404例Barrett食管分析

我院2006年5月~2008年6月内镜及病理检查Barrett食管(BE)404例。结果BE占胃镜人数的4.4%,短段BE占BE的83.2%,发现10例异型增生,其中6例异型增生都发生在伴有肠上皮化生的黏膜上。BE的确诊要依靠活组织病理检查,为提高检出率必须采用四象活检法。     

内镜黏膜切除术在Barrett食管诊治中的临床应用

目的探讨内镜黏膜切除术(EMR)在Barrett食管(BE)诊治中的应用价值。方法选取EMR术后病理诊断为异型增生的50例患者,对手术前后病理结果进行对照,同时对手术并发症进行观察和处理。结果切除病变57处,病变首次完全切除者52处(91.2%),术后病理诊断轻度异型增生9处,中度异型增生20处,重度异型增生28处。手术前后病理诊断相符者45处占78.9%,12处不相符的病变中有10处手术前活检病理级别低于术后病理级别。并发症出血12例,均经处理后停止出血,无一例发生穿孔。结论 EMR治疗BE比较安全,并且能提高诊断率,值得临床推广应用和深入研究。     

Barrett食管的光动力治疗

Barrett食管（BE）是食管及食管、胃连接部腺癌惟一已知的癌前病变。目前认为,食管下端的复层鳞状上皮被化生的柱状上皮所代替,无论化生的是胃上皮、小肠上皮,还是大肠上皮,都可以定义为BE。BE的癌变将经历特殊肠化生一不典型增生一原位癌一浸润性腺癌的病理进程。BE腺癌的诊断依据如下：①确诊的原发性食管腺癌;②有BE病史;③具备确切的组织学形态;④找BE从异型增生发展到原位癌和浸润癌的过渡形态。     

超声内镜下黏膜切除术在上消化道病变治疗中的应用观察

目的探讨超声内镜下黏膜切除术(EMR)在上消化道病变治疗中的应用效果。方法选择2013年1月—2015年12月在石家庄市第一医院就诊并在消化内镜中心行胃镜检查发现的上消化道隆起性病变108例,行超声内镜(EUS)指导EMR或内镜下黏膜分片切除术(EPMR),观察并分析其治疗效果。结果 103例行EMR,均一次性成功切除病灶;5例病灶2.0 cm行EPMR,最终完全切除。术后病理检查结果显示食管化生性息肉2例,食管平滑肌瘤10例,食管乳头状瘤16例,食管间质瘤6例,食管黏膜内癌2例;贲门腺瘤2例,贲门增生性息肉8例,胃腺瘤30例,胃嗜酸性肉芽肿2例,胃增生性息肉8例,胃间质瘤8例,胃异位胰腺5例,胃脂肪瘤3例;十二指肠球部腺管状腺瘤伴轻~中度异型增生4例,十二指肠降部Brunner腺瘤2例。108例中6例术中出现少量出血,予相应治疗,成功止血。108例术后6个月复查,病变愈合,未见病变残留和复发。结论 EUS指导EMR治疗上消化道病变效果良好,并发症少。     

内镜分级治疗Barrett食管的临床价值探讨

目的:探讨内镜分级治疗Barrett食管(BE)的临床价值。方法:通过NBI内镜引导靶向活检,对BE病灶实施动态病理监测,早期识别特殊肠化生细胞(SIM)、低度异型增生(LGD)、高度异型增生(HGD)、原位癌等病变阶段,在内镜下实施氩离子凝固疗法(APC)、透明帽辅助内镜黏膜切除术(EMRC)、内镜黏膜下剥离术(ESD)分级治疗。结果:术后第6个月复发内镜BE6例,病理BE4例,应用APC治疗后消失;本组未见出血、穿孔、狭窄等并发症。结论:内镜下APC、EMRC、ESD分级治疗BE近期疗效好、并发症少,是一种安全、有效的干预手段。     

Barrett食管与胃食管反流病及食管腺癌的关系

胃食管反流(gastroesophageal reflux,GER)在人群中普遍存在,Barrett食管(Barrett’s esophagus,BE)及食管腺癌(esophageal adenocarcinoma,EA)的发病率也在逐年升高。为了解BE与胃食管反流病(gastroesophageal reflux dis-ease,GERD)、EA的关系,本文复习近年相关文献,从病理生理基础及诊断、治疗方法入手进行探讨,结果发现三者的病情进展过程为正常食管黏膜-GERD-BE化生-BE低度和高度异型增生-EA。故BE的治疗应以减轻GER症状为主,并定期筛检和评价预后,以早期发现EA。     

