窄带成像技术联合放大内镜与胃镜活检诊断早期胃癌的价值比较

目的:评估比较窄带成像技术联合放大内镜(narrow band imaging-magnifying endoscopy N B I-M E)、内镜病理活检在早期胃癌诊断中的价值.方法:首先在普通白光下系统观察,发现可疑病变(胃黏膜形态或颜色改变)后行NBIME观察,采集照片并做出内镜下诊断,于病灶最明显处取活检并行病理检查.所有患者均行内镜下切除或外科手术治疗,术后行病理活检.分别计算NBI-ME、内镜活检诊断早期胃癌的敏感度、特异度、阳性预测值、阴性预测值、准确率.比较内镜活检与术后切除病理的一致性,并计算Kappa值.结果:123例纳入本研究,最终术后切除病理示胃炎51例,低级别上皮内瘤变(low-grade neoplasia,LGIN)24例,早期胃癌48例.NBIM E诊断早期胃癌的敏感度、特异度、阳性预测值、阴性预测值、准确率分别为97.9%、80.0%、75.8%、98.4%、87.0%,内镜活检的对应值分别为66.7%、94.7%、88.9%、81.6%、83.7%.NBI-ME诊断早期胃癌的敏感度明显高于内镜活检(P0.005),特异度低于内镜活检(P0.005),两者准确率无明显差异(P0.05).内镜下活检病理与术后切除病理Kappa值为0.642(P0.05).结论:NBI-ME对早期胃癌诊断价值较高,对于NBI-ME下符合早期胃癌诊断的患者建议行内镜或手术进一步治疗.     

蓝激光放大内镜VS分型对胃部癌前病变及早期癌的诊断价值

目的评价蓝激光放大内镜VS分型对胃部癌前病变及早期癌的诊断价值。方法2014年1月至2017年1月间,于武汉大学人民医院消化内镜中心行蓝激光胃镜检查发现胃黏膜病变,并取活检或行内镜黏膜下剥离术大块活检的313例患者（322处病变）纳入回顾性研究,统计蓝激光放大内镜VS分型诊断胃部癌前病变及早期癌的准确率、灵敏度、特异度、阳性预测值、阴性预测值。结果322处病变,病理诊断癌性病变57处、非癌性病变265处。蓝激光放大内镜下,98.2％（56／57）的癌性病变VS形态不规则／消失,100.0％（57／57）的癌性病变有清晰的分界线。以病理诊断为金标准,蓝激光放大内镜VS分型诊断的准确率为93.8％（302／322）,Kappa=0.810,一致性好;灵敏度、特异度、阳性预测值、阴性预测值分别为98.2％（56／57）、92.8％（246／265）、74.7％（56／75）、99.6％（246／247）。结论蓝激光放大内镜VS分型诊断胃部癌前病变及早期癌的准确率、灵敏度、特异度均较高,是诊断胃部癌前病变及早期癌的有效方式之一。     

共聚焦激光显微内镜对胃非隆起型病变的诊断价值

目的探讨共聚焦激光显微内镜检查（CLE）对胃非隆起性病变良、恶性的鉴别诊断价值。方法对37例常规内镜发现的胃非隆起型病变患者行CLE检查。静脉注射荧光素钠后对病变区域进行观察,然后进行靶向活检。对CLE或靶向活检病理诊断为恶性病变者进行内镜或手术治疗,术后对整块标本进行病理学检查;对良性患者予规范药物治疗并每隔3个月复查胃镜,直至病变愈合。结果CLE诊断癌性病变11例,良性病变26例。靶向活检病理证实CLE诊断的11例癌变者中10例为癌,1例为良性;26例良性者中1例为癌,余皆为良性。共12例接受切除治疗（3例内镜治疗,9例外科手术）,术后病理学证实与靶向活检病理诊断完全一致。良性者随访中未发现有恶变,经平均3．16（3．58±1．20）个月的内镜随访,病变均愈合。CLE对胃非隆起性病变癌变诊断的灵敏度、特异度和准确度分别为90．9％、96．2％和90．9％,阳性预测值和阴性预测值分别为90．9％和96．2％;CLE与组织学检查的Kappa值为0．871。结论CLE对胃非隆起型病变具有较高的诊断价值,将有望替代活检病理做出实时组织学诊断。     

