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。     

内镜黏膜下剥离术治疗相对适应证老年早期食管鳞癌69例疗效分析

目的评价内镜黏膜下剥离术(ESD)治疗相对适应证老年(年龄≥60岁)早期食管鳞癌病人的安全性、有效性和长期生存情况。方法回顾性分析2008年1月至2013年12月复旦大学附属中山医院内镜中心行ESD治疗早期食管鳞癌病人的临床资料,筛选出其中符合日本食管学会(JES)食管癌诊治指南内镜治疗相对适应证且术后无追加治疗的老年病人共69例,观察并分析术后并发症以及长期生存情况。结果 62例(89.9%)病人侵犯至黏膜肌层(M3),7例(10.1%)侵犯至黏膜下层200μm(SM1),6例(8.7%)存在淋巴管浸润。术后1例(1.4%)病人发生出血,经内镜下治疗后止血;2例(2.9%)穿孔经内镜缝合后闭合;22例(31.8%)发生食管狭窄。术后复发率为11.6%(8/69),中位复发时间为24个月。1例病人出现肝和淋巴结转移。5年无病存活率为86.2%;有4例(5.8%)病人死亡,5年总体存活率为90.0%,中位生存时间为56个月。结论 ESD治疗相对适应证老年早期食管鳞癌病人,不进行追加治疗也可能获得较好的长期生存,并且安全性和有效性较高。     

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。     

胃黏膜内癌的EMR与ESD治疗

一些早期胃癌可采用缩小手术，甚至内镜下手术如内镜黏膜切除术（endoscopic mucosalre—section．EMR）及内镜黏膜下层剥离术（endoscopic submucosal dissection．ESD）就可达到根治目的。胃癌内镜治疗的根治切除前提条件包括：1）无淋巴结转移；2）保证水平方向（黏膜内浸润范围）和垂直方向（浸润深度）有足够的安全切缘；3）术后切除标本可进行详细的病理组织学检查。其内镜治疗具体适应证为：所有无淋巴结转移的无溃疡糜烂的分化型黏膜内癌，直径3cm以下的有溃疡糜烂的分化型及2cm以下的无溃疡糜烂的未分化型黏膜内癌；直径3cm以下无溃疡糜烂的分化型黏膜下层癌，直径2cm以下无溃疡糜烂的未分化型黏膜下层癌。ESD和EMR可能成为治疗早期胃癌的标准方法；且ESD的1次切除率高，局部复发率低。     

内镜下黏膜剥离术:欧洲胃肠内镜学会指南

<正>本指南是欧洲胃肠内镜学会(ESGE)的官方声明,是根据GRADE系统评估的强度和证据的质量推荐。主要建议如下:①对于Barrett食管内可见的病变行根治性内镜切除(强烈推荐,中等质量证据)。对于黏膜内癌,内镜下黏膜剥离术并未显示出较内镜下黏膜切除术的优势,因此可优先考虑内镜下黏膜切除术。内镜下黏膜剥离术可用于部分病例,如病变大于15 mm以及具有黏膜下层侵犯风险者(强烈推荐,中等质量证据)。②对于浅表性食管鳞状细胞癌应行内镜下整块切除,有明显黏膜     

消化道类癌三种内镜治疗方法的比较

目的比较普通圈套器电切、内镜黏膜切除术(EMR)和内镜黏膜下剥离术(ESD)治疗消化道类癌的有效性和安全性。 方法回顾性分析2006年1月至2015年6月病理符合消化道类癌患者的临床资料,比较普通圈套器电切治疗(普通圈套器电切组,12例)、内镜黏膜切除术治疗(EMR组,47例)和内镜黏膜下剥离术治疗(ESD组,39例)的组织学完全切除率、并发症,以及术后随访6～36个月观察其疗效。 结果内镜治疗消化道类癌的组织学完全切除率为78.57%(77/98)。普通圈套器电切组的组织完全切除率为66.67% (8/12),EMR组为82.98% (39/47),ESD组为76.92% (30/39),差异均无统计学意义 (P＝0.463)。仅1例ESD治疗后发生穿孔,其他患者未出现并发症。所有患者随访6～36个月,均未复发。 结论内镜治疗对病变未超过黏膜下层的小的消化道类癌是一种安全有效的方法。     

