透明帽在消化内镜诊治中的应用

随着各种内镜治疗附件的应用,镜下止血、息肉切除、异物取出、支架置放、圈套器结扎等内镜治疗技术逐渐成熟.透明帽作为治疗附件在内镜诊断及治疗中应用广泛,包括食管上端及锐利异物的取出、协助结肠镜进镜、提高放大内镜成像效果以及在内镜下黏膜切除(endoscopic mucosal resection,EMR)、内镜黏膜下剥离(endoscopic submucosal dissection,ESD)、食管静脉曲张套扎(endoscopic variceal ligation,EVL)中应用.现将透明帽在消化内镜诊治中的作用做一综述.     

消化内镜前端透明帽的临床应用进展

内镜前端透明帽在内镜诊断和治疗中发挥了重要的作用,包括透明帽辅助黏膜下肿瘤结扎术、内镜下黏膜切除术、异物取出、内镜下静脉曲张结扎术和硬化剂注射术、内镜黏膜下剥离术、经口内镜下肌切开术、经内镜隧道式黏膜剥离术等。本文就不同类型透明帽在消化内镜诊疗中的作用作一综述。     

透明帽在内镜下氩气刀治疗上消化道病变中的应用价值

目的探讨透明帽在内镜下氩气刀治疗上消化道病变中的应用价值。方法选取20例适合内镜下氩气刀治疗的上消化道病变患者,在内镜先端加置合适透明帽后用德国速灵ARCO2000氩气刀进行治疗。结果 20例患者均快速成功完成治疗。结论透明帽在内镜下氩气刀治疗上消化道特殊部位病灶中的应用值得推广。     

内镜下黏膜切除术在治疗早期食管癌和重度不典型增生中的应用

目的探讨内镜下黏膜切除术（EMR）治疗早期食管癌、重度不典型增生的应用价值。方法对我院2004年2月～2009年4月经色素内镜筛查且活检证实为早期食管癌及重度不典型增生的32例患者,在静脉麻醉下进行内镜下黏膜切除术透明帽法治疗,其中早期癌8例,重度不典型增生24例。结果对早期食管癌及重度不典型增生的32例患者进行内镜下黏膜切除术透明帽法治疗,成功27例,小量出血2例,无穿孔及狭窄等严重并发症。结论严格筛选患者行内镜下黏膜切除术透明帽法治疗早期食管癌、癌前病变是安全而有效的方法。     

改良式透明帽在18例上消化道黏膜平坦隆起性病变中临床应用

目的评价改良式透明帽在内镜黏膜切除术中的应用效果,并对其适应症和操作方法等问题进行讨论。方法选择符合内镜黏膜切除术适应症的18例应用改良透明帽,切除了27处病变。对手术发生的并发症进行观察和处理。结果 18例患者中共切除病变27处,完全切除率100%。术后病理诊断起源于黏膜肌层的食管平滑肌瘤2处,食管乳头状瘤3处,黏膜慢性炎2处。胃:增生性息肉12处,炎性息肉7处,重度不典型增生1处。并发症主要是岀血,术中创面渗血2处,均行高频电凝止血。1例发生术后迟发性出血,应用钛夹止血成功。无便血及穿孔发生。结论改良式透明帽在EMR术中可以安全应用,操作简单,特别适合在基层推广应用。     

结肠镜下标准黏膜剥离切除术(EMR)--技法与经验

内镜下黏膜切除术（Endoscopic Mucosal Resection，EMR）是近年来发展起来的一类新技术，对胃肠道早期癌、平坦型腺瘤及黏膜下肿瘤可以应用该技术行内镜下切除。经典的EMR技术包括：黏膜下注射法黏膜切除术（EMR术）、黏膜下注射法分片黏膜切除术（Endoscopic Piecemeal Mucosal Resection，EPMR术）、透明帽辅助法黏膜切除术（Cap-EMR术）及附加外套管透明帽辅助EMR术．其中黏膜下注射法EMR术已成为标准的平坦型病变内镜下治疗方法．适用于直径在9．0mm以下的早期癌及平坦型腺瘤，在日本已广泛应用，国内已有少数大医院成功开展此顶技术，EPMR术与标准的注射法EMR术原理相同．适用于于直径在20～30mm的大型平坦型病变．超过30mm的病变日本内镜学会建议外科手术处理。Cap-EMR术适合于胃及直肠的小型黏膜下肿物，尤其适用于直径在10lnln以内的无转移证据的类癌，附加外套管Cap-EMR术目前仅在日本个别医院有应用，国内尚未见报道。     

食管颗粒细胞瘤ESD切除1例并国内文献回顾

食管颗粒细胞瘤发病罕见,本文通过对1例典型病例诊疗情况描述以及对国内相关文献检索和回顾,进一步对此病的临床症状、镜下表现、诊断方法、发病机制、治疗、预后情况进行整理、总结和探讨.超声内镜的应用有助于提高此疾病的诊断率,病理是确诊该疾病的金标准.一般认为直径2 cm且未侵及肌层者可以采用内镜黏膜切除术(endoscopic mucosal resection),考虑到少数复发和潜在恶性可能,透明帽辅助内镜黏膜下剥离术(endoscopic submucosal dissection)具有更高的安全性.     

