食管动力性疾病的内镜诊治

食管动力性疾病包括贲门失弛缓症和胃食管反流病．是临床上常见的一组疾病．严重影响患者的生活质量。虽然食管测压为食管动力性疾病诊断的金标准,但消化内镜在该类疾病的诊断中发挥着重要作用。随着光学和机械学的革新．内镜器械得到了迅猛发展．目前已发展成为兼具治疗的检查手段。本文结合国内外最新研究进展．就近年来发展的内镜下黏膜切除术、内镜下黏膜下层剥离术和经口内镜下肌切开术等技术对食管动力性疾病的临床应用价值进行阐述。     

胃食管反流病的治疗进展

胃食管反流病是由胃内容物反流引起的症状或并发症,是一种常见的消化系统疾病。随着饮食结构的变化,胃食管反流病的发病率近年来呈上升趋势。目前,胃食管反流的治疗手段主要包括心理干预、药物治疗、内镜下治疗和外科手术。新技术的出现,为食管反流病的治疗带来更多的希望。     

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。     

天津市南开医院、天津市微创外科中心腹腔镜、内镜培训班招生通知

天津市微创外科中心是国内最早开展内镜和腹腔镜治疗的单位之一,经过30余年的发展在内镜ERCP诊治胆管、胰腺疾病,腹腔镜治疗复杂性肝、胆、胰、脾、胃肠疾病,以及胃食管返流性疾病（返流性食管炎、食管裂孔疝）、贲门失迟缓症、微创减肥术（内镜胃内水球、腹腔镜可调节胃束带术、腹腔镜袖套式胃减容术）等方面积累了丰富经验。年完成内镜ERCP 1 600例、各类腹腔镜手术2 000例。     

外科治疗食管憩室10例临床分析

目的探讨食管憩室的诊断、手术适应证、手术方式和疗效。方法回顾分析1991年9月至2004年4月收治食管憩室10例的临床资料、手术方式和临床疗效。结果全组咽食管憩室4例，中段食管憩室5例，膈上食管憩室1例。合并食管癌2例，食管功能性疾病2例，憩室癌变1例，食管支气管瘘1例，全部行手术治疗，术后早期无严重并发症和手术死亡，10例随访2月～13年，远期疗效优良率100％。结论食管憩室是一种少见的食管良性疾病，食管吞钡是主要的诊断方法。因常合并其它疾病，有症状的食管憩室大多需手术治疗。手术应注意对合并疾病和憩室病因的处理，防止术后憩室复发。     

食管平滑肌瘤的诊断与治疗

目的 总结10年来食管平滑肌瘤诊断与治疗的经验。方法 分析1993年至2002年间52例食管平滑肌瘤患者的临床资料。结果 本组54％的患者以进食困难为首发症状。诊断准确率：上消化道钡剂低张双对比造影检查为64％，CT为44％，胃镜为27％，超声内镜为90％。本组患者经胸腔镜手术6例，内镜下切除术9例，行食管平滑肌瘤摘除术32例，食管部分切除、食管胃吻合术5例。仅1例术后出血，经再次手术止血；其余未发生严重的术后并发症。结论 超声内镜是诊断食管平滑肌瘤的有效手段，对于适合的病例要积极考虑胸腔镜手术及内镜摘除以减轻创伤。     

外科治疗食管憩室10例临床分析

目的　探讨食管憩室的诊断、手术适应证、手术方式和疗效。方法　回顾分析 1991年9月至 2 0 0 4年 4月收治食管憩室 10例的临床资料、手术方式和临床疗效。结果　全组咽食管憩室 4例 ,中段食管憩室 5例 ,膈上食管憩室 1例。合并食管癌 2例 ,食管功能性疾病 2例 ,憩室癌变 1例 ,食管支气管瘘 1例 ,全部行手术治疗 ,术后早期无严重并发症和手术死亡 ,10例随访 2月～ 13年 ,远期疗效优良率 10 0 %。结论　食管憩室是一种少见的食管良性疾病 ,食管吞钡是主要的诊断方法。因常合并其它疾病 ,有症状的食管憩室大多需手术治疗。手术应注意对合并疾病和憩室病因的处理 ,防止术后憩室复发     