共聚焦显微内镜对胃癌及癌前期病变的实时病理诊断价值

目的 了解共聚焦显微内镜(CLE)实时诊断胃癌及癌前病变的准确性及与最终病理诊断间的一致性。方法2010年1月至2011年3月间,在上海交通大学医学院附属瑞金医院消化科门诊及住院患者中筛选临床疑及胃癌或癌前病变者进行CLE检查,检查中使用荧光素钠作为荧光剂。采用四级诊断标准对CLE图像进行实时诊断,并据此对病灶行导向活检。对CLE确诊或高度疑为恶性的病变行外科手术治疗。总结常规内镜、CLE及最终病理诊断情况。结果总计160例患者纳入研究,其中1例因荧光素钠过敏而未能完成检查,其余159例患者完成CLE检查。总被检病灶194个,病灶数共计1、2、3个者分别有130、23、6例。CLE总体诊断准确率93.3％(181/194)。CLE对恶性病变的诊断敏感度为93.6％,特异度为99.3％。CLE与最终病理诊断间的一致性良好(Kappa值=0.876)。荧光素钠相关严重不良反应发生率仅0.6％(1/160)。结论CLE检查可精确判定胃癌及癌前病变,与组织病理学一致性良好,对胃癌早期诊断、避免漏诊或误诊具重要意义。     

82例胃黏膜高级别上皮内瘤变患者中鉴别浸润性胃癌的临床研究

目的 应用常规内镜及共聚焦激光显微内镜(CLE)对胃黏膜高级别上皮内瘤变(HGIEN)患者病灶行再次检查,从中鉴别浸润性胃癌.方法 选取2005年1月至2010年12月间上海交通大学医学院附属瑞金医院消化科82例胃镜活检病理检查为HGIEN者,男性61例,女性21例,其中38例行普通胃镜检查,44例除普通胃镜检查外还接受了CLE检查.对比内镜活检病理诊断,符合指征者行手术及病理学检查.结果 82例患者中经复查证实,良性溃疡或炎性反应8例(24.4％),胃黏膜低级别上皮内瘤变12例(14.6％),HGIEN 10例(12.2％),浸润性胃癌52例(63.4％).浸润性胃癌患者中分化型癌36例,未分化型癌16例.CLE诊断为浸润性胃癌的21例中,17例(81.0％)与病理学诊断一致,CLE诊断与病理诊断一致性参数κ值=0.7250.结论 从内镜活检病理诊断胃黏膜HGIEN患者中鉴别浸润性胃癌是必要的.     

共聚焦激光显微内镜对胃部溃疡型病变的鉴别诊断价值

目的 评价共聚焦激光显微内镜(confoeal laser endomicroscopy,CLE)对胃部溃疡型病变的鉴别诊断价值.方法 将CLE普通内镜模式下诊断为胃部溃疡型病变的患者纳入研究,转为CLE共聚焦内镜模式.对溃疡边缘和(或)表面黏膜进行扫查.随后对相同部位行黏膜活检.将CLE检查结果 与病理组织学结果 进行对比.结果 共43例患者入选,扫查部位150个,获得图像12 769幅.与病理组织学结果 比较,CLE诊断炎性病变的敏感度为83.54%、特异度为85.92%、阳性预测值为86.84%、阴性预测值为82.43%;诊断上皮内瘤变的敏感度为53.57%、特异度为88.52%、阳性预测值为51.72%、阴性预测值为89.26%;诊断胃癌的敏感度为88.37%、特异度为93.46%、阳性预测值为84.44%、阴性预测值为95.24%.在CLE与病理诊断的一致性检验中,对于炎性病变的κ值为0.69,上皮内瘤变的κ值为0.42,胃癌的κ值为0.81.结论 CLE对于胃部溃疡型病变的组织学类型可作出即刻诊断,其诊断的敏感度、特异度、阳性预测值、阴性预测值均较高,有利于指导靶向活检,提高癌前病变及胃癌的检出率.     