内镜下窄带成像技术在诊断Barrett食管中的应用

Barrett食管(Barrett esophagus,BE)是指食管下段的复层鳞状上皮被单层柱状上皮所替代的一种病理现象,可伴或不伴肠化,其中伴有特殊肠上皮化生(specialized intestinal metaplasia,SIM)者属于食管腺癌的癌前病变。目前认为BE的癌变经过SIM→低度异型增生→高度异性型增生→原位癌→浸润性     

食管黏膜活检高级别上皮内瘤变与手术后病理对比研究

目的探讨食管黏膜活检病理诊断高级别上皮内瘤变与其术后病理的关系。方法回顾分析经内镜活检诊断为食管高级别上皮内瘤变并行手术72例患者的临床资料。结果术后病理16例(22.22%)维持高级别上皮内瘤变诊断,30例(41.67%)为早期食管癌,26例(36.11%)为进展期食管癌。内镜下病灶形态多样,表现为局灶黏膜粗糙、充血发红或糜烂、小溃疡形成、轻度隆起、不规则肿块等。结论内镜下食管黏膜活检诊断高级别上皮内瘤变时一部分患者已存在浸润性癌,应引起足够重视并应积极治疗。     

内镜超声在食管黏膜下肿物临床诊疗中的应用价值

目的探讨内镜超声在食管黏膜下肿物(SMT)临床诊疗中的应用价值。方法回顾性分析该院113例胃镜下发现的食管SMT并行超声内镜(EUS)检查的患者,收集患者115处SMT病变的临床特点、内镜检查治疗和病理组织学结果等资料,并对术后患者进行随访。结果 SMT好发于食管上段44处(38.26%)和中段(38/115,33.04%);病理结果显示,84.35%为平滑肌瘤(97/115),另外5处食管囊肿(4.35%),5处黏膜下固有腺体增生伴导管扩张(4.35%),2处间质瘤(1.74%),2处脂肪瘤(1.74%),1处神经鞘瘤(0.87%),1处血管瘤(0.87%),1处浆液性腺瘤(0.87%),1处颗粒细胞瘤(0.87%);EUS诊断符合率分别为平滑肌瘤93.00%(93/100),食管囊肿55.50%(5/9),间质瘤0.00%(0/3),脂肪瘤100.00%(2/2),血管瘤100.00%(1/1)。EUS诊断起源于黏膜肌层者,主要选择内镜下黏膜切除术(EMR)(76.12%,51/67)和内镜黏膜下剥离术(ESD)(23.88%,16/67)治疗,起源于黏膜下层者,主要选择EMR(35.71%,5/14)和ESD(64.29%,9/14)治疗,起源于固有肌层或累及固有肌层者,多选择经内镜黏膜下隧道肿瘤切除术(STER)(84.85%,28/33)治疗。免疫组化结果示平滑肌瘤98.97%(96/97)平滑肌肌动蛋白(SMA)和97.94%(95/97)结蛋白(Desmin)表达阳性。结论 EUS对SMT的病理性质可进行较准确的诊断,并指导食管SMT内镜下微创手术方式的选择,能进行安全有效的治疗,但对食管间质瘤、神经鞘瘤等少见食管肿瘤的诊断具有一定的局限性。     

醋酸联合亚甲蓝染色对胃黏膜隆起型病变的诊断价值

目的探讨内镜下醋酸联合亚甲蓝染色对胃黏膜隆起型病变的临床诊断价值。方法因各种消化道症状接受胃镜检查者,发现胃黏膜隆起型病变者随机分为3组,分别用亚甲蓝、醋酸、醋酸联合亚甲蓝染色(简称联合组),然后活检或镜下切除后做病理检查。结果共入选270例,每组90例。联合组中12例出现喷洒染色剂后黏膜退色,其早期癌、高级别上皮内瘤变发现率为33.3%(4/12),33.3%(4/12);25例出现喷洒染色剂后黏膜着色不良,黏膜表面腺管开口紊乱,其肠上皮化生、低级别上皮内瘤变的发现率之和为72.0%(18/25)。联合组共检出癌5例(5.6%)、高级别上皮内瘤变5例(5.6%),肠上皮化生21例(23.3%)。结论内镜下醋酸联合亚甲蓝染色可提高胃黏膜隆起型病变患者癌及癌前病变的发现率,黏膜退色可提高癌和高级别上皮内瘤变的检出率,黏膜着色不良对于肠上皮化生和低级别上皮内瘤变的诊断有一定的指示意义,并可以为内镜下切除病变范围提供可靠的依据。     