超声内镜对直肠类癌诊断及治疗的价值探讨

直肠类癌是起源于消化道APUD细胞系统的肿瘤,多发生于消化道的黏膜及黏膜下层,内镜检查通常表现为黏膜下肿物,与其他黏膜下肿物鉴别较为困难。而EUS的应用使对消化道黏膜下肿物的诊断水平有了较大提高。本文回顾性分析2006年3月-2008年10月我院应用EUS指导进行透明帽辅助的内镜黏膜下切除术（endoscopic submucosal resection using the cap,EsMRC）治疗的直肠类癌患者18例的临床资料,旨在探讨EUS指导直肠类癌诊断及治疗的价值。     

内镜活检钳临床使用技巧

正内镜活检钳作为内镜附件常规用于消化道可疑病灶取病检,但内镜医生却能将活检钳的用途扩大,在内镜诊断和治疗中发挥了重要的作用。活检钳不仅用于取病检,还可以用于异物取出、推移并充分显示病灶、打标记、作标尺、钳夹牵引辅助内镜黏膜下剥离术(ESD)、良性肿瘤钳除、辅助插管等。本文就不同类型活检钳在消化内镜诊疗中的作用作一综述。1活检钳结构和种类内镜活检钳又称为内镜活体取样钳。活检钳结     

内镜下黏膜剥离术中使用碘伏维持镜头及透明帽清晰度效果观察

[目的]探讨在内镜下黏膜剥离术(ESD)中,使用碘伏棉签擦拭镜头及透明帽以维持其清晰度的效果。[方法]选取2017-06-2017-08期间,接受ESD治疗且病灶直径≥2 cm的消化道早期癌或癌前病变的101例患者,随机分为观察组(51例)和对照组(50例)。观察组先使用碘伏棉签擦拭镜头及透明帽再进行手术,术中电刀产生烟雾致镜头及透明帽模糊用内镜注水功能冲洗不能解决时,退镜再用碘伏棉签擦拭;对照组术中镜头及透明帽模糊时使用0.9%氯化钠溶液棉签。对比分析2组擦拭方法维持镜头及透明帽清晰度的时间及手术时间内擦拭次数。[结果]观察组手术时间明显少于对照组,差异有统计学意义(P0.05);观察组、对照组在总时间为≤30 min的手术中维持的清晰度时间比较差异无统计学意义,但在30 min的手术中,观察组较对照组维持的清晰度时间更长;观察组术中退出内镜擦拭的次数少于对照组的次数。[结论]ESD中,用碘伏棉签擦拭可有效预防镜头及透明帽模糊,减少退镜擦拭镜头及透明帽次数,有利于手术连续、顺利进行,缩短手术时间,降低手术风险,值得推广。     

Early gastric cancer: diagnosis, treatment techniques and outcomes

The detection of early gastric cancer is performed by endoscopic study with or without the dye-spraying method, which is useful in detecting small lesions or surface lesions. For the diagnosis of early gastric malignancy, magnification endoscopy, narrow-band imaging and optical coherence tomography are used for histological diagnosis and research. On the other hand, endoscopic ultrasonography is used to discuss the depth of carcinoma invasion, but cannot be used to detect the malignant lesions except for the rare cases of scirrhus-type gastric carcinoma, the histological results of which are sometimes difficult to obtain by biopsy study. The role of endoscopic ultrasonography diagnosis is to assist in making a decision of therapeutic strategy. Curative endoscopic treatment of early gastric cancer is common according to the development of various endoscopic techniques and accessories. Curative treatment is feasible using these techniques.     

Esophageal varices hemorrhage. Endoscopic treatment

The patient with bleeding esophageal varices represents always a challenge to the medical team carrying a high mortality in spite of advances in pharmacologic and endoscopic treatments, notwithstanding that bleeding is just one added complication in the setting of the ailments of portal hypertension. Sclerotherapy, once the treatment of choice, has been displaced in recent year by variceal ligature, with less morbidity and equal success rate, both of them being technically simple. In the same way, variceal ligature has displaced sclerotherapy as treatment for secondary prophylaxis, with less complications and less sessions needed for variceal erradication and bleeding prevention. On the other hand, sclerotherapy is not indicated for patients with large varices, while ligature competes with pharmacologic treatment, some people suggesting the superiority of ligature because of better patient compliance, although probably the best option would be a combination of both. Thus, endoscopic treatment has an important role in this clinical situation, both for diagnosis as for management of active bleeding and primary prophylaxis.     