蓝激光成像结合放大内镜对早期胃癌及癌前病变的诊断价值

目的 评价蓝激光成像（BLI）结合放大内镜对早期胃癌及癌前病变的诊断价值。 方法 2015年9月至2016年5月对普通白光内镜（WLE）依据黏膜形态或色泽发生异常改变筛查出的249处局灶性病变分别行白光单独放大、BLI-contrast放大和BLI-bright放大检查,依据VS诊断标准评估内镜表现,以组织活检的病理诊断为金标准,采用Kappa一致性检验评价白光单独放大、BLI-contrast放大、BLI-bright放大镜下诊断与病理诊断的一致性;采用McNemar配对卡方检验,比较BLI-contrast放大、BLI-bright放大与白光单独放大镜下诊断的效果。 结果 活检病理结果显示,249处病灶中慢性胃炎149处,肠上皮化生67处,低级别上皮内瘤变8处,高级别上皮内瘤变或早期胃癌25处。白光单独放大、BLI-contrast放大、BLI-bright放大镜下诊断与病理诊断一致的病灶分别占76.7％、85.1％、86.7％,Kappa值分别为0.571、0.730、0.760。对于高级别上皮内瘤变或早期胃癌的筛查,白光单独放大、BLI-contrast放大、BLI-bright放大镜下诊断的敏感度分别为72.0％、92.0％、92.0％,特异度分别为95.5％、98.2％、99.1％,一致性分别为93.2％、97.6％、98.4％,Kappa值分别为0.642、0.871、0.911。与白光单独放大比较,BLI-contrast放大和BLI-bright放大镜下诊断与病理诊断的一致性明显升高（P＜0.05）;在诊断高级别上皮内瘤变或早期胃癌时,BLI-contrast放大和BLI-bright放大镜下诊断与病理诊断的一致性较白光单独放大提高（P＜0.05）。 结论 BLI结合放大内镜可提高内镜下诊断早期胃癌及癌前病变的的准确性。     

大样本前瞻性研究共聚焦激光显微内镜对胃黏膜表浅性病变的诊断价值

普通内镜对胃黏膜表浅性肿瘤的诊断存在困难,往往发现病变后需要进行活组织病理检查最终获得诊断.共聚焦激光显微内镜(confocal laser endomicroscopy,CLE)是近年出现的新型内镜技术,主要包括探针式CLE (probe-based CLE,pCLE)和整合型CLE(integrated CLE,iCLE),可以在普通内镜检查的同时观察组织的显微结构,无需活检即可做出组织学诊断.本研究拟建立iCLE对胃黏膜浅表性病变的诊断标准,并评价iCLE的诊断价值.     

美蓝染色对提高胃黏膜不典型病变活检阳性率的价值

目的探讨内镜下美蓝染色对胃黏膜不典型病变中早期胃癌及其癌前病变的诊断价值。方法将326例胃黏膜表现不典型的成人患者随机分成染色内镜组和普通内镜组，分别在病变部位活检送病理组织学检查。结果染色内镜组166例患者中，印例胃黏膜上皮有肠化、50例上皮呈轻度-中度不典型增生、8例为重度不典型增生、8例为早期胃癌且经手术及术后病理证实病灶仅限于黏膜层且无淋巴结转移。普通内镜组160例，病理检查结果为伴有肠上皮化生40例、轻-中度不典型增生20例、重度不典型增生2例，无早期胃癌。染色内镜组早癌及癌前病变总检出率为75．9％，其中早期胃癌检出率为12．1％，均明显高于普通内镜组。结论内镜下美蓝染色指导活检可提高胃黏膜不典型增生和早期胃癌的检出率。     