Mucosectomy for high‐grade dysplasia in Barrett's esophagus

Reports on the natural history of high‐grade dysplasia (HGD) are sometimes contradictory, but suggest that 10–30% of patients with HGD in Barrett's esophagus (BE) will develop a demonstrable malignancy within five years of the initial diagnosis. Surgery has to be considered the best treatment for HGD or superficial carcinoma, but is contraindicated in patients with severe comorbidities. Non‐surgical treatments such as intensive endoscopic surveillance, endoscopic ablative therapies, and endoscopic mucosal resection (EMR) have been proposed. EMR is a newly developed procedure promising to become a safe and reliable non‐operative option for the endoscopic removal of HGD or early cancer within BE. It is important to assess the depth of invasion of the lesion and lymph node involvement before choosing EMR. This technique permits more effective staging of disease obtaining a large sample leading to a precise assessment of the depth of malignant invasion. Complications such as bleeding and perforation may occur, but can be treated endoscopically. Trials are needed to compare endoscopic therapy with surgical resection to establish clear criteria for EMR and ablative therapies.     

Mucosectomy for high-grade dysplasia in Barrett's esophagus.

Reports on the natural history of high-grade dysplasia (HGD) are sometimes contradictory, but suggest that 10-30% of patients with HGD in Barrett's esophagus (BE) will develop a demonstrable malignancy within five years of the initial diagnosis. Surgery has to be considered the best treatment for HGD or superficial carcinoma, but is contraindicated in patients with severe comorbidities. Non-surgical treatments such as intensive endoscopic surveillance, endoscopic ablative therapies, and endoscopic mucosal resection (EMR) have been proposed. EMR is a newly developed procedure promising to become a safe and reliable non-operative option for the endoscopic removal of HGD or early cancer within BE. It is important to assess the depth of invasion of the lesion and lymph node involvement before choosing EMR. This technique permits more effective staging of disease obtaining a large sample leading to a precise assessment of the depth of malignant invasion. Complications such as bleeding and perforation may occur, but can be treated endoscopically. Trials are needed to compare endoscopic therapy with surgical resection to establish clear criteria for EMR and ablative therapies.     

Histology of Barrett's esophagus and dysplasia

This article explores issues related to the diagnosis of Barrett's esophagus (BE) in endoscopic biopsies and dysplasia in Barrett's epithelium. The definitions of BE, including long- and short-segment BE, are reviewed, with an emphasis on the significance of intestinal metaplasia (IM). IM of the gastroesophageal junction and cardia is reviewed and problems in its distinction from short-segment BE are discussed. In addition, the article reviews the classification of dysplasia in Barrett's mucosa, with reference to problematic areas, such as sampling error and interobserver variability. Biomarkers and their role in the diagnosis of dysplasia and stratification of risk are summarized.     

Clinical impact of conventional endosonography and endoscopic ultrasound-guided fine-needle aspiration in the assessment of patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma who have been referred for endoscopic ablation therapy

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett's esophagus and high-grade dysplasia or intramucosal adenocarcinoma. However, there is lack of uniformity regarding which staging method should be used prior to therapy, and some investigators even question whether staging is required prior to ablation. We report our experience with a protocol of conventional endoscopic ultrasound staging prior to endoscopic therapy. PATIENTS AND METHODS: A total of 25 consecutive patients with a diagnosis of high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus who had been referred to the University of Chicago for staging in preparation for endoscopic therapy between March 2002 and November 2004 were included in the study. All 25 patients underwent repeat diagnostic endoscopy and conventional endosonography with a radial echo endoscope. Any suspicious lymph nodes that were detected were sampled using endoscopic ultrasound-guided fine-needle aspiration. RESULTS: Baseline pathology in the 25 patients (mean age 70, range 49-85) revealed high-grade dysplasia in 12 patients and intramucosal carcinoma in 13 patients. Five patients were found to have submucosal invasion on conventional endosonography. Seven patients had suspicious adenopathy, six regional (N1) and one metastatic to the celiac axis (M1a). Fine-needle aspiration confirmed malignancy in five of these seven patients. Based on these results, five patients (20%) were deemed to be unsuitable candidates for endoscopic therapy. CONCLUSIONS: By detecting unsuspected malignant lymphadenopathy, conventional endosonography and endoscopic ultrasound with fine-needle aspiration dramatically changed the course of management in 20% of patients referred for endoscopic therapy of Barrett's esophagus with high-grade dysplasia or intramucosal carcinoma. Based on our results, we believe that conventional endosonography and endoscopic ultrasound with fine-needle aspiration when nodal disease is present should be performed routinely in all patients referred for endoscopic therapy in this setting.     