恶性食管呼吸道瘘的外科治疗13例分析

目的总结近年来临床收治的恶性食管呼吸道瘘病例,包括食管气管瘘（TEF）和食管支气管瘘（BEF）的临床处治体会。方法总结自1996年8月至2008年2月收治的13例恶性食管呼吸道瘘病例。结果13例中TEF6例;BEF7例,其中：右侧6例、左侧1例。术前均有饮水呛咳和不同程度的支气管、肺内感染。诊断经X线拍片：口服水溶性造影剂直立位拍片;内镜：纤维胃镜、纤支镜检查后获得确诊。治疗均采取手术治疗,分别为：（1）TEF或BEF旷置、颈部食管-胃或结肠吻合术;（2）食管癌＋瘘＋肺叶切除、颈部食管-胃吻合术。13例术后均可获得良好的近期康复。结论对于临床发生的恶性食管呼吸道瘘,应积极争取手术治疗,及时的手术治疗是防治肺内严重感染,改善预后的有效方法。     

Barrett食管的危险因素及治疗进展

食管腺癌发病率的增长速度居各种食管恶性肿瘤的第2位,目前认为Barrett食管是食管腺癌的一种癌前病变.Barrett食管的发病率与社会经济状况密切相关,在生活水平较高的发达国家,与Barrett食管相关的食管腺癌发病率迅速增长.Barrett食管的危险因素包括胃食管反流病、白人或西班牙裔种族、男性、年龄、吸烟、肥胖等.Barrett食管的治疗主要包括药物治疗、内镜治疗及外科手术治疗,但对Barrett食管有效的化学预防目前仍需进一步的临床随机试验加以阐明.     

内镜下食管肿瘤切除术中并发纵隔胸膜瘘1例

纵隔胸膜瘘是直接威胁患者生命的严重疾病。随着消化内镜诊疗技术的推广,食管肿瘤切除术中并发纵隔胸膜瘘的可能大大增加,及时发现液气胸、早期引流及抗感染成为改善患者预后的关键。报道食管肿瘤患者在全身麻醉下行食管肿瘤切除术中发生穿孔引发食管纵隔胸膜瘘1例,以期为相关疾病的麻醉管理和围手术期处理提供借鉴和参考。     

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。     

Endoscopic surgery for malignant esophageal disease

Endoscopic surgery for benign esophageal disease has been well established and is widely performed. On the other hand, endoscopic surgery for malignant esophageal disease has not yet been well established. However, we have developed and have been performing thoracoscopic esophagectomy with lymphadenectomy for esophageal cancer. We introduce here the results of our endoscopic surgery for esophageal cancer. In the early period of this surgery, more operative complications occurred, such as recurrent nerve palsy, chirothorax, bleeding, etc. However, these complications have gradually decreased. The survival rates of patients in each pathological stage who underwent this surgery are comparable to those of patients who underwent conventional surgery. In conclusion, thoracoscopic esophagectomy has become safe and will be acknowledged as the standard procedure for the treatment of esophageal cancer.     

Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery

Background Measuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research.Methods An expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research.Results Randomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function.Conclusions Laparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.Presented at the 11th International Congress of the European Association for Endoscopic Surgery (E.A.E.S.), Glasgow, Scotland, United Kingdom, June 2003(D. Korolija, S. Sauerland, E. Neugebauer) Conference organizers on behalf of the Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.), c/o E.A.E.S. Office, P.O. Box 335, 5500 AH Veldhoven, The Netherlands     

Clinical, endoscopic and morphological criteria for assessing function of esophageal anastomosis

Clinical and endoscopic data on 115 patients after surgery with creation of esophageal anastomosis was analyzed. Functional status of esophageal anastomosis was studied with x-ray, endoscopic, morphological, and US-assisted endoscopic METHODS: The findings provided information for development of functionally effective esophageal anastomosis criteria. Potential of US-assisted endoscopy was demonstrated. Objective and early diagnosis of the depth and intensity of inflammatory infiltration in early postoperative period allowed conduction of adequate treatment. The study of tissue structure in the zone of esophageal anastomosis in a late postoperative period discovers the cause of functional insufficiency of esophageal anastomosis.     

