人源性纤维蛋白胶对食管病变内镜黏膜剥离术后并发症的防治效果分析

目的评价人源性纤维蛋白胶对食管早期鳞癌及癌前病变内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）术后并发症的防治效果。方法将2017年4月—2020年4月因食管早期鳞癌或癌前病变在东南大学附属中大医院消化内科行ESD治疗的210例病例纳入回顾性分析,其中退镜前创面使用人源性纤维蛋白胶预防术后并发症的73例（79处病变）纳入观察组,剩余137例未使用者（156处病变）纳入对照组,对比分析2组ESD术后并发症及术后疼痛发生情况。结果2组在患者一般资料及病变位置、纵径大小、巴黎分型、病理类型、浸润深度、病变环周范围、剥离面积、手术时长和局部使用激素方面,差异均无统计学意义（P＞0.05）。穿孔、迟发性出血和食管狭窄发生率观察组分别为2.7%（2/73）、1.4%（1/73）和16.4%（12/73）,对照组分别为2.9%（4/137）、1.5%（2/137）、13.1%（18/137）,2组间差异均无统计学意义（P＞0.05）。术后疼痛总体发生率观察组为53.4%（39/73）,对照组为70.8%（97/137）,2组间差异有统计学意义（χ2=6.302,P=0.012）。其中,轻度疼痛、中度疼痛和重度疼痛发生率手术当天观察组分别为9.6%（7/73）、6.8%（5/73）和5.5%（4/73）,对照组分别为27.0%（37/137, χ2=8.724,P=0.003）、17.5%（24/137, χ2=4.554,P=0.033）和0.7%（1/137, χ2=2.805,P=0.094）;术后第1天观察组分别为26.0%（19/73）、5.5%（4/73）和6.8%（5/73）,对照组分别为29.2%（40/137, χ2=0.237,P=0.626）、14.6%（20/137, χ2=3.912,P=0.048）和4.4%（6/137, χ2=0.193,P=0.660）;术后第2天观察组分别为5.5%（4/73）、0和1.4%（1/73）,对照组分别为19.0%（26/137, χ2=7.087,P=0.008）、2.9%（4/137）和0。结论人源性纤维蛋白胶对食管早期鳞癌及癌前病变ESD术后出血、穿孔、狭窄无明显预防作用,但可显著降低ESD术后疼痛的发生率,尤其是术后轻-中度疼痛的发生率。     

硝苯地平诱发内镜黏膜下剥离术后出血一例

内镜黏膜下剥离术后出血与患者本身因素及手术者技术水平相关。本文报道了1例硝苯地平诱发内镜黏膜下剥离术后出血的病例,通过急诊内镜止血及停用硝苯地平后未再出血。     

内镜黏膜下剥离术的辅助牵引技巧

内镜黏膜下剥离术（ESD）作为一种治疗早期消化道肿瘤的方法,具有创伤小、花费低、恢复快、对患者生活质量影响小等优点,且治疗效果和外科手术相当,近年来得到蓬勃发展和广泛应用。手术中如何保持病变组织张力和视野清晰是减少并发症、保证手术安全性和有效性的关键,尤其对于困难ESD治疗更为关键。本文系统回顾ESD各种辅助牵引技术,并总结各自优缺点,以期为临床应用及研究提供借鉴。     

内镜黏膜下剥离术和内镜下黏膜切除术治疗早期胃癌的术后出血影响因素分析

目的：分析影响早期胃癌内镜黏膜下剥离术和内镜下黏膜切除术(ESD/EMR)术后出血的可能影响因素,以便降低出血风险,对术后出血高危人群进行特殊关注。方法：回顾性收集2012年6月至2018年5月于北京友谊医院内镜中心因诊断早期胃癌而行ESD/EMR治疗患者的临床资料,包括病人基本信息(年龄、性别、疾病史)、临床特征(病变大小、部位、形态)及术后病理信息(病理类型、浸润深度)等,分析上述因素对ESD/EMR术后发生出血的影响。结果：共有255例早期胃癌患者纳入研究,其中11例发生术后出血(4.3%)。术后出血病例与未出血病例相比,心脑血管疾病史、氯吡格雷服药史、多发病变在两组间分布有统计学差异 (P=0.004, P=0.017及P=0.042)。多因素分析显示心脑血管疾病史(OR=5.151, 95% CI：1.242-21.356, P=0.024)、多发病变(OR=7.245, 95% CI：1.471-35.684, P=0.015)及主要病变≥2cm (OR=4.713, 95%CI：1.011-21.982, P=0.048)是术后发生出血的可能危险因素。生存分析结果显示：有心脑血管疾病史(P<0.001)、多发病变(P=0.013)、主要病变≥2cm的患者(P=0.031),ESD/EMR术后发生出血的风险明显增高。结论：ESD/EMR术后应重点关注具有心脑血管疾病史、病变部位多发、病变较大的患者的出血风险。     