蓝激光内镜联动成像模式对幽门螺杆菌感染相关性胃炎的诊断价值

目的 评价蓝激光内镜联动成像（LCI）观察模式在幽门螺杆菌（HP）感染相关性胃炎诊断中的价值。方法 2016年11月至2017年6月间,在南方医科大学深圳医院行蓝激光内镜检查诊断为慢性胃炎的40例患者作为研究对象,分别应用蓝激光内镜普通白光和LCI模式观察全胃黏膜外观形态,白光模式下依据慢性胃炎活检病理诊断共识取材,LCI模式下于异常发红部位取材,并行13碳尿素试验。使用Kappa分析检验2种方法与最终病理诊断的一致性,使用配对卡方检验分析2种方法间一致性的差异。结果 白光模式预测HP感染的阳性预测值为54.5％（6／11）,与最终病理诊断的一致性为0.475（19／40）,Kappa=0.635;LCI模式预测HP感染的阳性预测值为81.5％（22／27）,与最终病理诊断的一致性为0.875（35／40）,Kappa=0.741;配对卡方检验提示,预测结果与最终病理诊断的一致性2种内镜模式间差异有统计学意义（P＜0.01）。40例均行13碳尿素试验,阳性19例,其中1例LCI模式下活检病理诊断为HP阴性;13碳尿素试验阴性21例,其中4例LCI模式下活检病理诊断为HP阴性： 两者诊断一致性良好,Kappa=0.751。黏膜存在红白边界,白光模式0例、LCI模式15例;黏膜弥漫发红,白光模式0例、LCI 模式11例：白光模式下黏膜外观形态与蓝光LCI模式下黏膜外观形态相比较,经秩和检验提示差异具有统计学意义（Z=-4.455,P＜0.01）。结论 蓝激光内镜LCI观察模式较白光模式可明显提高HP感染相关性胃炎的诊断率,具有较好的临床使用价值。     

Human gastric myoelectric activity and gastric emptying following gastric surgery and with pacing.

Postoperative gastric myoelectric activity, gastric emptying, and clinical course were correlated in 17 patients at high risk of developing gastroparesis after gastric surgery. In addition, an attempt was made to pace the stomach with an electrical stimulus and determine the effect of pacing on early postoperative gastric emptying. Gastric dysrhythmias (bradygastria, slow wave frequency < 2 cycles/min; tachygastria, slow wave frequency > 4 cycles/min) persisted beyond the first postoperative day in 6 patients (35%). Delayed gastric emptying was identified by a radionuclide meal in 15 patients (88%), but symptoms of gastroparesis developed in only 6 of 15 (40%). Patients with postoperative gastroparesis had more frequent dysrhythmias than asymptomatic patients (67% vs. 18%), but these differences were not significant, although we cannot exclude a type II statistical error. Gastric rhythm was entrained in 10 of 16 patients (63%). Pacing increased the gastric slow wave frequency (3.1 vs. 4.1 cycles/min; P < 0.01) but did not improve gastric emptying (gastric retention at 60 minutes, 86% +/- 6% for control and 90% +/- 2% for paced). In conclusion, gastric dysrhythmias do not appear to play a major role in the development of postsurgical gastroparesis. Although gastric rhythm could be entrained in the majority of patients, pacing did not improve gastric emptying overall.     

胃微生态与胃癌的研究进展

胃微生态平衡是人体健康的重要前提,幽门螺杆菌(Helicobacter pylori,Hp)是目前已发现的与胃癌相关的关键病原体之一,普遍存在于人胃黏膜上皮。Hp感染可引起胃内其他菌群的改变,还可引起长期慢性的胃黏膜损伤,导致一系列胃黏膜上皮恶性进展和胃癌的发生。本文就胃微生态与Hp感染的关系、Hp感染在胃癌发生中的作用、胃内其他菌群在胃癌发生中的作用及微生态制剂在胃癌治疗的作用进行综述。进一步揭示Hp感染对胃微生态平衡的影响,胃微生态平衡和Hp感染在胃癌发生发展中的作用及微生态制剂在胃癌治疗中的意义。     

The relationship between gastric microbiota and gastric disease

Traditionally, the stomach was believed to be a sterile organ unsuitable for microbiota growth. However, the discovery of H. pylori subverted this conception. With the development of molecular techniques, an abundance of microbiota of great diversity was found in the stomach. In addition, various lines of evidence suggest that the gastric microbiota plays a critical role in the development and progression of the gastric disease.The gastrointestinal microbiome plays an important role in various physiologic and pathologic processes.     

