深镇静下监测麻醉对消化内镜检查的影响分析

目的 探讨麻醉管理介入对消化内镜检查操作是否存在无痛之外的其他获益。方法对2010年9月至2015年9月在北京大学人民医院接受消化内镜检查及治疗的所有患者进行检索。依照是否实施深镇静下监测麻醉（DS-MAC）分为普通组及MAC组。选取该时段所有行上消化道内镜异物取出术的患者,对比两组的操作成功率;选取2014年9月至2015年9月所有行上消化道内镜检查的患者,对比两组食管上段胃黏膜异位的检出率;选取2014年9月至2015年9月行普通消化内镜检查及MAC消化内镜检查的术间各一间,对比两组各自然月行消化内镜检查的例数。结果MAC组操作成功率高于普通组（100.0％比89.7％,χ2=11.737,P=0.001）;MAC组食管上段胃黏膜异位检出率高于普通组（4.3％比1.7％,χ2=58.751,P＜0.001）;MAC组每月行消化内镜检查例数高于普通组［（350.2±36.2）例比（213.2±27.9）例,t=17.591,P＜0.001］。结论深镇静消化内镜检查可提高操作的成功率、精准度及操作速度,推广内镜检查过程中麻醉管理的介入是有益的。     

上消化道内镜的规范化操作

上消化道内镜能清晰地观察食管、胃、十二指肠球部、降段甚至水平段的黏膜形态及生理和病理改变,并且可以在发现病变的同时进行活体组织病理学和细胞学检查以确定诊断,因此已经成为诊断上消化道疾病的一项临床常规检查.目前在我国,上消化道内镜已经得到广泛普及,多数消化科医生已经能够顺利完成上消化道内镜检查基本操作,但由于历史原因,多数医生是经过"师带徒、手把手"的训练方式学会和掌握上消化内镜操作方法的,甚至尚有少数医生仍然采用双人操作法进行上消化道内镜检查,缺乏统一的操作规范及相应的诊断和治疗标准.部分医生对于溃疡、胃食管反流、息肉、进展期胃癌等常见疾病可以作出正确诊断,但在发现早期上消化道肿瘤方面还重视不够.而上消化道肿瘤如能在癌前病变的阶段发现并治疗,则肿瘤的早期诊断率和治愈率可望明显提高.本章着重阐述上消化道内镜在临床诊断与治疗中的规范化操作方法,对内镜检查的术前准备、适应症和禁忌症等进行了介绍,并对胃癌相关病变的检查注意事项进行了讨论.     

老年人上消化道内镜检查的特点

目的 探讨老年人上消化道内镜检查(UGE)结果的特点.方法 因上消化道症状在我院行UGE的患者共28 694例,老年组2 974例,中青年组25 720例,对两组UGE內镜表现结果进行对比分析.结果 食管炎、食管裂孔疝、食管静脉曲张、慢性萎缩性胃炎、胃窦息肉、十二指肠息肉、十二指肠憩室、胃溃疡及上消化道癌的发生率老年组较中青年组高,分别为6.96%、0.84%、2.82%、1.04%、1.51%、0.37%、0.64%、9.48%、7.06%和3.96%、0.15%、1.21%、0.36%、0.66%、0.10%、0.12%、5.57%、3.05%(P<0.001);慢性浅表性胃炎、胆汁反流性胃炎发生率老年组较中青年组低,分别为33.39%、2.08% 和44.00%、4.01%(P<0.001);慢性糜烂性胃炎、胃体胃底部息肉、十二指肠球部和球后溃疡的发生率老年组与中青年组相当分别为37.02%、2.01%、10.32%、0.50% 和35.43%、1.60%、9.30%、0.36%(P>0.05).结论 老年人UGE结果与中青人明显不同,食管病变、胃溃疡及上消化道癌增多.除非有禁忌证,对不明原因上消化道症状的老年人应尽早做UGE.     

上消化道内镜对咽喉部及食管入口检查的价值

上消化道内镜对食管、胃和十二指肠疾病的诊治价值无可质疑,但消化内镜医师如对内镜诊断涉人不深或初学者,在内镜操作时对食管入口及咽喉部疾病诊断往往容易忽视.现将我科应用电子内镜在对食管、胃和十二指肠检查过程中诊断食管入口及咽喉部疾病35例报道如下.     

