隧道内镜技术在食管胃疾病中的应用价值

隧道内镜技术是在经自然腔道内镜外科手术（NOTES）和内镜下黏膜剥离术（ESD）基础上发展起来的一种新的内镜治疗技术。经过短暂5年的发展和完善．隧道内镜技术已经开始应用于临床疾病的治疗。本文就隧道内镜技术治疗贲门失迟缓症以及固有肌层来源的黏膜下肿瘤（submUCosaltumors．SMTs）等食管胃疾病的指征、方法、疗效和并发症情况进行评价。     

食管疾病内镜手术远期疗效的研究进展

食管疾病包括食管恶性疾病及良性疾病,在我国发病率高.随着内镜技术的发展,许多既往需要药物治疗或外科手术的疾病,现在可以通过内镜手术进行根治.本文对常见食管疾病包括食管早期鳞状细胞癌、食管狭窄、贲门失弛缓症、食管黏膜下肿瘤内镜手术的远期随访做一综述.     

早期和浅表性食管鳞状细胞癌内镜治疗现状

食管癌目前已成为我国主要恶性肿瘤之一,其发病率和病死率逐年增加,发病原因多而复杂。早期食管鳞状细胞癌是指局限于食管黏膜层的鳞状细胞癌,而侵犯到黏膜下层的鳞状细胞癌属于浅表性食管癌。随着内镜检查的普及和技术的进步,早期和浅表性食管鳞状细胞癌的诊断率不断提高,目前内镜下治疗的方法主要有内镜下切除和非切除治疗,其中内镜下切除治疗主要有内镜下黏膜切除术、内镜下黏膜剥离术等,相对于手术治疗,内镜下切除治疗具有安全、创伤小、操作简单、并发症少等优点,提高了患者的生存质量。但对于淋巴结转移风险较大的患者,若行内镜下治疗后,建议术后密切随访。随着针对较大病变的内镜下隧道式黏膜下剥离术等技术的开展,内镜下治疗将会为早期食管肿瘤的患者提供更好的治疗方案。     

食管乳头状瘤内镜下诊治分析

目的探讨食管乳头状瘤内镜下诊断、治疗及临床特点。方法对23例经内镜及病理检查确诊为食管乳头状瘤患者的临床资料进行回顾性分析。结果食管乳头状瘤检出率为0．12％（23／19166）,无特异性临床表现,发生于食管中下段者共22例（95．65％）,伴有反流性食管炎者10例（43．48％）,经内镜下钳除、微波或高频电凝切除治疗者17例,均无明显出血及穿孔等并发症,随访6～12个月,未见复发及恶变。结论食管乳头状瘤是食管发病率较低的良性肿瘤,好发于食管中下段,其发病可能与黏膜的慢性炎性刺激等因素有关,内镜下容易治疗,且不易复发。     

黏膜下隧道技术

黏膜下隧道技术是在利用内镜下黏膜剥离术在黏膜层与肌层之间建立隧道,利用该隧道空间进行内镜下治疗的技术。黏膜下隧道技术的应用包括:(1)黏膜层疾病的治疗,如食管大面积甚至环周早癌的剥离等。(2)肌层相关病变的治疗,如黏膜下隧道内镜肿瘤切除术(STER)、内镜下食管下段环形肌切开术(POEM)等。(3)诊断与治疗胃肠道管腔外疾病,如淋巴结切除、肿瘤切除、经自然腔道内镜手术(NOTES)等。由于隧道使黏膜层切开部位和操作部位分开,术后入口易关闭,故有"黏膜安全瓣"之称。     

抗反流黏膜切除术治疗不伴有食管裂孔疝的难治性胃食管反流病的疗效分析

目的:评价抗反流黏膜切除术治疗不伴有食管裂孔疝的难治性胃食管反流病的临床疗效及安全性。方法:回顾性分析2018年1月至2020年6月苏北人民医院胃肠中心收治的不伴有食管裂孔疝的难治性胃食管反流病28例患者的临床资料,其中采用内镜下黏膜切除术（EMR）16例,内镜黏膜下剥离术（ESD）12例,比较手术前后胃食管反流症状、...     

以酸反流为主的食管溃疡临床研究现状

食管溃疡在消化道溃疡中发病率较低,本病主要由于不同病因所引起的、发生于食管各段的炎性坏死性病变,表现为食管黏膜层、黏膜下层直至肌层被破坏。因为近年来人们对疾病重视程度的提升,以及胃镜检查的普及,该病检出率呈上升趋势。食管溃疡临床症状多样、缺乏特异性表现,主要表现为胸骨后剧痛,溃疡多发或病变严重者可出现中、重度上消化道出血等。现对于食管溃疡的流行病学、病因、临床和内镜下表现,以及一般治疗和并发症治疗综述如下。     

