Que faire devant une tumeur superficielle étendue du rectum ?

Lateral spreading tumors are superficial spreading neoplasms now increasingly diagnosed using high definition endoscopy and chromoscopic colonoscopy. There are two types of LST: granular type (LST-G) and non-granular type, (LST-NG). LST-NG type, especially the pseudodepressed type, has a significantly higher frequency of submucosal invasion than LST-G type. LSTs are usually removed, therefore, by endoscopic mucosal resection (EMR) but larger tumors (> 2 cm) may require piecemeal resection in case of LST-G type. Endoscopic submucosal dissection (ESD) allows en-bloc resection irrespective of the size of the lesionand is indicated in LST-NG type or large elevated lesions suspected to be carcinoma. Transanal endoscopic microsurgery (TEM) offers a minimally invasive alternative to radical surgery. Rectal ESD is still under evaluation in France in a SFED/INCa prospective trial.     

State of the art on endoscopic mucosal resection and endoscopic submucosal dissection

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) provide new alternatives for minimally invasive treatment of superficial gastrointestinal malignancies. Evidence suggests that these techniques can be performed safely and have comparable outcomes to surgery with less morbidity and better quality of life due to their tissue-sparing nature when compared with conventional surgery. Although the techniques and accessories have become standardized, there is room for improvement, and further research and development are required. Current challenges facing American gastroenterologists or endoscopic surgeons include access to training and lack of appropriate reimbursement for these heavy-weighted and technically demanding procedures. Nevertheless, EMR and ESD are here to stay and are only the first steps toward true radical endoluminal resection of GI malignancies.     

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。     

直肠类癌33例内镜治疗体会及文献回顾

目的总结直肠类癌的内镜下治疗方法与各自的优势。方法对2009年1月至2012年12月33例直肠类癌行内镜下治疗患者的临床资料进行回顾性分析,所有患者根据情况分别选择内镜下黏膜切除术（EMR）或经内镜黏膜下剥离术（ESD）治疗,总结其内镜下表现特点及治疗情况。结果 33例直肠类癌中,14例行EMR治疗,19例行ESD治疗。病灶位于直肠距肛门齿状线4～15cm,切除病灶直径0.3～1.5 cm。7例行EMR中途改行ESD,2例EMR术后肿瘤残留追加外科手术。病理学分析ESD组完整切除率（100%）较EMR组完整切除率（85.7%）有所提高,但差异无统计学意义（P〉0.05）。两组均未出现大出血、穿孔等并发症。结论相比EMR,ESD可能有利于实现直肠类癌病变的完整切除,减少复发,且安全性不亚于EMR。对于较小的直肠类癌,ESD不失为一种有效的治疗手段。     

Endoscopic submucosal dissection for residual/local recurrence of early gastric cancer after endoscopic mucosal resection

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) is a widely accepted treatment for early gastric cancer; however, incomplete resection with residual local disease and recurrences continues to be a difficult problem. The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for residual/local recurrent early gastric cancer lesions after EMR. PATIENTS AND METHODS: The en bloc resection rate, histologically complete resection rate, complications, and local recurrence were assessed in 15 patients who underwent ESD for residual/local recurrent early gastric cancer lesions after EMR. RESULTS: The nonlifting sign after injection of a glycerin solution was positive due to scar formation in all cases. En bloc resection was attempted in all cases, with a complete resection rate of 93.3 % (14 of 15). The lesion was completely resected with histologically adequate margins in the 14 patients who received complete en bloc resection. The average operation time was 85.4 +/- 52.9 min, and the mean follow-up period for all patients was 18.1 +/- 7.4 months. Major bleeding during the procedure in one case was the only complication (one of 15, 6.7 %). None of the patients experienced recurrence of early gastric cancer after ESD. CONCLUSIONS: ESD appears to be a safe and effective treatment for residual/local recurrent early gastric cancer lesions after EMR, and it is useful for histological confirmation of successful treatment.     

超声内镜在上消化道黏膜隆起型病变诊断和治疗中的应用

目的探讨超声内镜在上消化道黏膜隆起型病变的诊断和内镜治疗中的价值。方法运用超声内镜检查114例上消化道黏膜隆起型病变,并对其中26例进行超声内镜引导下病变切除术。结果黏膜隆起病变性质以间质瘤最常见,占51.8%,其次,壁外压迫占21.9%,较少见有恶性肿瘤、脂肪瘤、异位胰腺、囊肿等。对26例黏膜下肿瘤进行切除,超声诊断和病理符合率达77.0%。手术并发症少见。结论超声内镜可初步定性上消化道黏膜隆起型病变,对黏膜下肿瘤的治疗选择有指导作用;超声内镜引导下内镜切除黏膜下间质瘤安全、有效。     