What's new in portal hypertension?

Portal hypertension is defined as increased pressure in the portal venous system. The most common cause of portal hypertension is cirrhosis. In this setting, there is an increase in intrahepatic resistance leading to an increase in portal pressure. By increasing portal blood flow, splanchnic vasodilation further aggravates portal hypertension. New pathogenic pathways are being established which might result in new therapeutic strategies. The presence of varices at endoscopy and/or other abdominal portosystemic collaterals confirms the diagnosis of portal hypertension. The role of non‐invasive and imaging tests in the diagnosis and prognosis of portal hypertension has been clarified. Non‐selective beta‐blockers decrease both the risk of variceal haemorrhage and hepatic decompensation. Terlipressin, somatostatin or octreotide, in combination with early endoscopic therapy, are recommended for the treatment of acute variceal haemorrhage. Early Transjugular intrahepatic portosystemic shunt (TIPS) is effective as salvage therapy in acute variceal bleeding in selected patients and prevents rebleeding more effectively than endoscopic and medical therapy resulting in an increased survival.     

New haemostatic techniques: histoacryl injection, banding/endoloop ligation and haemoclipping.

New endoscopic modalities for the haemostasis of upper gastrointestinal bleeding include cyanoacrylate tissue glue injection for oesophageal and gastric varices, ligation using bands and loops for variceal and non-variceal bleeding, and clips for non-variceal bleeding. These new modalities aim to improve primary and secondary haemostasis rates and the safety of endoscopic treatment. Preliminary experience using these modalities has been encouraging, but prospective randomized trials using adequate patient numbers are still needed to validate their efficacy and safety. The choice of treatment will depend on the clinical context and the anatomy of the bleeding lesion. Cyanoacrylate injection, which achieves rapid haemostasis and obliteration of the treated varix, is ideally suited to acute variceal bleeding and the obliteration of large gastric varices. Bands and loops are used in conjunction with a transparent cap attachment for the elective treatment of oesophageal varices. The clip is most effective when a vessel from a non-variceal bleeding source can be identified.     

小探头超声用于胃底静脉曲张诊断及判断组织粘合剂疗效的初步评价

目的 与常规内镜下肉眼判断比较,评价小探头超声检查在诊断胃底静脉曲张及评价内镜下组织粘合剂治疗疗效中的临床价值。方法 １０例临床诊断为肝硬化的患者于内镜治疗前先行胃底腔内小探头超声检查,随后对诊断存在胃底静脉曲张的患者行内镜下组织粘合剂治疗,而后即刻再行小探头超声检查以观察其疗效。结果 常规内镜下肉眼判断与小探头超声检查对胃底静脉曲张的诊断准确率分别为７０％（７／１０）和１００％（１０／１０）;后     

Endoscopic ultrasound-guided interventions in special situations

Endoscopic ultrasound(EUS) was introduced in 1982 and has since become a popular advanced procedure for diagnosis and therapeutic intervention. Initially, EUS was most commonly used for the diagnosis of pancreatobiliary diseases and tissue acquisition. EUS was first used for guided cholangiography in 1996, followed by EUS-guided biliary drainage in 2001. Advancements in equipment and endoscopic accessories have led to an expansion of EUS-guided procedures, which now include EUS-guided drainage of intra-abdominal abscesses or collections, intravascular treatment of refractory variceal and nonvariceal bleeding, transmural pancreatic drainage, common bile duct stone clearance, enteral feeding tube placement and entero-enteric anastomosis. Patients with surgically altered upper gastrointestinal anatomies have greatly benefited from EUS also. This systematic review describes and discusses EUS procedures performed in uncommon diseases and conditions, as well as applications on more vulnerable patients such as young children and pregnant women. In these cases, routine approaches do not always apply, and thus may require the use of innovative and unconventional techniques. Increased knowledge of such special applications will help increase the success rates of these procedures and provide a foundation for additional advances and utilizations of the technique.     