Standard radical esophagectomy in thoracic esophageal cancer

In Japan, the standard radical surgical procedure in patients with thoracic esophageal cancer is right thoracoabdominal esophagectomy with lymphadenectomy. However, with the development of endoscopic surgery and improvements in chemotherapy and chemoradiotherapy, the role of radical surgery has been changing. The indications for radical surgery are stage I disease without indications for endoscopic resection (endoscopic mucosal resection or endoscopic submucosal dissection), stage II disease, or stage III disease without T 4 tumors. Because of the favorable results of chemoradiotherapy in the treatment of stage I disease, the Japan Clinical Oncology Group (JCOG) started a randomized, controlled trial comparing surgery and chemoradiotherapy in the treatment of stage I thoracic esophageal cancer. The 5-year overall survival rates in patients who underwent surgery alone for thoracic esophageal cancer were 88% with stage I and 52% with stage II + III disease in Japan. The most important area in lymphadenectomy is the region from the neck to superior mediastinum, and three-field dissection is widely performed in Japan. However, there is no evidence that three-field dissection is necessary or that two-field dissection is sufficient. The efficacy of postoperative adjuvant chemotherapy for the treatment of thoracic esophageal cancer was confirmed in a Japanese randomized, controlled trial and it is expected that the timing of adjuvant chemotherapy will change from post- to pre-surgery (neoadjuvant chemotherapy).     

Surgery for benign submucosal tumors of the esophagus (leiomyoma and hemangioma)

Among the submucosal tumors of the esophagus, leiomyoma is the most frequently found. Esophageal leiomyoma usually originates from the muscle layer of the esophageal wall and grows spirally around the esophageal axis. In the surgical treatment of leiomyoma, we enucleate the tumor through video-assisted thoracic surgery. When we enucleate leiomyoma, we must be very careful to aviod perforation of the esophageal mucosa. Esophageal hemangioma is a relatively rare disease. The location of this disease is mainly within the submucosal layer, without invading the muscle layer proper. After confirming the localization within the mucosa or submucosa with endoscopic ultrasonography, esophageal hemangioma can be resected safely using the endoscopic mucosal resection technique. In the treatment of benign esophageal submucosal tumors, "informed consent" is as essential as in esophageal cancer surgery. We have no absolute criteria concerning the indications for surgery for benign esophageal submucosal tumors. We must give reasons why the operation is necessary and indicated to the patients. Surgical treatment of esophageal submucosal tumors should be as minimally invasive as possible.     

Optimization of prognosis and surgical prophylaxis of bleedings from esophageal varicose veins

New methods of prediction of bleeding from the esophageal varicose veins improve treatment outcomes. These methods consist of endoscopic assessment of varicose vein and mucous membrane with determination of thickness of the vein wall and mucosa, and also assessment of reflux-esophagitis with endoscopic ultrasonography. Original operation of azigoportal disconnection was performed in 13 patients followed-up after surgery from 1 to 4 years. The results obtained demonstrate high efficacy of this surgery for prophylaxis of repeated bleedings from esophageal varicose veins.     

Esophagobronchial Fistula Closure Using a Novel Endoscopic Over-the-Scope-Clip

We report on a patient who presented with a symptomatic esophagobronchial fistula arising from an esophageal diverticulum with recurrent pulmonary infections despite prophylactic antibiotics. She was not an optimal candidate for esophageal stenting, bronchial stenting, or surgery and had refused a gastrostomy tube placement. We performed a successful endoscopic fistula closure using a novel endoscopic over-the-scope-clip device providing an effective seal of the fistula with durable resolution of symptoms.     

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasivesurgery(MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.