残胃复发癌治疗策略

残胃复发癌的治疗策略取决于癌的浸润深度。内镜下黏膜切除术（EMR）、内镜黏膜下剥离术（ESD）适应证以外的早期残胃癌原则上应行全胃切除术;黏膜内癌应行D1或D1+淋巴结清扫术; 黏膜下层癌应行D1+或D2淋巴结清扫术;缝合部位或吻合口癌应行D2淋巴结清扫术。进展期残胃癌应行全胃切除术和D2淋巴结清扫术。对于能治愈性切除的进展期T3或T4残胃癌,按淋巴流向及淋巴结转移规律行D2+、16a2b1淋巴结清扫术,必要时合并脏器切除。     

内镜黏膜下剥离术治疗消化道黏膜下肿瘤

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗消化道黏膜下肿瘤(submucosal tumor,SMT)的疗效和安全性。方法对内镜发现的19例消化道SMT(食管6例,胃6例,十二指肠1例,乙状结肠1例,直肠5例)进行超声内镜检查(18例病变位于黏膜下层,1例位于固有肌层),应用头端弯曲的针形切开刀进行ESD治疗。黏膜下注射生理盐水抬高病变,使病变与肌层相分离,预切开病变周围黏膜,剥离病变下方黏膜下层结缔组织,完整切除病变。结果病变最大直径0.5～3.0cm(平均1.6cm)。18例成功完成ESD治疗,手术时间15～105min(平均45min)。2例ESD术中出现内镜难以控制的大出血,1例成功保守治疗(三腔管食管囊压迫),1例转开腹手术。无术后出血。ESD穿孔3例:2例术中消化道穿孔(十二指肠球部和胃底),应用金属夹缝合成功,未转开腹手术;1例直肠类癌剥离深至肌层,术后出现皮下气肿,保守治疗气肿减退。所有ESD剥离病变包膜完整,基底和切缘未见病变累及。结论ESD治疗消化道SMT安全、有效,可以完整切除消化道黏膜下层病变,提供完整的病理诊断资料。对于来源于固有肌层的SMT,应慎行ESD。     

大肠类癌的内镜及超声内镜特点

目的 探讨大肠类癌的内镜及超声内镜特点,提高内镜诊疗水平.方法 收集2002-2007年收治的22例大肠类癌患者的临床资料.分析内镜及超声内镜特点及其与浸润深度的关系.结果 早期癌内镜表现为直径1.5cm、黏膜光滑、黏膜内黄白色颗粒样结构;进展期癌内镜表现为直径0.8～3.0cm、黏膜不平、黄白色结节样或表面溃疡.超声内镜特征为:稍低回声,内部散在点状稍高回声,起源于黏膜固有层或黏膜下层不规则卵圆形结构,边缘模糊且不规则.16例黏膜内癌及黏膜下浅层癌行内镜黏膜切除术,其中10例追加氩气刀治疗.随访4～36个月无复发.1例黏膜下深层类癌及5例进展期类癌行外科手术.结论 内镜及超声内镜可诊断大肠类癌及其浸润深度,对早期类癌行内镜治疗可取得较好效果.     

内镜剥离术治疗食管环周早癌的安全性和疗效评估

目的 探讨内镜黏膜下剥离术（ESD）治疗食管环周早癌（Early Esophageal Cancer,EEC）的疗效价值，评估其治疗安全性。方法回顾性分析在2021年1月至2022年6月于本院接收治疗的食管环周早癌患者，共60例，将患者分为内镜下黏膜剥离术（Endoscopic Submucosal Dissection,ESD）组和内镜黏膜切除术（endoscopic mucosal resection,EMR）组，各30例。其中ESD组采用ESD治疗，EMR组采用内镜下黏膜切除术（EMR）治疗。统计并分析两组患者围手术期指标、术后并发症以及病灶切除情况。结果 围手术期指标比较：ESD组患者手术时间明显高于EMR组，比较差异具有统计学意义（P<0.05），出血量以及住院时间组间比较差异无统计学意义（P>0.05）;ESD组共发生6例（20.00%）术后并发症，与EMR组的8例（26.67%）相当，比较差异无统计学意义（P>0.05）;ESD组的病灶整块、切缘阴性、治愈性切除比例明显优于EMR组，比较差异具有统计学意义（P<0.05）。结论 ESD治疗EEC预后...     