内镜外套管在辅助急诊内镜治疗食管胃静脉曲张出血中的作用研究

目的 探讨内镜外套管在辅助急诊内镜治疗食管胃静脉曲张破裂出血中的作用.方法 选择临床诊断为肝硬化门静脉高压食管胃静脉曲张破裂出血患者62例作为治疗组,采用外套管辅助急诊内镜注射硬化剂治疗.另选择同期行常规急诊内镜治疗的62例食管胃静脉曲张破裂出血患者作对照组,比较两组治疗效果.结果 治疗组62例患者在行急诊内镜止血中先用外套管压迫止血均获成功,止血效率为100%,显著高于对照组的80.65%（P＜0.05） 治疗组食管胃静脉曲张注射后消失率为59.32%显著高于对照组7.27%（P＜0.05）.胸痛和食管溃疡、总住院天数、总医疗费用,治疗组显著低于对照组（P＜0.05）.结论 应用外套管辅助急诊内镜注射硬化剂治疗食管胃静脉曲张出血可提高治疗效率,减少患者负担.     

磁控胶囊内镜在37例上消化道疾病患者诊断中的临床应用

目的 探讨磁控胶囊内镜在上消化道疾病诊断中的临床应用.方法 对37例有上消化道症状的患者随机进行食管胃十二指肠镜检查和磁控胶囊内镜检查.通过体外巡航胶囊内镜控制系统对磁控胶囊内镜进行控制,完成磁控胶囊内镜对食管、贲门、胃底、胃体、胃窦和十二指肠球部的观察,并与食管胃十二指肠镜检查结果进行比较,观察磁控胶囊内镜对上消化道病变的检出率、阳性预测值、阴性预测值、敏感性以及特异性.结果 食管胃十二指肠镜检查发现病变34例,磁控胶囊内镜发现病变32例,两者检查一致率为86.5％.磁控胶囊内镜检查对上消化道病变检查的敏感性为91％,特异性为67％,阳性预测值为97％,阴性预测值为40％.结论 磁控胶囊内镜对发现上消化道病变有较高的敏感性和阳性预测值,并且检查过程无创、可控,可用于上消化道疾病的诊断.     

自制内镜外套管在治疗食管胃静脉曲张出血中的应用

目的 探讨自制内镜外套管在治疗食管胃静脉曲张出血中的成功率及并发症的预防.方法 选择食管胃静脉曲张出血患者11例,采用内径1.05 cm、外径1.35 cm,长50 cm的钢丝强化塑料套管,将塑料制成的直径3.8 cm×3.8 cm气囊固定于套管的头部,其腔与尾部的注气管相连,尾部内镜插入口有防反流垫,侧面有冲洗孔的内镜外套管套在内镜外,随内镜一起插入食管胃内边冲洗边从外套管侧孔抽出积血.如发现食管静脉出血先用外套管头部气囊压迫止血,同时在其出血灶肛侧注射硬化剂,如发现胃静脉出血用外套管气囊压迫近贲门处的食管静脉,在其出血静脉注射硬化剂止血.结果 所有患者的出血病灶经外套管冲洗后视野清晰,暴露充分,给予血管内注射硬化剂后出血全部停止.未出现误吸、穿孔等并发症.结论 在急诊内镜治疗食管胃静脉曲张破裂出血中应用外套管可有效清除积血,保持视野清晰,是提高硬化剂止血成功率的有效方法 .     

气管插管下配合无痛内镜诊治上消化道大出血60例

[目的]探讨上消化道大出血的诊治方法。[方法]110例上消化道大出血患者分为气管插管组60例和非气管插管组50例。气管插管组在气管插管下进行无痛胃镜下检查、治疗;非气管插管组在未行气管插管条件下行无痛胃镜检查、治疗。观察2组止血成功率、操作时间、并发症及死亡率。[结果]气管插管组镜下止血成功率98.3%,操作时间20～60(40±5)min,术后发热2例,无并发症及死亡患者;非气管插管组镜下止血成功率62.0%,操作时间40～80(60±8)min,术后3例发热,3例并发吸入性肺炎,无死亡患者;19例改为气管插管下操作,全部止血成功。[结论]气管插管下配合无痛内镜诊治上消化道大出血,可提高上消化道大出血内镜下止血成功率,且安全,值得尝试。     