激光致食管黏膜纤维化对套扎后食管曲张静脉复发的预防

目的探讨激光致食管下段黏膜纤维化对套扎治疗后食管静脉曲张复发的预防作用。方法对42例食管静脉曲张经多次套扎治疗后食管曲张静脉消失的患者,按入院治疗先后顺序简单随机的方法分成激光治疗组和对照组(每组21例),激光治疗组患者在套扎治疗后2周于食管下段黏膜下注射光敏剂靛氰绿溶液(1 mg／ml),用波长810 nm、功率10 W激光照射,使食管下段黏膜广泛纤维化变性,治疗后每3个月内镜复查1次,观察疗效。对照组患者在套扎治疗后不再进行其他治疗,每3个月内镜复查1次。结果激光治疗组激光治疗后食管下段5 cm范围内黏膜广泛纤维化,治疗后无出血、狭窄等并发症。术后12个月食管静脉曲张累积复发3例(14％),明显低于对照组的43％(9／21)(x2=4.20,P<0.05)。结论激光诱导食管黏膜纤维化预防套扎治疗后食管静脉曲张复发安全、有效。     

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．     

小探头超声内镜在治疗食管黏膜下肿瘤中的应用价值

食管黏膜下肿瘤是内镜检查时较常见的病变,常规内镜常无法准确判断其来源、性质和大小。盲目切除食管黏膜下肿瘤易发生穿孔及大出血等并发症。使用小探头超声内镜（miniprobe sonography,MPS）能对黏膜下肿瘤进行超声扫描,了解其结构、大小及来源,根据超声内镜检查结果决定治疗方案,降低了手术的风险,可以很好地解决上述难题。近年来,我们采用MPS对48例食管黏膜隆起性病变进行检查,现将结果分析如下,以探讨MPS在食管黏膜下肿瘤中的应用价值。     

食管功能检查的临床应用

目的 探讨食管腔内压力测定和２４小时食管ｐＨ监测在临床的应用价值。方法 用上述食管功能检查方法对：（１）胃食管反流性疾病采用内、外科不同治疗方法的比较：（２）鉴别食管源性胸痛;（３）评价抗酸药物的作用;以及（４）胆囊切除术后胃食管功能监测等。结果 通过食管功能检查完成了对上述四项内容的验证和评价,取得了良好的效果。结论 食管腔内压力测定和２４小时食管ｐＨ监测是诊断食管功能性疾病是最敏感和特异的检查     

Diagnosis of gastroesophageal reflux and Barrett esophagus

Gastroesophageal reflux is a very common disorder. Typical symptoms are heartburn, regurgitation and chest pain. Recently, it has been demonstrated that gastroesophageal reflux may generate or worse extraesophageal symptoms such as asthma, chronic bronchitis, posterior laryngitis, and chronic cough. The diagnosis of gastroesophageal reflux is suggested by typical symptoms which improve under a therapy with proton pump inhibitors. pH-monitoring over 24 hours is able to establish directly the diagnosis by measuring acid reflux into the esophagus. Manometry detects the two most common causes of gastroesophageal reflux: insufficiency of the lower esophageal sphincter or esophageal motility abnormalities. Gastroesophageal reflux can lead to reflux esophagitis, which is diagnosed endoscopically. An endoscopy should routinely be performed in case of dysphagia, anemia, or loss of weight. A long-term sequela of gastroesophageal reflux is the development of Barrett's-esophagus, a condition which has to be verified by endoscopy and biopsy. This premalignant lesion is defined by a metaplastic change from the normal squamous mucosa to a specialized intestinal epithelium characterized by goblet cells. Because dysplasia in these metaplastic areas can lead to esophageal adenocarcinoma, regular endoscopic surveillance with biopsies is recommended. Gastroesophageal reflux can significantly impair the quality of life and can cause complications that include the neoplastic progression from Barrett's esophagus to carcinoma. Therefore, appropriate diagnostic procedures and adequate therapy are required. This article summarizes the diagnostic approach to patients with gastroesophageal reflux, reflux esophagitis and Barrett's-esophagus. The impact of endoscopy, pH-monitoring, esophageal manometry, radiology and scintigraphy are reviewed.     

Technique of per-oral endoscopic myotomy (POEM) of the esophagus (with video)

Background

Per-Oral Endoscopic Myotomy (POEM) is becoming an acceptable alternative to laparoscopic cardiomyotomy for esophageal motility disorders. The aim of this video is to provide key technical steps to completing this procedure.

Method

Each patient underwent diagnostic investigations including high resolution manometry (HRM), esophageogastroduodenoscopy (EGD), and timed-barium swallow for primary esophageal motility disorders preoperatively. Patients undergoing POEM procedures are preoperatively prepared by taking Nystatin swish-and-swallow for 3 days, 24 h of clear liquid diet, and 12 h of NPO. Preoperative antibiotics are given. Under general anesthesia and with the patient in the supine position, endoscopy with CO₂ insufflation is prepared. Special endoscopic instruments and electrocautery settings are required to perform the POEM procedure, as illustrated in the slides. POEM is performed in six key/critical steps: (1) diagnostic endoscopy; (2) taking measurements; (3) esophageal mucosotomy creation; (4) submucosal tunneling; (5) selective circular myotomy of the anterior lower esophageal sphincter; and (6) closure of the mucosotomy. According to our protocol, all patients get an esophogram the next morning after surgery prior to discharge. The patient receives objective testing (HRM with 24 PH Impedance test, EGD, and timed-barium swallow) 6 months postoperatively.

