食管胃交界部固有肌层来源黏膜下肿瘤内镜下切除方法的选择与评价

目的评价以内镜黏膜下剥离术（ESD）为基础的各种内镜切除技术在食管胃交界部（EGJ）固有肌层来源黏膜下肿瘤（SMT）治疗中的临床价值和适应证的选择。方法回顾性分析复旦大学附属中山医院内镜中心所有接受内镜下切除治疗的患者资料库．筛选出2007年3月至2011年6月间经内镜下超声或CT证实固有肌层来源的EGJ处SMT患者143例。详细记录患者的临床病理资料、内镜切除方法、完整切除率、并发症发生率及术后随访资料。结果143例患者中男74例，女69例，平均年龄49．1岁。135例（94-4％）病变成功完成内镜下整块切除，其中接受内镜黏膜下挖除术126例，无腹腔镜辅助的内镜全层切除术6例，内镜经黏膜下隧道肿瘤切除术3例：另外8例肿瘤于内镜下部分切除后，基底部尼龙绳套扎。肿瘤平均直径为17．6mm．平均手术时间45．1min．平均出血量50．0ml。术中穿孔6例，贲门黏膜撕裂1例。均通过内镜下处理及保守治疗好转。术后病理示，平滑肌瘤121例，胃肠间质瘤20例。颗粒细胞瘤1例．肌间脂肪瘤1例。术后经3。48个月的随访，未见局部复发和远处转移病例。结论在EGJ固有肌层来源SMT治疗中．各种内镜切除方法均安全有效．临床医师需根据肿瘤的临床特征具体选择．

Selection and evaluation of endoscopic resection for submucosal tumors of the esophagogastric junction originating from muscularis propria

Obejective To investigate the clinical application and indication of endoscopic dissection technique for submucosal tumors （SMTs） of the esophagogastric junction （EGJ） originating from the muscularis propria. Methods A total of 143 SMTs of the EGJ were treated by endoscopic resection in the Endoscopy Center of Zhongshan Hospital Affiliated to Fudan University between March 2007 and June 2011. The clinical and histopathologic feature, surgical approach, en bloc resection rate, complications, and postoperative follow up were evaluated. Results There were 74 males and 69 females with a mean age of 49.1 years old. The en bloc resection rate was 94.4%（135/143）. There were 126 patients who underwent endoscopic submucosal excavation in an en bloc fashion. Six patients underwent endoscopic full-thickness resection without laparoscopic assistance. Three patients underwent submucosal tunneling endoscopic resection. The other 8 SMTs were partially resected for histological evaluation and the residual tumors were further treated with nylon snare ligation. The mean lesion size was 17.6 mm. The mean procedure time was 45.1 minutes and the mean intraoperative bleeding was 50.0 ml. Perforations occurred in 6 patients and metal clips were used to close the defect. One patient with Mallory-Weiss syndrome was successfully treated with conservative treatment. Pathological examination showed that the lesions were leiomyoma （n=121）, gastrointestinal stromal tumor （n=20）, granulosa cell tumor（n=1）, and intermuscular hpoma（n=1）. No local recurrence and distant metastasis were noted during the follow-up （range, 3-48 months）. Conclusion Endoscopic resection technique is safe and effective, and should be selected for each patient individually.