PTVE联合PSE、内镜下硬化治疗食管胃底静脉曲张破裂出血效果分析

目的评价经皮肝穿刺胃冠状静脉栓塞术(PTVE)联合部分性脾动脉栓塞(PSE)、内镜下硬化治疗食管胃底静脉曲张破裂出血的临床效果。方法 83例肝硬化食管胃底静脉曲张出血患者随机分为联合组(42例)和内镜组(41例),联合组采取PTVE联合PSE、内镜下硬化治疗,内镜组行单纯内镜下硬化治疗,比较两组止血时间、止血成功率、再出血率以及静脉曲张和肝功能分级改善情况、不良反应发生情况等。结果联合组患者止血时间明显短于内镜组(P=0.007),而联合组止血成功率为100%,明显高于内镜组80.49%(P=0.001);联合组行EIS治疗次数为(1.3±0.4)次,明显低于内镜组的(5.7±1.6)次(P=0.000);联合组术后门脉压力较术前显著降低,而内镜组则略有升高(P=0.000);6、12个月时联合组再出血率分别为4.76%、7.14%,均明显低于内镜组19.51%、24.39%(P均0.05);联合组术后12个月中重度食管静脉曲张率为19.05%,明显低于内镜组48.78%(P=0.004);联合组术后12个月肝功能Child-Pugh分级改善1级或1级以上者17例,改善率40.48%,内镜组8例,改善率21.95%,两组比较差异有统计学意义(P=0.037);两组患者均未出现明显的不良反应情况。结论 PTVE联合PSE、内镜下硬化是治疗食管胃底静脉曲张破裂出血安全、有效的方法。     

上消化道异物内镜取出失败的相关因素分析

目的分析上消化道异物内镜取出失败的相关因素。方法选取2002年1月-2012年12月在汕头市中心医院消化内镜中心接受治疗的上消化道异物患者,用Excel表格收集资料,包括异物种类、异物所滞留部位、异物吞入到就诊的时间、取异物术前相关检查、误吞异物人员构成、是否麻醉下手术、术中是否使用透明帽、手术医师年资。统计异物取出成功和失败例数,分析内镜下上消化道异物取出失败的影响因素。结果 367例患者中,成功取出上消化道异物346例,成功率为94.3%,取出失败21例,失败率为5.7%。经多因素Logistic回归分析,影响异物取出失败的相关因素有5项:金属异物、异物滞留食管、吞服异物24 h、无术前检查、内镜无透明帽。结论金属异物、异物滞留食管、吞服异物24 h、无术前检查、内镜无透明帽等是上消化道异物取出失败的独立影响因素。做好充分的术前准备、及时进行内镜手术、术中使用透明帽等是控制失败率的关键。     

Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial

BACKGROUND: Changes in medical practice have constrained the time available for education and the availability of patients for training. Computer-based simulators have been devised that can be used to achieve manual skills without patient contact. This study prospectively compared, in a clinical setting, the efficacy of a computer-based simulator for training in upper endoscopy. METHODS: Twenty-two fellows with no experience in endoscopy were randomly assigned to two groups: one group underwent 10 hours of preclinical training with a computer-based simulator, and the other did not. Each trainee performed upper endoscopy in 19 or 20 patients. Performance parameters evaluated included the following: esophageal intubation, procedure duration and completeness, and request for assistance. The performance of the trainees also was evaluated by the endoscopy instructor. RESULTS: A total of 420 upper endoscopies were performed; the computer pretrained group performed 212 and the non-pretrained group, 208. The pretrained group performed more complete procedures (87.8% vs. 70.0%; p < 0.0001), required less assistance (41.3% vs. 97.9%; p < 0.0001), and the instructor assessed performance as "positive" more often for this group (86.8% vs. 56.7%; p < 0.0001). The length of procedures was comparable for the two groups. CONCLUSIONS: The computer-based simulator is effective in providing novice trainees with the skills needed for identification of anatomical landmarks and basic endoscopic maneuvers, and in reducing the need for assistance by instructors.     