Endoscopic screening for varices in cirrhosis: findings,implications, and outcomes

At least two thirds of cirrhotic patients develop esophageal varices during their lifetime. Severe upper gastrointestinal (UGI) bleeding as a complication of portal hypertension develops in about 30%-40% of cirrhotics. Despite significant improvements in the early diagnosis and treatment of esophagogastric variceal hemorrhage, the mortality rate of first variceal hemorrhage remains high (20%-35%). Primary prophylaxis, the focus of this article, is treatment of patients who never had previous variceal bleeding to prevent the first variceal hemorrhage. The potential of preventing first variceal hemorrhage offers the promise of reducing mortality, morbidity, and associated health care costs. This article (1) reviews endoscopic grading of size and stigmata for esophageal and gastric varices, (2) describes data on prevalence and incidence of esophageal and gastric varices from prospective studies, (3) discusses independent risk factors from multivariate analyses of prospective studies for development of first esophageal or gastric variceal hemorrhage and possible stratification of patients based on these risk factors, (4) comments on the potential cost effectiveness of screening all newly diagnosed cirrhotic patients and treating high-risk patients with medical or endoscopic therapies, and (5) recommends further studies of endoscopic screening, stratification, and outcomes in prospective studies of endoscopic therapy. The author's recommendations are to perform endoscopic screening for the following subgroups of cirrhotics: all newly diagnosed cirrhotic patients and all other cirrhotics who are medically stable, willing to be treated prophylactically, and would benefit from medical or endoscopic therapies. Exclude patients who are unlikely to benefit from prophylactic therapies designed to prevent the first variceal hemorrhage, those with short life expectancy, and those with previous UGI hemorrhage (they should have already undergone endoscopy). For low or very low risk cirrhotic patients-those found to have no varices or small varices without stigmata-repeat endoscopy is recommended because screening for progression may be warranted in 2 or more years.     

Sclerotherapy versus banding in the treatment of variceal bleeding

Endoscopic sclerotherapy has been the mainstay in the management of esophageal variceal bleeding to control acute bleeding and decrease recurrent bleeding. Endoscopic variceal ligation is a new technique that is equally effective in the control of acute bleeding but achieves obliteration of varices in fewer treatment sessions with presumably less cost, results in a lower rebleeding rate, has fewer complications, and is associated with reduced mortality. Combination therapy with both endoscopic variceal ligation and endoscopic sclerotherapy appears to have no clear advantage over variceal ligation alone. On the basis of the results of a number of trials comparing sclerotherapy with band ligation, endoscopic variceal ligation has evolved to be the preferred first line modality for the endoscopic treatment of variceal bleeding.     

Variceal bleeding and portal hypertensive gastropathy

Cirrhosis can be the end stage of any chronic liver disease. At the time of diagnosis of cirrhosis varices are present in about 60% of decompensated and 30% of compensated patients. The risk factors for the first episode of variceal bleeding in cirrhotic patients are the severity of liver dysfunction, large size of varices and the presence of endoscopic red colour signs but only one-third of patients who have variceal haemorrhage have the above risk factors. Recent interest has been directed at identifying haemodynamic factors that may reflect the pathophysiological changes which lead to variceal bleeding, e.g. it has been confirmed that no bleeding occurs if HVPG falls below 12 mmHg and also a hypothesis has been put forward in which bacterial infection is considered a trigger for bleeding. Pharmacological treatment with beta-blockers is safe, effective and is the standard long-term treatment for the prevention of recurrence of variceal bleeding. Combination of beta-blockers with isosorbide-5-mononitrate needs further testing in randomized controlled trials. The use of haemodynamic targets for reduction in HVPG response needs further study, and surrogate markers of pressure response need evaluation. If endoscopic treatment is chosen, variceal ligation is the modality of choice. The combination of simultaneous variceal ligation and sclerotherapy does not offer any benefit. However, the use of additional sclerotherapy for the complete eradication of small varices after variceal ligation needs to be evaluated. The results of current prospective randomized controlled trials comparing variceal ligation with pharmacological treatment are awaited with great interest. Finally, the use of transjugular intrahepatic portosystemic shunt (TIPS) for the secondary prevention of variceal bleeding is not substantiated by current data, as survival is not improved and because of its worse cost-benefit profile compared to other treatments. In contrast, there still is a role for the selective surgical shunts in the modern management of portal hypertension. The ideal patients should be well compensated cirrhotics, who have had troublesome bleeding - either who have failed at least one other modality of therapy (drugs or ligation), have bled from gastric varices despite medical or endoscopic therapy, or live far from suitable medical services. Recently, ligation has been compared to beta-blockers for primary prophylaxis but so far there is no good evidence to recommend banding for primary prophylaxis, if beta-blockers can be given.     

The role of surgery in the treatment of portal hypertension

The role of surgery in the treatment of portal hypertension continues to evolve. Pharmacologic and endoscopic therapies are the primary treatment modalities for the prophylaxis and treatment of variceal bleeding and ascites. Failure of these therapies is the indication for invasive intervention such as TIPS, surgical shunt, or devascularization. Distal splenoreal shunting provides selective variceal decompression with less encephalopathy and accelerated hepatic failure than portal decompression. Liver transplantation remains the treatment of choice for patients with poor hepatic function.