内镜黏膜下剥离术治疗消化道黏膜下肿瘤的疗效分析

目的探讨内镜黏膜下剥离术(ESD)治疗消化道黏膜下肿瘤(submucosal tumor,SMT)的疗效及安全性。方法选取我院2008年3月-2011年6月经胃肠镜检查发现消化道黏膜下肿瘤48例,回顾性分析48例患者资料,包括患者的基本情况、病变部位、大小、治疗经过以及病理结果等,统计并发症发生情况及术后随访结果。结果病灶直径为0.8～5.8 cm,平均(3.3±0.75)cm,ESD手术时间为27～167 min,平均(71.0±22.6)min,ESD完整切除病灶45例(45/48,93.75%),穿孔3例(3/48,6.25%),其中1例大出血,1例食管患者ESD术后出现食管狭窄,经内镜下球囊扩张食管狭窄消失。所有病人均完成了术后6个月的内镜随访,1例患者见肿瘤复发。结论 ESD技术对较大病变可以整块切除,并提供完整的病理诊断资料;消化道SMT行ESD术是安全、有效的。     

胃部病变内镜黏膜下剥离术后出血危险因素分析

[目的]探讨内镜黏膜下剥离术(ESD)治疗胃部病变术后出血的危险因素。[方法]收集行胃ESD治疗的899例患者的临床资料,对病例的年龄、性别、病变直径、病变位置、手术持续时间、创面处理方式等进行单因素及多因素分析,总结术后出血的危险因素及发病时间规律,为术前及术中评估出血风险提供参考。[结果]899例患者中,20例(2.22%)出现术后出血,其中90%发生在术后5 d内。单因素χ²分析结果显示,男性的出血发生率高于女性,病变直径≥3 cm的出血发生率高于病变直径<3 cm的患者,不同病变位置及创面处理方式的出血发生率存在差异(P<0.05)。多因素Logistic回归分析结果显示,未使用止血夹(P=0.008,OR=4.487,95%CI:1.478～13.620)、病变直径≥3 cm(P=0.008,OR=3.376,95%CI:1.371～8.313)是胃ESD后出血的独立危险因素。[结论]未使用止血夹、病变直径≥3 cm的患者,胃部病变ESD后出血的发生率较高,术后5 d是发生出血的危险期。     

止血夹预防早期胃癌内镜黏膜下剥离术后迟发性出血的疗效分析

目的　评价止血夹预防早期胃癌内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）后出血的疗效。方法　回顾性收集2013年6月—2020年8月就诊于北京友谊医院确诊为早期胃癌行ESD患者资料459例,将其分为病变切除后使用止血夹预防性夹闭创面的A组162例、病变切除后未使用止血夹夹闭创面的B组297例,观察术后2周患者是否发生出血。对患者进行单因素及亚组分析,分析每组患者的术后出血发生率及临床病理特征。结果　A组术后出血发生率3.1%（5/162）,B组术后出血发生率8.1%（24/297）,差异有统计学意义（χ2=4.418,P=0.036）。A组与B组进行亚组比较,肿瘤长径>20 mm时,两组术后出血率差异有统计学意义［3.5%（2/57）比15.3%（13/85）,χ2=5.016,P=0.025］;肿瘤位于胃下部时,两组术后出血率差异有统计学意义［1.0%（1/97）比10.4%（20/192）,χ2=8.425,P=0.004］;肿瘤浸润深度为M/SM1时,两组术后出血率差异有统计学意义［3.2%（5/157）比8.1%（23/285）,χ2=4.072,P=0.044］。当肿瘤长径≤20 mm、肿瘤位于胃上/中部、肿瘤浸润深度为SM2时,A组与B组的术后出血发生率差异均无统计学意义（P>0.05）。结论　止血夹可预防早期胃癌ESD术后迟发性出血的发生,且主要体现在肿瘤长径>20 mm、肿瘤位于胃下部、肿瘤浸润深度在M/SM1的病变上,对肿瘤长径≤20 mm、肿瘤位于胃上/中部病变的预防作用不大。     

胃内镜黏膜下剥离术术中出血的危险因素分析

目的:总结胃内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)术中出血的临床特点,分析导致出血的危险因素。方法:回顾性总结2015年1月—2019年12月北京协和医院消化内镜中心所有接受胃ESD治疗的患者,分析患者病史资料、胃内病变特点、操作过程及患者预后。结果:共纳入422例...     