�ھ��Ĥ�°��������������Ӧ֤��������ʳ���۰�69����Ч����

??Outcomes evaluation of endoscopic submucosal dissection for relative indication group of early esophageal squamous cell carcinoma in aged patients: An analysis of 69 cases LI Bing??QI Zhi-peng??ZHOU Ping-hong??et al. Endoscopy Center and Endoscopy Research Institute??Zhongshan Hospital??Fudan University??Shanghai 200032??China
Corresponding author??ZHONG Yun-shi??E-mail??zhong.yunshi@zs-hospital.sh.cn
Abstract Objective To evaluate the safety??efficacy and long-term outcomes of endoscopic submucosal dissection (ESD) for relative indication group of early esophageal squamous cell carcinoma in aged patients. Methods The clinical data of early esophageal squamous cell carcinoma treated by ESD from January 2008 to December 2013 in the Endoscopy Center of Zhongshan Hospital, Fudan University were analyzed retrospectively. A total of 69 cases of elderly patients were with the relative indications from the part of endoscopic treatment of Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus April 2012 edited by the Japan Esophageal Society and no additional treatment were picked out. The incidence of complications and long-term outcomes were observed and analyzed. Results 62 (89.9%) cases were infiltrated to muscularis muscular (M3)??7 (10.1%) cases were infiltrated into submucosal within 200 μm (SM1); 6 (8.7%) cases were lymphatic infiltration. There were 1 (1.4%) case with postoperative bleeding who underwent endoscopic hemostatic procedures after the ESD??2 (2.9%) cases with perforation who underwent the endoscopic suturing closure and 22 (31.8%) cases with esophageal stricture after operation. The recurrence rate was 11.6% (8/69) and the median recurrence time was 24 months. Liver and lymph node metastasis were existed in 1 case. As a result??the 5-year disease-free survival rate was 86.2%. The 5-year overall survival rate was 90.0% in the case of 4 patients (5.8%) died??and the median survival time was 56 months. Conclusion ESD could achieve comparatively ideal long-term outcomes in the treatment of early esophageal squamous cell carcinoma of aged patients without additional treatment, which has high safety and effectiveness.     

Multimodality treatments with endoscopic mucosal resection of esophageal squamous cell carcinoma with submucosal invasion

Background and study aims: A standard treatment for esophageal squamous cell carcinoma (SCC) with submucosal invasion is considered to be radical resection at present. In this study, we evaluated the efficacy of multimodality treatments with endoscopic mucosal resection (EMR) of esophageal SCC with submucosal invasion. Method: Eighteen cases of SCC with submucosal invasion were treated with EMR. Lymphatic invasion was found in 11 cases (67%), and there were no cases of blood vessel invasion. EMR was performed prior to any other treatment. Chemotherapy and/or radiotherapy were added if indicated by the histopathological features. Results: There were no cases of local recurrence. Lymph-node recurrence was detected in 1 case treated with EMR alone. There were no cases of cancer death. The overall survival rate was 83% in all patients.Conclusions: Multimodality treatments with EMR were effective in treating esophageal SCC with submucosal invasion.     

Transthoracic Esophagectomy After Endoscopic Mucosal Resection in Patients with Early Esophageal Carcinoma

Introduction  For patients with esophageal carcinoma limited to the mucosa endoscopic mucosal resection (EMR) is the therapy of choice whereas surgical resection is advocated for submucosal tumors. Methods  This study analyzes the histopathologic results of patients with early esophageal carcinoma who underwent EMR prior to transthoracic esophagectomy. Sixteen patients with early esophageal carcinoma and EMR as first line treatment were included in this retrospective study. Ten patients underwent transthoracic esophagectomy because of submucosal infiltration combined incomplete tumor resection at the lateral/basal resection margin. In one patient each, surgical therapy was indicated due to submucosal infiltration or incomplete resection only. Three patients underwent surgical resection due to residual neoplasia within an esophageal stenosis following EMR. Surgical specimens were examined for pT and pN stage according to the UICC. Results  Three patients had a squamous cell carcinoma (SCC) and 13 patients an adenocarcinoma (AC), nine patients with a long segment Barrett’s esophagus. The distribution of the pT stages was as follows: 6× pT0 (no histopathologic evidence of residual tumor), 1× pT1m1, 1× pT1m2, 3× pT1m3, 1× pT1sm1, 1× pT1sm2, 1× pT2, and 2× pT3. Three of 16 patients (18.8%) with a pT1sm1, pT2, and pT3 stage had nodal metastases. In all three patients metastatic nodes were located in the mediastinum. In two patients, a second carcinoma was detected during histopathologic work-up (1× AC in the cardia and 1× SCC in the cervical esophagus). Conclusion  The data of this highly selected patients indicate that the boundary between the therapy of mucosal and submucosal tumors is not as clear as stated. Therefore, treatment of early esophageal carcinoma demands a close interdisciplinary cooperation.     