内镜套帽法治疗食管早期癌及癌前病变

目的　探讨内镜套帽法切除食管早期癌及癌前病变的应用价值。方法　采用套帽法切除食管早期癌及癌前病变 5 7例 ,其中食管早期癌 33例 ,癌前病变 2 4例 ;全组术前和术后均经病理证实。结果　 5 7例中完全切除 4 8例 (84 .2 % ) ,不完全切除 9例中 1例改手术治疗 ,1例放射治疗 ,余行微波或氩离子凝固治疗 ;重度不典型增生灶 2 1例中 ,术后病理灶性癌变 6例 (2 8.6 % ) ;中度不典型增生灶 10例 ,术后重度不典型增生 2例 (2 0 .0 % ) ,灶性癌变 1例(10 .0 % ) ;1例术中出血 ,无穿孔、狭窄发生 ;随访 5年以上 12例 ,>3～ 5年 11例 ,1～ 3年 2 3例 ,不足 1年 11例 ,1例术后复发 ,非癌死亡 3例。结论　套帽法完全切除率较高 ,操作较简单 ,优于其他方法 ;病灶显示及切除技巧是影响完全切除的主要因素 ;中度不典型增生短期复查无好转和重度不典型增生 ,应采用内镜治疗 ;内镜黏膜切除治疗在食管癌防治策略中具有重要价值和意义     

Diagnosis and management of Barrett's esophagus: What's next?

The past decade has led to marked improvements in our understanding regarding the pathogenesis and risk of progression of Barrett's esophagus (BE), enhanced imaging technology to improve dysplasia detection, and the development and refinement of endoscopic techniques, such as mucosal ablation and endoscopic mucosal resection(EMR), to eradicate BE. However, many questions remain including identifying which, if any, candidates are most appropriate for screening for BE; how to improve current surveillance protocols; predicting which patients with BE will develop neoplastic progression; identifying the most appropriate candidates for endoscopic eradication therapy; developing algorithms for appropriate management posteradication; and understanding the potential role of chemoprophylaxis. This article describes potential future advances regarding screening, surveillance, risk stratification, endoscopic eradication therapies, and chemoprevention and provides a potential future management strategy for patients with BE.     

Photodynamic therapy and endoscopic mucosal resection for Barrett's dysplasia and early esophageal adenocarcinoma

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas. MATERIALS AND METHODS: All patients with Barrett's esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT. RESULTS: In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia. CONCLUSIONS: The use of EMR resection in Barrett's high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett's mucosal adenocarcinoma. EMR should be strongly considered for Barrett's dysplasia patients being evaluated for endoscopic ablation therapy.     

内镜下黏膜剥切术联合氩离子血浆凝固术治疗消化道息肉的临床价值研究

目的分析内镜下黏膜剥切术(EMR)联合氩离子血浆凝固术(APC)治疗消化道多发息肉的临床应用价值。方法选取2014年11月至2015年12月收治的80例患有消化道多发息肉的患者作为研究对象,回顾性分析其临床资料,检查患者息肉,并将其按照随机的方法分为两组,即观察组(40例,息肉118枚)和对照组(40例,息肉112枚),其中观察组患者采用EMR联合APC治疗消化道多发息肉,而对照组给予高频电凝切除术治疗,统计分析两组患者的的一次性切除率、并发症的发生率及术后6个月随访后并发症发生情况。结果观察组患者中一次性切除108枚(91.53%),而对照组则一次性切除92枚(82.14%),前者明显高于后者,差异有统计学意义(P0.05);观察组患者总并发症的发生率为20.0%,而对照组则为40.0%,差异有统计学意义(P0.05)。术后6个月对两组患者的并发症情况进行了随访,其中对照组患者总并发症发生率高于观察组,差异有统计学意义(P0.05)。结论采用内镜下EMR联合APC用于治疗消化道息肉具有疗效确切、操作简便、耗时少、安全性好及术后并发症发生率低等优势,具有较好的临床应用价值,可在临床上推广应用。     