Computer-based virtual reality colonoscopy simulation improves patient-based colonoscopy performance

BACKGROUND:

Colonoscopy simulators that enable one to perform computer-based virtual colonoscopy now exist. However, data regarding the effectiveness of this virtual training are limited.

OBJECTIVE:

To determine whether virtual reality simulator training translates into improved patient-based colonoscopy performance.

METHODS:

The present study was a prospective controlled trial involving 18 residents between postgraduate years 2 and 4 with no previous colonoscopy experience. These residents were assigned to receive 16 h of virtual reality simulator training or no training. Both groups were evaluated on their first five patient-based colonoscopies. The primary outcome was the number of proctor ‘assists’ required per colonoscopy. Secondary outcomes included insertion time, depth of insertion, cecal intubation rate, proctor- and nurse-rated competence, and patient-rated pain.

RESULTS:

The simulator group required significantly fewer proctor assists than the control group (1.94 versus 3.43; P≤0.001), inserted the colonoscope further unassisted (43 cm versus 24 cm; P=0.003) and there was a trend to intubate the cecum more often (26% versus 10%; P=0.06). The simulator group received higher ratings of competence from both the proctors (2.28 versus 1.88 of 5; P=0.02) and the endoscopy nurses (2.56 versus 2.05 of 5; P=0.001). There were no significant differences in proctor-, nurse- or patient-rated pain, or attention to discomfort.

CONCLUSIONS:

Computer-based colonoscopy simulation in the initial stages of training improved novice trainees’ patient-based colonoscopy performance.     

The safety of intubation in patients with esophageal varices

Twenty-four alcoholic cirrhotic patients with esophageal varices and recent cessation of upper gastrointestinal bleeding were studied. All had flexible fiberoptic endoscopy, and many had nasogastric intubation for tamponade or lavage within 48 hours following the bleeding episode. In 22 patients endoscopy revealed esophageal varices to be the source of bleeding; of the 2 remaining, 1 had acute erosive gastritis and 1 a duodenal ulcer. No bleeding occurred in any of these patients subsequent to the procedures. No other complications related to the procedure developed. Fear of esophageal intubation in the presence of varices is not based on factual data.     

Evaluation of hands-on training in colonoscopy: Is a computer-based simulator useful?

Background and aimsThe advantages of using a computer-based simulator during colonoscopy training are debated. We aimed to explore its usefulness in objectively measuring trainees’ competence in colonoscopy.MethodsTwelve colonoscopy trainees (fully trained in upper GI endoscopy) were evaluated using a computer-based simulator (GI-Mentor, Symbionix) before and during hands-on training (i.e. after 60 colonoscopies); the controls were 15 experts (>90% of caecal intubation). Both trainees and experts performed two “screening” simulations (easy and difficult) in a randomised order, and the time to reach the caecum and withdrawal time was assessed.ResultsThe percentage of caecal intubation progressively increased during hands-on training. All of the trainees intubated the caecum during the easy and difficult simulations, both before and during hands-on training. The median time (interquartile range) to reach the caecum upon easy simulation was the only variable influenced by hands-on training: 2.7 min (2.1–3.2) before and 1.9 min (1.6–2) during training (p < 0.01). Withdrawal time was ≥6 min in the case of five trainees before training, and three during hands-on training. Computer-based simulator performance did not correlate with hands-on training performance.ConclusionsThe computer-based simulator was not found to be useful in evaluating competence during hands-on training in colonoscopy.     

A prospective controlled study of the risk of bacteremia in emergency sclerotherapy of esophageal varices

Reported incidences of bacteremia after endoscopy with esophageal variceal sclerotherapy are conflicting. A prospective controlled study was conducted to determine the frequency of bacteremia after emergency endoscopy with esophageal variceal sclerotherapy compared with frequency after elective esophageal variceal sclerotherapy and after emergency endoscopy in patients with upper gastrointestinal bleeding from nonvariceal sources. A total of 126 endoscopies were studied in 72 patients. Groups consisted of (a) emergency endoscopy without esophageal variceal sclerotherapy, 37 sessions with 36 patients; (b) elective esophageal variceal sclerotherapy, 33 sessions with 14 patients; and (c) emergency esophageal variceal sclerotherapy, 56 sessions with 36 patients. Blood cultures were obtained before and 5 and 30 minutes after endoscopy. There was a higher frequency of preendoscopic bacteremia in emergency esophageal variceal sclerotherapy (13%) than in emergency endoscopy alone (0%) (P = 0.02). Clinically significant bacteremia in emergency esophageal variceal sclerotherapy was observed in 7 of 56 (13%) sessions, compared with 0 of 33 in elective esophageal variceal sclerotherapy (P = 0.03) and 1 of 36 (3%) in emergency endoscopy alone (P = 0.45). Of these cases, 3 (5.4%) were potentially caused by emergency esophageal variceal sclerotherapy, but not clinically significant postendoscopic bacteremia was attributable to the procedure in the other groups.     