术后替加氟辅助化疗对Ro切除的食管鳞癌患者生存率的影响

目的探讨替加氟用于辅助化疗对Ro切除食管鳞癌患者生存率的影响。方法收集汕头市中心医院肿瘤外科1987年1月至1996年12月食管鳞癌RO手术病例411例,其中单纯手术组74例,术后口服替加氟化疗组337例。化疗方案：替加氟800～1200mg／d．连续服用3周后休息一周,总剂量达到40g以上。结果单纯手术组5年生存率50．1％,替加氟术后化疗组5年生存率44．3％,两组患者5年生存率相比未见显著性差异（P=0．853）。另外,从不同性别、年龄、肿瘤部位、大体类型、分化程度、浸润深度、有无淋巴结转移和分期等亚组人群分析来看,单纯手术组与替加氟术后化疗组的生存率皆无显著性差异。Cox回归模型分析结果显示,年龄、分化程度、淋巴结转移是影响生存率的独立因素,而术后替加氟化疗对预后没有产生明显影响。结论替加氟用于术后辅助化疗没有明显提高RO切除的食管鳞癌患者的生存率。食管癌术后辅助化疗缺乏有效方案,有待今后进一步深入研究。     

管状胃在胸腹腔镜联合食管癌根治术中的应用探讨

目的探讨管状胃在胸腹腔镜联合食管癌根治术中的临床应用价值。方法选取2011年1月至2015年12月在我院行胸腹腔镜联合食管癌根治术治疗的胸段食管癌患者160例,将其分为两组,分别采用管状胃代食管手术和传统全胃缝缩术治疗。记录两组患者手术完成情况、比较两组患者淋巴结清扫个数、失血量、手术时间、胸管留置时间、术后引流量、围手术期和随访期间并发症发生率、记录并发症处理情况、比较两种手术方法的总体疗效。结果两种术式在胸部淋巴结清扫个数、术中失血量、胸管留置时间和术后引流量方面无明显差异(P0.05);管状胃代食管术手术时间、腹部淋巴结清扫个数明显多于全胃缝缩术(P0.05)。管状胃代食管术的并发症发生率明显低于全胃缝缩术(P0.05)。管状胃代食管术住院时间、术后进食时间、复发和转移率、2年生存率和生活质量均明显优于全胃缝缩术(P0.05)。两组1年生存率无明显差异(P0.05)。结论管状胃代食管术可有效减少食管癌术后并发症,提高患者生活质量和生存率,安全可靠。     

早期食管癌内镜及病理特点分析

目的 总结早期食管癌内镜及病理特点,探讨其对临床诊断的价值.方法 回顾性分析2003年1月至2007年12月西南医院收治的62例早期食管癌患者的临床资料,总结其内镜和病理特点.结果 食管上段癌8例,中段癌42例,下段癌12例.内镜分型依次为表面扩散生长型30例,双向生长型11例,腔内生长型9例,壁内生长型7例,混合生长型5例.多数肿瘤直径为1.0～2.9 cm.行外科手术治疗38例、内镜黏膜切除术治疗23例、内镜黏膜下层剥离术治疗1例.术后病理检查:原位癌13例,黏膜内癌22例,黏膜下癌27例,黏膜内癌和黏膜下癌的淋巴结转移率分别为5%(1/22)和15%(4/27).病理分型:鳞癌57例,腺癌2例,小细胞癌、肉瘤化癌、梭形细胞癌各1例.结论 早期食管癌好发于食管中段,以表面扩散生长型多见,以鳞癌为主,普通内镜联合卢戈液和美蓝检查是发现早期食管癌的重要方法.     