消化道内镜黏膜下剥离术并发出血的研究进展

术中、术后出血是内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗消化道病变过程中常见的并发症之一。准确评估和预防出血直接关系到手术的成功和ESD技术的推广。本文系统回顾国内外ESD出血相关研究,对ESD并发出血的危险因素及预防措施进行综述。准确评估出血风险并在此基础上做好术前、术中、术后充分的相关止血预案可明显降低ESD出血发生率,推进其在基层医院广泛安全应用。     

消化道早期癌内镜黏膜下剥离术后出血的危险因素分析

目的 探讨内镜黏膜下剥离术（ESD）治疗消化道早癌并发出血的独立危险因素。方法 2008年6月至2015年2月福建省立医院消化内镜中心,及2015年5月至2018年4月福建省立医院南院消化内镜中心,行ESD治疗的430例消化道早癌（449处病灶）,按术后出血情况分为出血组和未出血组,分析患者一般情况、内镜治疗情况及术后病理结果等因素与ESD术后出血的关系。结果 430例消化道早癌（449处病灶）行ESD治疗,16例（3.7%）发生术后出血。按是否发生术后出血分成出血组（n=16）和未出血组（n=433）后,单因素分析结果提示,患者年龄（t=0.465,P=0.642）、性别构成（χ2=0.035,P=0.642）、是否有糖尿病（χ2=0.647,P=0.421）、是否有冠心病（P=1.000）、病灶大小（t=1.598,P=0.111）、是否≥2个病灶（P=1.000）、病变部位（χ2=6.183,P=0.289）、操作时间（t=1.335,P=0.201）、病理分级（χ2=0.687,P=0.709）、病变浸润深度（χ2=0.134,P=0.714）2组间差异均无统计学意义,是否有高血压病2组间差异有统计学意义（χ2=4.793,P=0.029）。Logistic回归分析结果显示,有高血压病是ESD术后出血的独立危险因素（OR=3.358,95%CI：1.227～9.186,P=0.018）。结论 高血压与消化道早癌ESD术后出血密切相关,伴有高血压者ESD术后出血风险大。     

止血粉预防内镜黏膜下剥离术后迟发性出血的随机对照试验

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)术后创面喷洒止血粉对迟发性出血的预防作用。方法2017年6月至2018年8月,在苏州大学附属第一医院总院、榆林市第二医院接受ESD治疗者作为研究对象,计划纳入试验组、对照组各100例,以随机信封方式在ESD手术开始后进行分组,ESD结束后试验组创面予止血粉喷洒,对照组则不予处理。主要观察试验组止血粉喷洒用时、用量及其不良事件,并对比分析2组的手术时间、迟发性出血(术后30 d内)发生率、早期迟发性出血(术后48 h内)发生率以及术后住院时间。结果初始纳入200例患者,有1例中途退出、3例转外科手术,最终共有196例纳入数据分析,其中试验组97例、对照组99例,2组的基线资料具有可比性(P均>0.05)。试验组止血粉喷洒时间(68.78±19.75)s,用量(2.51±0.93)g,有1例(1.03%)出现止血粉输送管路堵塞,术后随访30 d未发生止血粉相关不良事件。手术时间试验组为(61.92±11.71)min,对照组为(59.76±11.01)min(t=1.330,P=0.185);迟发性出血发生率试验组为1.03%(1/97),对照组为8.08%(8/99)(P=0.035);试验组无早期迟发性出血,对照组发生率为6.06%(6/99)(P=0.029);试验组术后住院时间为(4.57±0.85)d,对照组为(4.86±1.37)d(t=1.778,P=0.077)。结论ESD术后创面喷洒止血粉能有效预防迟发性出血的发生,尤其是对早期迟发性出血的预防作用更为显著,但喷洒装置的效能还有待进一步提高。     

Effect of prophylactic endoscopic closure for an artificial ulceration after colorectal endoscopic submucosal dissection: a randomized controlled trial

Abstract

Objective: Endoscopic submucosal dissection (ESD) is now commonly performed as a treatment for not only gastric tumor but also colorectal tumor. However, colorectal ESD has a substantial risk of complications, including post-ESD electrocoagulation syndrome, bowel perforation and bleeding. This study aimed to investigate whether prophylactic endoscopic closure can reduce the occurrence of complications after colorectal ESD.