Topical pharyngeal anesthesia does not improve upper gastrointestinal endoscopy in conscious sedated patients

OBJECTIVE: We undertook this study to determine whether topical pharyngeal anesthesia with conscious sedation is superior to conscious sedation alone, with respect to procedure performance or tolerance in patients undergoing diagnostic upper gastrointestinal endoscopy. METHODS: Ninety-five patients undergoing diagnostic upper endoscopy with conscious sedation were randomized to receive either topical pharyngeal anesthesia with 2% tetracaine/14% benzocaine spray or no pharyngeal anesthesia. Conscious sedation was achieved in all patients using intravenous midazolam and meperidine. Patients were asked to rate their pretest anxiety, comfort during endoscopy, recollection of the procedure, and willingness to undergo subsequent examinations using a 100-mm visual analog scale. Additionally, they were asked to estimate procedure duration and rate their tolerance for topical pharyngeal anesthesia. All examinations were performed by two endoscopists who were blinded to whether or not patients had received pharyngeal anesthesia. Endoscopists were asked to determine whether they believed that patients had received topical pharyngeal anesthesia and to estimate ease of esophageal intubation and procedure performance using a 100-mm visual analog scale. Procedure duration and doses of midazolam and meperidine were measured. RESULTS: The two groups did not differ with respect to age, gender, and previous endoscopic history. There were no significant differences between the two groups with respect to pretest anxiety, procedural comfort, and willingness to undergo subsequent examinations. Patients receiving topical pharyngeal anesthesia rated it as moderately unpleasant. Endoscopists were able to discriminate patients who received pharyngeal anesthesia from those who did not with a sensitivity of 0.73 and a specificity of 0.59. There were no significant differences between the two groups with respect to ease of intubation, procedure performance, procedure duration, and dosing of midazolam or meperidine. CONCLUSIONS: In patients undergoing diagnostic upper endoscopy using intravenous midazolam and meperidine, the use of topical pharyngeal anesthesia does not improve patient tolerance or procedure performance. Elimination of this agent in the performance of diagnostic upper endoscopy will save time and money without adversely affecting patient care or outcomes.     

Gastroduodenal peptic ulcers, duodenal adhesions, and upper gastrointestinal motility disturbances in patients who have undergone cholecystectomy

The frequency of duodenal and gastric ulcer disease, the thickness of the pyloric muscle, and adhesions of the duodenum were evaluated in a routine, consecutive, prospective autopsy series of 100 patients, and the length of the pyloric canal, adhesions of the duodenum, and motility disturbances in the upper gastrointestinal series were studied in a separate radiologic material of 69 symptomatic patients with cholecystectomy in their history. Both series were compared with matched unoperated controls. The frequency of active gastric ulcers and ulcer scars was observed to be increased and that of active duodenal ulcers and ulcer scars decreased among the cholecystectomized patients in the autopsy series (p = 0.01 in both cases). This difference was not as pronounced when only active ulcers were included, but for active duodenal ulcers the difference was still significant (p = 0.04). One-fourth of the cholecystectomized patients but none of the controls had severe adhesions of the duodenum. In the autopsy series the thickness of the pyloric muscle and in the radiologic series the length of the radiologic pyloric canal were thickened/lengthened in an average of 26%/11% in patients who had undergone cholecystectomy (p less than 0.001 and p less than 0.10, respectively). The lengthening of the pyloric canal was in significant positive correlation with the motility disturbance/adhesion score of the upper gastrointestinal series.(ABSTRACT TRUNCATED AT 250 WORDS)     