A randomized, prospective cross-over trial comparing methylene blue-directed biopsy and conventional random biopsy for detecting intestinal metaplasia and dysplasia in Barrett's esophagus

BACKGROUND AND STUDY AIMS: The value of methylene blue-directed biopsies (MBDB) in detecting specialized intestinal metaplasia and dysplasia in Barrett's esophagus remains unclear. The aim of this study was to compare the accuracy of MBDB with random biopsy in detecting intestinal metaplasia and dysplasia in patients with Barrett's esophagus. PATIENTS AND METHODS: A prospective, randomized, cross-over trial was undertaken to compare MBDB with random biopsy in patients with Barrett's esophagus segments 3 cm or more in length without macroscopic evidence of dysplasia or cancer. Dysplasia was graded as: indefinite for dysplasia, low-grade dysplasia, high-grade dysplasia, or carcinoma, and was reported in a blinded fashion. RESULTS: Fifty-seven patients were recruited, 44 of whom were male. A total of 1,269 biopsies were taken (MBDB-651, random biopsie-618). Analysis of the results by per-biopsy protocol showed that the MBDB technique diagnosed significantly more specialized intestinal metaplasia (75 %) compared to the random biopsy technique (68 %; P = 0.032). The sensitivity and specificity rates of MBDB for diagnosing specialized intestinal metaplasia were 91 % (95 % CI, 88 - 93 %) and 43 % (95 % CI, 36 - 51 %), respectively. The sensitivity and specificity rates of MBDB for diagnosing dysplasia or carcinoma were 49 % (95 % CI, 38 - 61 %) and 85 % (95 % CI, 82 - 88 %), respectively. There were no significant differences in the diagnosis of dysplasia and carcinoma - MBDB 12 %, random biopsy 10 %. The methylene blue staining pattern appeared to have an influence on the detection of specialized intestinal metaplasia and dysplasia/carcinoma. Dark blue staining was associated with increased detection of specialized intestinal metaplasia (P < 0.0001), and heterogeneous staining (P = 0.137) or no staining (P = 0.005) were associated with dysplasia and/or carcinoma detection. The MBDB technique prolonged the endoscopy examination by an average of 6 min. CONCLUSION: The diagnostic accuracy of the MBDB technique was superior to that of the random biopsy technique for identifying specialized intestinal metaplasia, but not dysplasia or carcinoma. The intensity of methylene blue staining has an influence on the detection of specialized intestinal metaplasia and dysplasia or carcinoma, which may help in targeting the biopsies. Although MBDB prolongs the endoscopy procedure slightly, it is a safe and well-tolerated procedure. Further clinical studies on the MBDB technique exclusively in endoscopically normal dysplastic Barrett's esophagus are needed.     

Endoscopic mucosal resection of early esophageal squamous cell cancer using the Duette mucosectomy kit

BACKGROUND AND STUDY AIM: Endoscopic mucosal resection (EMR) is a less invasive alternative treatment strategy to surgery for intramucosal esophageal squamous cell carcinoma (SCC). This study described our initial experience with the newly introduced Duette Multiband Mucosectomy Kit (Cook Ireland Ltd, Limerick, Ireland) for the treatment of extensive early esophageal SCC. PATIENTS AND METHODS: Five patients with extensive early esophageal SCC, covering at least half of the circumference of the esophageal wall and measuring a mean of 2.8 cm longitudinally, underwent EMR after EUS staging. RESULTS: EMR was successfully completed in one session in five patients. Post-EMR stricture occurred in four patients but was successfully treated with bougienage. One patient did not return for follow-up after bougienage and died from ischemic heart disease 3 months later. For the remaining four patients, there was no recurrence over a mean follow up of 14.7 months. CONCLUSION: This new device obviates the need for repeated insertion of the endoscope during the process of ligation and resection and thus facilitates EMR of extensive SCC.