Materials and methods: Patients who underwent colorectal ESD in our unit were randomly assigned to either of two groups. Prophylactic endoscopic closure for an artificial ulceration after ESD was performed in group I but not in group II. After the procedure, the incidence of complications, visual analog scale (VAS) score for abdominal pain, and laboratory findings were investigated.

Results: Of the 220 patients (110 per group) enrolled in this study, 137 were men. No significant differences were found in age, sex, comorbidity, medication history, tumor location, size of resected specimen, and pathologic result between the two groups. No significant difference was found in ESD outcomes, including hospitalization period, laboratory findings, VAS score for abdominal pain, incidence of surgical operation, and incidence of post-ESD complications, between the two groups.

Conclusions: Contrary to popular belief, prophylactic endoscopic closure after colorectal ESD does not decrease the incidence of complications, and it does not ameliorate inflammatory response and abdominal pain.

Clinical trial registration number: KCT0001666.     

Usefulness of the clip-flap method of endoscopic submucosal dissection: A randomized controlled trial

AIM To prospectively investigate the efficacy and safety of clipflap assisted endoscopic submucosal dissection(ESD) for gastric tumors.METHODS From May 2015 to October 2016, we enrolled 104 patients with gastric cancer or adenoma scheduled for ESD at Shiga University of Medical Science Hospital. We randomized patients into two subgroups using the minimization method based on location of the tumor(upper, middle or lower third of the stomach), tumor size( 20 mm or 20 mm) and ulcer status: ESD using an endoclip(the clip-flap group) and ESD without an endoclip(the conventional group). Therapeutic efficacy(procedure time) and safety(complication: Gastrointestinal bleeding and perforation) were assessed. RESULTS En bloc resection was performed in all patients. Four patients had delayed bleeding(3.8%) and two had perforation(1.9%). No significant differences in en bloc resection rate(conventional group: 100%, clip flap group: 100%), curative endoscopic resection rate(conventional group: 90.9%, clip flap group: 89.8%, P = 0.85), procedure time(conventional group: 70.8 ± 46.2 min, clip flap group: 74.7 ± 53.3 min, P = 0.69), area of resected specimen(conventional group: 884.6 ± 792.1 mm~2, clip flap group: 1006.4 ± 1004.8 mm~2, P = 0.49), delayed bleeding rate(conventional group: 5.5%, clip flap group: 2.0%, P = 0.49), or perforation rate(conventional group: 1.8%, clip flap group: 2.0%, P = 0.93) were found between the two groups. Lessexperienced endoscopists did not show any differences in procedure time between the two groups.CONCLUSION For patients with early-stage gastric tumors, the clipflap method has no advantage in efficacy or safety compared with the conventional method.     

Effect of a proton pump inhibitor or an H2-receptor antagonist on prevention of bleeding from ulcer after endoscopic submucosal dissection of early gastric cancer: a prospective randomized controlled trial

OBJECTIVES: With conventional methods of endoscopic mucosal resection for early gastric cancer (EGC), proton pump inhibitors (PPIs) and H2-receptor antagonists (H2RAs) have a similar effect on preventing bleeding from artificial ulcers. An objective of this study is to investigate whether a stronger acid suppressant (i.e., PPI) more effectively prevents bleeding after the recent advanced technique of endoscopic submucosal dissection (ESD) for EGC. METHODS: This was a prospective randomized controlled trial performed in a referral cancer center. A total of 143 patients with EGC who underwent ESD were randomly assigned to the treatment groups. They received either rabeprazole 20 mg (PPI group) or cimetidine 800 mg (H2RA group) on the day before ESD and continued for 8 wk. The primary end point was the incidence of bleeding that was defined as hematemesis or melena that required endoscopic hemostasis and decreased the hemoglobin count by more than 2 g/dL. RESULTS: In baseline data, the endoscopists who performed the ESD were significantly different between the groups. Finally, 66 of 73 patients in the PPI group and 64 of 70 in the H2RA group were analyzed. Bleeding occurred in four patients in the PPI group and 11 in the H2RA group (P= 0.057). Multivariate analysis revealed that treatment with the PPI significantly reduced the risk of bleeding: adjusted hazard ratio 0.47, 95% confidence interval 0.22-0.92, P= 0.028. One delayed perforation was experienced in the H2RA group. CONCLUSIONS: PPI therapy more effectively prevented delayed bleeding from the ulcer created after ESD than did H2RA treatment.