Conclusion

In six key steps, POEM can be accomplished as described in the video.     

Future trends in flexible endoscopy

Over the past 20 years, flexible endoscopy has evolved from a primarily diagnostic endeavor to one of the most rapidly growing fields of therapeutic surgery. Multitudes of techniques and technologies have been developed to treat a wide spectrum of gastrointestinal diseases. Endoscopic suturing, radiofrequency energy delivery, mucosal resection, and thermal ablative techniques are among the most promising modalities in the field. Furthermore, the development of endoscopic transgastric surgery opens the door to a variety of novel intraluminal procedures. Though the ultimate role of these innovations is yet to be determined, the future of feasible surgical endoscopy holds great potential.     

胰腺癌的内镜诊治进展

目的介绍胰腺癌的内镜诊治进展。方法查阅国内、外近几年有关胰腺癌内镜诊治的文献并做综述。结果近年来,随着消化内镜的发展,特别是超声内镜,超声内镜下细针穿刺技术,逆行性胰胆管造影,内镜下胰管活检、胰液中脱落细胞检测、肿瘤标志物检测、经口胰管镜、光学相干体层摄影等技术的发展,胰腺癌的早期诊断率逐渐提高;而且对于晚期胰腺癌,内镜下可开展支架置入、放射性粒子植入、神经阻滞等多种治疗。结论消化内镜提高了胰腺癌的早期诊断率,同时为晚期胰腺癌的治疗提供了新的选择。     

Primary esophageal motility disorders (concise review for clinicians)

Primary esophageal motility disorders comprise various abnormal manometric patterns which usually present with dysphagia or chest pain. Some, such as achalasia, are diseases with a well defined pathology, characteristic manometric features, and good response to treatments directed towards the palliation of symptoms. Other disorders, such as diffuse esophageal spasm and nutcracker esophagus, have no well defined pathology and could represent a range of motility abnormalities associated with subtle neuropathic changes, gastresophageal reflux and anxiety states. On the other hand, hypocontracting esophagus is generally caused by weak musculature commonly associated with gastresophageal reflux disease. Although manometric patterns have been defined for these disorders, the relation with symptoms is poorly defined and in some cases the response to medical or surgical therapy unpredictable. The aim of this paper is to present a wide spectrum of the primary esophageal motility disorders, as well as to give a concise review for the clinicians encountering these specific diseases.     

Advances in the management of esophageal perforation

Therapy for acute esophageal perforation in the last decade has benefited from newer technology in endoscopy and imaging. Success with nonoperative therapies such as endoluminal stenting and clipping has improved outcomes and shortened length of stay in selected patients. Iatrogenic injury currently comprises most acute esophageal perforation, and nonoperative therapy may be appropriate in a significant percentage of patients. The decision regarding operative vs non-operative therapy is best done by a dedicated surgical team with experience in all the surgical and endoscopic treatment options. Boerhaave syndrome occurs less often and may be treated with endoscopic therapy, although it more likely requires operative intervention. This article reviews current advances in the diagnosis and management of acute esophageal perforation.     

Role of conservative therapy and surgical treatment in disease caused by gastroesophageal reflux

A series of 82 subjects affected with reflux esophagitis is presented. Gastroesophageal reflux and peptic esophagitis were discovered and staged by contrast meal and endoscopy with biopsy. All patients underwent medical therapy based on drugs affecting gastroesophageal motility and acidity of gastric content: this therapy was administered for three months, then was performed a control endoscopic examination. Endoscopic recovery of esophagitis allowed a long term maintenance therapy, endoscopically controlled every year. When esophagitis persisted, cycles of medical attack therapy, were repeated. surgical operation was performed in 15 cases in which either three cycles of medical therapy failed to improve esophageal lesions, or when endoscopy showed worsening esophagitis.     

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??Application status and development trend of endoscopic management in biliary toact disease LI Zhao-shen*, FANG Jun, BAI Yu.*Department of Gastroenterology, Changhai Hospital, the Second Military Medical University, Shanghai 200433, China
Corresponding authors: BAI Yu, E-mail: baiyu1998@hotmail.com; LI Zhao-shen, E-mail:zhaoshenli@hotmail.com
Abstract The application of endoscopy in the diagnosis and therapy for biliary disorders has evolved immensely. Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a purely diagnostic procedure to almost exclusively a therapeutic procedure. For example??extraction of difficult common bile duct stones, management of biliary strictures and assessment of Spyglass. Endoscopic ultrasound (EUS), which continues to be a procedure of high diagnostic yield, is becoming a therapeutic modality for management of biliary diseases. For example??EUS-guided biliary drainage (EUS-BD), removal of intrahepatic bile duct stones through EUS-guided hepaticogastrostomy.