上消化道胶囊内镜发展与创新北大核心CSCD

上消化道疾病高发,传统插管式胃镜是检查上消化道疾病最常用的检查方法和"金标准"。为了更舒适无创的检查上消化道黏膜,多项研究提出了上消化道胶囊内镜的概念,但是由于上消化道各部位解剖与生理结构的差异,目前可以使用的胶囊内镜如单纯被动式、磁控式、线控式、磁控联合线控式以及侧视胶囊内镜都存在一定的局限性,无法实现对上消化道整体黏膜情况的观察。文章试图通过介绍适用于食管、胃以及十二指肠检测的胶囊内镜,分析各内镜的诊断效能及其不足,探讨未来上消化道胶囊内镜可能的发展方向。     

Prevalence of upper gastrointestinal tract findings in patients with noncardiac chest pain versus those with gastroesophageal reflux disease (GERD)-related symptoms: results from a national endoscopic database

BACKGROUND: Available data on the prevalence of esophageal and upper gut findings in patients with noncardiac chest pain (NCCP) are scarce and limited to one center's experience. AIM: To determine the prevalence of esophageal and upper gut mucosal findings in patients undergoing upper endoscopy for NCCP only versus those with gastroesophageal reflux disease (GERD) symptoms only, using the national Clinical Outcomes Research Initiative (CORI) database. METHODS: During the study period, the CORI database received endoscopic reports from a network of 76 community, university, and Veteran Administration Health Care System (VAHCS)/military practice sites. All adult patients who underwent an upper endoscopy for NCCP only or GERD-related symptoms only were identified. Demographic characteristics and prevalence of endoscopic findings were compared between the two groups. RESULTS: A total of 3,688 consecutive patients undergoing an upper endoscopy for NCCP and 32,981 for GERD were identified. Normal upper endoscopy was noted in 44.1% of NCCP patients versus 38.8% of those with GERD (P<0.0001). Of the NCCP group, 28.6% had a hiatal hernia (HH), 19.4% erosive esophagitis (EE), 4.4% Barrett's esophagus (BE), and 3.6% stricture/stenosis. However, HH, EE, and BE were significantly more common in the GERD group as compared with the NCCP group (44.8%, 27.8%, and 9.1%, respectively, P<0.0001). In univariate analysis of patients with NCCP, male gender was a risk factor for BE (OR 1.86, 95% CI 1.35-2.55, P=0.0001) and being nonwhite was protective (OR 0.43, 95% CI 0.22-0.86, P=0.02). In this group, male gender was also a risk factor for EE (OR 1.31, 95% CI 1.11-1.54, P=0.001) and age>or=65 yr was protective (OR 0.73, 95% CI 0.6-0.89, P=0.002). The NCCP group had a significantly higher prevalence of peptic ulcer in the upper gastrointestinal tract as compared with the GERD group (2.0% vs 1.5%, P=0.01). CONCLUSIONS: In this endoscopic prevalence study, most of the endoscopic findings in NCCP were GERD related, but less common as compared with GERD patients.     

经皮经肝组织胶栓塞治疗食管静脉曲张与内镜下套扎治疗的疗效比较

目的比较经皮经肝α氰基丙烯酸正辛酯（TH胶）栓塞术（PTVE）与内镜下食管静脉套扎术（EVL）治疗食管静脉曲张的临床疗效。方法急性及近期食管胃静脉曲张出血的肝硬化患者随机分成PTVE组（52例）及EVL组（50例）进行干预治疗,观察术后上消化道再出血率、食管曲张静脉复发率及生存率。结果随访期间（PTVE组平均24个月,EVL组25个月）两组的上消化道再出血率分别为15．4％（8／52）和42％（21／50）（χ^2=8．87,P=0．005）,其中食管曲张静脉再出血率为5．8％（3／52）和24％（12／50）（χ^2=5．38,P=0．012）,两组食管静脉曲张复发率分别为17．3％（19／52）和52％（26／50）（χ^2=13．61,P〈0．001）,两组生存率相似,（χ^2=3．30,P=0．054）。结论PTVE能使曲张静脉及其穿支静脉和贲门胃底静脉周围静脉一并栓塞,术后食管静脉曲张的再出血率低于EVL治疗,具有较好临床价值。