postoperative Complications and Functional Results After Subtotal Gastrectomy with Billroth II Reconstruction for Primary Gastric Cancer

Subtotal gastrectomy is considered the preferred treatment for gastric cancer with antral location. The aim of this study was to assess the incidence of early postoperative complications and late functional results in patients who underwent subtotal gastrectomy with Billroth II reconstruction for primary gastric adenocarcinoma. The results of 310 patients were analyzed with regard to postoperative complications and death rates. Functional results as they relate to the gastric resection were evaluated in 195 disease-free patients. Of the 310 patients, 77 developed postoperative general and surgical complications (24.8%) and 13 consequently died (in-hospital mortality: 4.2%). Although infrequent (6 cases, 1.9%), anastomotic leak was the most serious complication (4 cases died during the postoperative phase). Considering functional results, weight loss continued for the first trimester after surgery, after which it stabilized. Loss of appetite was rarely observed; early after the operation the majority of patients were consuming a normal diet and regularly consumed less than five meals per day (83.6%). Dumping syndrome was uncommon and usually resolved within one year (12.3% at three months, 9.5% after one year, 5.2% after two years). On the other hand, postprandial abdominal fullness was frequently observed (43.1% at three months, 36.1% after one year, 21.3% after three years, and 16.5% after five years). Billroth II reconstruction after subtotal gastrectomy is associated with a limited risk of anastomotic complications. Anastomotic leak, although infrequent, is a life-threatening complaint and requires prompt recognition and aggressive surgical treatment. The incidence of late complications was low and the majority of patients recovered from them within one year after surgery, although the occurrence of postprandial abdominal fullness was not completely irrelevant.     

规范性个体化射频消融术在原发性肝癌外科治疗中的作用

目的探讨规范性个体化的射频消融术在原发性肝癌外科治疗中的作用。方法对2004年6月至2012年6月间562例行射频消融术的原发性肝癌病例进行回顾性分析,并与同期行肝部分切除术的574例病例进行对照研究。观察术后恢复、手术并发症、术后肿瘤残余复发、术后总体生存率和术后无瘤生存率等。结果两组均无手术死亡病例,术后均恢复出院。术后平均住院日和平均住院费用射频消融组显著低于手术切除组(P0.001,P=0.041),术后射频消融组无严重并发症,肝功能损害主要为轻中度,损害程度显著低于手术切除组(P0.001)。术后1个月手术切除组无肿瘤残留,射频消融组23例共41个瘤灶发现肿瘤残留。两组术后1、3、5年总体生存率无差异,手术切除组术后1、3、5年无瘤生存率显著高于射频消融组(P=0.024)。结论射频消融能够完全毁损肿瘤实质,且术后恢复快,并发症少,治疗得当可达到与手术切除相近的治疗效果,但其术后无瘤生存率低于手术切除,因此规范性个体化的手术方案设计是提高射频消融治疗原发性肝癌近远期疗效的关键因素。     

Indications and results of endovenous laser tratment (EVLT) for greater saphenous vein incompetentce. Our experience

AIM: Endovenous laser treatment (EVLT) seems to be a safe and less invasive method for the treatment of the great saphenous vein (GSV) incompetence. The aim of our study was to evaluate the indications and results of EVLT. METHODS: Between January 2003 and October 2004, 77 patients (55 C3 and 22 C4) underwent EVLT. In 23 cases phlebectomy was performed, in 16 patients a subfascial perforator vein ligations occurred. In 62 patients we used a percutaneous access to the distal GSV, in 15 cases a surgical isolation was performed. In all cases a 600 nm with 1 mm diameter laser was used. RESULTS: Follow-up was performed for a period of 6 months and showed GSV recanalization in 2 cases; 18 patients (23.3%) developed a transient postoperative pain along GSV, in 4 (5.1%) of them the pain persisted for 3 months. In 6 cases a reversible paresthesia due to a lesion of the saphenous nerve were recorded (7.7%) and in 1 case (1.2%) a skin burn occurred. No deep vein thromboses were observed. CONCLUSIONS: EVLT is a safe technique, with low incidence of recanalizations and postoperative complications. Our opinion is to extend the indication in selected cases of GSV incompetence.     

Percutaneous ultrasound-guided radiofrequency ablation of intrahepatic cholangiocarcinoma

This study evaluated the clinical applications, treatment effects, and complications of percutaneous ultrasound (US)-guided radiofrequency ablation (RFA) of intrahepatic cholangiocarcinoma. Ten patients (6 men and 4 women) with histologically proven cholangiocarcinoma underwent US-guided percutaneous RFA. Tumor diameters ranged from 1.9 to 6.8 cm. There were 12 sessions of RFA for 10 solitary cholangiocarcinomas. Eight patients were treated at a single session and two patients had two treatment sessions. The efficacy of RFA was evaluated using contrast-enhanced dynamic computed tomography 1 month after treatment and then every 3 months. Complete necrosis was defined as lack of contrast enhancement of the treated region. There was complete necrosis in eight tumors. In two patients with large tumors (4.7 and 6.8 cm in diameter), enhancement of residual tissue was observed after RFA treatment, indicating residual tumor. Complete necrosis was seen in all five tumors (100%) with diameters of 3.0 cm or less, two of three tumors (67%) with diameters of 3.1-5.0 cm, and one of two tumors (50%) with diameters of more than 5.0 cm. A large biloma was found in one patient after treatment. No serious complications occurred in the other nine patients. In conclusion, percutaneous RFA is effective and successful in the treatment of intrahepatic cholangiocarcinoma of 3 cm or less and satisfactory for tumors of 3-5 cm. The rate of serious complications after RFA is low. Further follow-up is necessary to determine long-term efficacy.