内镜黏膜下剥离术治疗食管病变21例

目的探讨内镜黏膜下剥离术（endosc opic submucosa｜ dissection,ESD）治疗食管黏膜层及黏膜下层病变的应用价值。方法2012年5月～2013年2月,对胃镜及超声胃镜发现的食管黏膜层及黏膜下层病变21例进行ESD治疗：黏膜下注射生理盐水,以抬高黏膜层;环行切开病变周围黏膜;对病变黏膜下层进行剥离,以完整切除病变。结果2l例黏膜病变均完整切除,术后病理证实早期食管癌13例,中重度不典型增生5例,黏膜下平滑肌瘤3例。病变直径1．0～4．0cm,平均2．8cm。手术时间20～115rain,平均55min。住院时间8～15d,平均10．6d。1例术后迟发性出血,紧急行内镜下止血夹夹闭、氩离子血浆凝固术（argonplasmacoagulation,APC）成功止血;无一例穿孔。结论ESD在治疗食管黏膜层及黏膜下层的病变中具有病变切除完整性好、切除率高、并发症少、复发率低、患者生存质量高等优点,值得推广。     

内镜下切除技术对食管胃连接部胃肠间质瘤的治疗价值

目的评价以内镜黏膜下剥离术（ESD）为基础的内镜下切除术在食管胃连接部（EGJ）胃肠间质瘤（GIST）治疗中的安全性及有效性。方法收集复旦大学附属中山医院内镜中心所有接受ESD治疗的患者资料．筛选出2007年11月至2011年6月间经病理证实的EGJ处GIST患者20例．总结并分析其临床病理及术后随访资料。结果20例EGJ处GIST均起源于固有肌层,其中男性11例,女性9例,年龄29～67（平均54．1）岁,病灶直径8-20（平均14．8）mm。所有病例均成功完成内镜切除手术．其中15例接受了内镜黏膜下挖除术．4例接受了无腹腔镜辅助的内镜全层切除术。1例接受了内镜经黏膜下隧道肿瘤切除术。手术时间15-90（平均47．8）min,术中出血量5-200ml,病灶的完整切除率为100％。术中穿孔4例,气腹3例,气胸1例,贲门黏膜撕裂1例,均通过内镜下处理及保守治疗恢复。20例患者术后均接受了3-36（平均13-2）个月的随访,无局部复发和远处转移病例。结论在EGJ处GIST的治疗中,以ESD为基础的内镜下切除技术是一种安全和有效的治疗手段。     

Depth of Submucosal Tumor Infiltration and its Relevance in Lymphatic Metastasis Formation for T1b Squamous Cell and Adenocarcinomas of the Esophagus

Background

Surgery for early esophageal carcinoma has been challenged by less invasive endoscopic approaches. Selecting patients in need for surgical intervention according to their risk of lymphatic spread is mandatory.

Objective

The aim of this study was to evaluate risk factors for lymphatic metastasis formation in T1b esophageal carcinomas.

Methods

Histopathological specimens following surgical resection for T1b esophageal carcinomas were reevaluated for overall submucosal layer thickness, depth of submucosal tumor infiltration, tumor length as well as lymphatic and vascular infiltration. Depth of tumor infiltration to overall submucosal thickness was divided in thirds (SM1, SM2, and SM3) and factors influencing lymphatic metastasis formation were assessed.

Results

A total of 67 patients with pT1b tumors were analyzed, including 36 adenocarcinomas (53.7 %) and 31 squamous cell carcinomas (46.3 %). Lymph node involvement was seen in 22.4 % (15/67) patients without significant differences between SM1 3/11 (27.3 %), SM2, 4/18 (22.2 %), and SM3 (8/38) (21.8 %) (p?=?0.909) carcinomas. On binomial log-regression models, only lymphangioinvasion and tumor length >2 cm was significantly associated with lymph node involvement.

Conclusion

As depth of submucosal tumor infiltration did not correlate with the formation of lymph node metastases and in regard of the risk of lymphatic spread in these cases, surgical resection is warranted in pT1b carcinomas.