Endoscopy,gastric ulcer,and gastric cancer

The practice of following benign-appearing gastric ulcers until healing was critically evaluated in a retrospective manner by reviewing all gastric ulcers that were followed with serial endoscopy and all gastric cancers diagnosed at the University of Alabama at Birmingham. The stated purpose of following ulcers to healing is to detect those gastric cancers that may be masquerading as benign ulcer and were not correctly diagnosed at initial endoscopy. Over a five-year period, 148 gastric ulcers were followed with serial endoscopy and in no case was an unsuspected carcinoma found at follow-up endoscopy. In addition, of 67 gastric cancers diagnosed between 1979 and 1986, 62 were suspected of being malignant by the endoscopist at initial examination for an accuracy of 92%. The accuracy rate based solely on biopsy and/or brush cytology was 94%. When endoscopic and biopsy and/or cytology impressions were combined, only one case of gastric carcinoma was not suspected. The overall accuracy was 99%. These results suggest that if either the endoscopic impression or the biopsy and cytology is suspicious for malignancy, then follow-up endoscopy until healing should be done. On the other hand, if, at the initial examination, the ulcer appears benign and biopsy plus cytology are negative, then serial endoscopy has a low benefit relative to its cost.     

Relationship between gastric mucosal hemodynamics and gastric motility

Continuous measurement of gastric mucosal hemodynamics (the index of mucosal hemoglobin concentration, the index of oxygen saturation and blood flow) in rats showed oscillatory changes. The mechanism of the oscillations was investigated using a probe specially designed for simultaneous measurement of hemodynamics and intragastric pressure. A hemodynamics-measuring probe for either reflectance spectrophotometry or laser-Doppler flowmetry was tied to a pressure microtransducer, inserted through an incision in the forestomach, and brought into gentle contact with the corpus mucosa. Synchronous oscillatory changes (4-6 cycles/min) in hemodynamics and motility were observed in the resting state (mean blood pressure: 120 mmHg). During moderate hemorrhagic hypotension (mean: 81 mmHg), oscillations in the hemodynamics increased in both amplitude and frequency, while motility remained constant. Oscillations in the hemodynamics were also affected by fluctuations in blood pressure and by topical application of norepinephrine to the corpus serosa. In water-immersion restraint rats, changes in the oscillations in the hemodynamics and motility were virtually synchronous; frequency decreased and amplitude increased. These findings suggest that oscillatory changes in gastric mucosal hemodynamics are regulated not only by gastric motility but also by arteriolar vasomotion of the gastric wall.     

Relationship between gastric mucosal hemodynamics and gastric motility

Continuous measurement of gastric mucosal hemodynamics (the index of mucosal hemoglobin concentration, the index of oxygen saturation and blood flow) in rats showed oscillatory changes. The mechanism of the oscillations was investigated using a probe specially designed for simultaneous measurement of hemodynamics and intragastric pressure. A hemodynamics-measuring probe for either reflectance spectrophotometry or laser-Doppler flowmetry was tied to a pressure microtransducer, inserted through an incision in the forestomach, and brought into gentle contact with the corpus mucosa. Synchronous oscillatory changes (4-6 cycles/min) in hemodynamics and motility were observed in the resting state (mean blood pressure: 120 mmHg). During moderate hemorrhagic hypotension (mean: 81 mmHg), oscillations in the hemodynamics increased in both amplitude and frequency, while motility remained constant. Oscillations in the hemodynamics were also affected by fluctuations in blood pressure and by topical application of norepinephrine to the corpus serosa. In water-immersion restraint rats, changes in the oscillations in the hemodynamics and motility were virtually synchronous; frequency decreased and amplitude increased. These findings suggest that oscillatory changes in gastric mucosal hemodynamics are regulated not only by gastric motility but also by arteriolar vasomotion of the gastric wall.     

The electrophoretic pattern of normal human gastric juice and of the gastric juice of patients with gastric ulcer and gastric cancer

This study reports the electrophoretic pattern of the proteins in human gastric juice of control patients and patients with gastric ulcer and gastric carcinoma. Autodigestion was prevented by intragastric neutralization. The statistical limits of normal are defined and the changes found in the gastric juice of gastric ulcer and gastric patients with gastric carcinoma described.