水下内镜切除术在消化道肿瘤治疗中的应用 （附452例综合分析）*

目的探讨水下内镜切除术在治疗消化道肿瘤中的疗效及安全性。方法通过美国国立医学图书馆搜索引擎PubMed,分别以"underwater endoscopic mucosal resection","underwater endoscopic submucosal dissection","underwater peroral endoscopic myotomy"为关键词,检索出相关文献,汇总病例并进行分析。结果共检索出40篇相关文献,纳入452例病例,其中水下内镜下黏膜切除术(UEMR)413例,水下内镜黏膜下剥离术(UESD)37例,水下经口内镜下肌切开术(UPOEM)2例。413例UEMR患者一共有468个病灶,切除成功率为98.5%,其中整块切除率达61.1%,整块切除者的R0切除率为94.3%;37例UESD患者共有39个病灶,所有病灶均经UESD完整剥离;2例UPOEM患者成功行水下黏膜下隧道建立及肌切开。全组术后并发症较低,以出血多见,其他包括穿孔、十二指肠腔狭窄、低钠血症、吸入性肺炎和自限性息肉切除术后综合征。结论水下内镜切除技术是一项较为安全有效的治疗手段,易于掌握且操作方便。今后仍需要更多的临床研究以及长期随访资料,以明确水下内镜切除技术与常规内镜下黏膜切除术(EMR)或内镜黏膜下剥离术(ESD)相比的优势及适应证,便于临床应用及推广。     

早期结直肠癌及癌前病变患者经内镜下黏膜切除术与黏膜剥离术治疗的疗效比较

目的比较内镜下黏膜切除术(EMR)与内镜下黏膜剥离术(ESD)在结直肠癌前病变与早期癌患者中的应用效果。方法选取2010年1月-2015年1月该院收治的116例早期结直肠癌患者与结直肠腺瘤患者为研究对象。其中,61例患者采用EMR治疗,为EMR组,55例采用ESD治疗,为ESD组。比较EMR与ESD在结直肠癌前病变与早期癌患者中的应用效果。结果 EMR组患者的手术时间明显短于ESD组患者,两组患者的病理情况、异型增生程度的差异无统计学意义(P0.05)。ESD组病变最大径≥2 cm的整块切除和病变最大径≥2 cm的组织治愈性切除的患者明显多于EMR组,差异有统计学意义(P0.05)。ESD组病变最大直径≥2 cm的患者明显多于EMR组,差异有统计学意义(P0.05)。EMR组和ESD组患者并发症总发生率分别为6.56%和23.63%,差异有统计学意义(P0.05)。EMR组和ESD组患者的复发率分别为5(8.20%)例和3(5.45%)例,差异无统计学意义(P0.05)。ESD术后出现并发症的危险因素为操作经验和病变大小(P0.05)。结论 ESD术和EMR术均能较好的整块切除病变最大径≥2 cm的早期结直肠癌与结直肠腺瘤,术后复发率较低。ESD术相对于EMR术更适合较大的病变,但术后复发率较高,且手术医师的操作经验和病变大小为ESD术后发生并发症的危险因素,应加强监测。     

Characteristics of metachronous multiple early gastric cancers after endoscopic mucosal resection

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) of early gastric cancer is a minimally invasive procedure. The incidence and characteristics of metachronous multiple gastric cancers were investigated in a retrospective study in patients with early gastric cancer after EMR treatment. PATIENTS AND METHODS: A total of 143 patients with early gastric cancer who had undergone EMR treatment were periodically followed up with endoscopic examinations for 24 months or longer. RESULTS: The median period of endoscopic follow-up was 57 months (range 24 - 157 months). None of the patients died of gastric cancer, and there were no treatment-related deaths. Five patients died of other diseases. Of 20 patients (14 %) with metachronous multiple gastric cancers, 15 were treated by EMR. One patient with differentiated submucosal cancer and four with undifferentiated cancers underwent surgery. Sixteen patients (11 %) had synchronous multiple early gastric cancer lesions within 1 year of the initial EMR. About half of the multiple lesions were located in the same third of the stomach as the primary lesion, and most lesions were similar in macroscopic type to the primary lesions. Most multiple lesions were of the differentiated type. CONCLUSIONS: Annual endoscopic examinations can preserve the whole stomach in most patients with early gastric cancer after successful EMR.     

十二指肠隆起性病变的内镜治疗

目的分析十二指肠隆起性病变内镜治疗的安全性及有效性。方法对十二指肠隆起性病变患者内镜治疗的临床资料、内镜治疗方法、病理特点、并发症和随访情况进行回顾性分析。结果 112例患者中111例均行内镜治疗,1例中转外科治疗。其中行电凝灼烧术49例,圈套切除术+内镜下黏膜切除术(EMR)36例,内镜黏膜下剥离术(ESD)27例。并发症发生率16.96%(19/112),其中1例因术中大出血,止血困难,中转开腹治疗,7例术中活动性出血,予电热活检钳止血治疗,穿孔6例,迟发性出血2例,一过性淀粉酶升高2例,迟发性穿孔1例。术后随访1~12个月总有效率100.0%。结论内镜治疗十二指肠隆起性病变,具有创伤小、恢复快、费用低和并发症少等优点,内镜治疗将在十二指肠肿瘤中发挥重要的作用。     

Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) of early gastrointestinal cancers has been shown to be effective in treating mucosal malignancies, but en bloc resection (where the entire tumor is removed in one piece) is often not achieved using conventional cap EMR. Other techniques, developed in Japan, include the application of different types of knife such as the insulated-tip instrument. We report our preliminary experience of the use of this knife, in conjunction with other techniques, in attempting en bloc resection of early mucosal cancers and adenomas and in the removal of submucosal tumors (SMTs) of the upper gastrointestinal tract. PATIENTS AND METHODS: A total of 37 patients (26 men, 11 women, age range 53 - 86) were included in the study; 23 patients had 24 mucosal lesions amenable to EMR, and 14 patients had SMTs shown on endosonography to spare the muscularis propria. Lesions were located in the esophagus (n = 13), the stomach (n = 24), and the duodenum (n = 1); 40 % of the mucosal lesions were 20 mm or larger (mean size 18mm), whereas the mean size of the submucosal lesions was 23 mm. After submucosal saline injection, circumcision and dissection of the mucosal lesions was attempted with the aim of achieving en bloc resection. For SMTs, cap mucosectomy of the overlying mucosa was done first, and the tumors were then freed using saline injection, and finally resected using snare polypectomy. RESULTS: The strict aim of the study, i. e. complete tumor removal in a single piece, was achieved in only 25 % of the mucosal lesions (some failures were due to unrecognized submucosal infiltration) and 36 % of the SMTs. When a more liberal definition of success was assumed, this rate increased to 65 % for mucosal lesions (piecemeal, no tumor found at surgery or follow-up endoscopy with biopsy) and 79 % for SMTs (piecemeal). No severe complications necessitating surgery or leading to major morbidity occurred. However, clinically significant complications were found in six patients (minor perforation managed conservatively (n = 1), severe pain without perforation (n = 1), bleeding requiring reintervention (n = 3), and aspiration (n = 1)). CONCLUSIONS: Although we are convinced that methods of achieving en bloc resection of mucosal cancers and SMTs must be pursued, the insulated-tip knife in conjunction with conventional endoscopes still has limitations. Innovative endoscope design (double-channel scopes) as well as the development of new accessories will help to overcome the current limitations and further promote endoscopic tumor resection.     

Meta-analysis comparing differing methods of endoscopic therapy for colorectal lesions

AIM: To compare the outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) of colorectal lesions. METHODS: An electronic systematic literature search of four computerized databases was performed in July 2014 identifying studies reporting the outcomes of colorectal ESD and EMR. The primary outcome measures were en-bloc resection rate, endoscopic clearance rate and lesion recurrence rate of the patients followed up. The secondary outcome was the complication rate (including bleeding, perforation and surgery post EMR or ESD rate). Statistical pooling and random effects modelling of the studies calculating risk difference, heterogeneity and assessment of bias and quality were performed. RESULTS: Six observational studies reporting the outcomes of 1324 procedures were included. The en-bloc resection rate was 50% higher in the ESD group than in the EMR group (95%CI: 0.17-0.83, P < 0.0001, I² = 99.7%). Endoscopic clearance rates were also significantly higher in the ESD group (95%CI: -0.06-0.02, P < 0.0001, I² = 92.5%). The perforation rate was 7% higher in the ESD group than the EMR group (95%CI: 0.05-0.09, P > 0.05, I² = 41.1%) and the rate of recurrence was 50% higher in the EMR group than in the ESD group (95%CI: 0.20-0.79, P < 0.001, I² = 99.5%). Heterogeneity remained consistent when subgroup analysis of high quality studies was performed (with the exception of piecemeal resection rate), and overall effect sizes remained unchanged for all outcomes. CONCLUSION: ESD demonstrates higher en-bloc resection rates and lower recurrence rates compared to colorectal EMR. Differences in outcomes may benefit from increased assessment through well-designed comparative studies.     

内镜黏膜下剥离术及内镜下黏膜切除术治疗十二指肠癌前病变及十二指肠早期癌的临床研究

目的 探索内镜黏膜下剥离术（ESD）及内镜下黏膜切除术（EMR）治疗十二指肠癌前病变及十二指肠早期癌的效果及安全性。方法 回顾性分析2016年9月－2021年3月16例于该院发现并行ESD及EMR治疗的十二指肠癌前病变或十二指肠早期癌患者的临床资料,分析ESD及EMR的临床疗效及安全性。结果 16例患者中,14例病变位于降段乳头对侧或偏对侧,2例病变位于球降交界部,病变大小0.8～2.6 cm,平均（1.2±0.7）cm,切除标本大小1.5～3.5 cm,平均（2.2±0.8）cm,手术时间54～127 min,平均（68.6±25.9）min。9例一次性整块切除病变;7例沿病变外周3 mm环形切开黏膜层及黏膜下层,用圈套器圈套切除,残留组织用碗状热凝钳切除;用止血夹对吻缝合或止血夹联合尼龙绳行荷包缝合创面。术后1例患者行ESD整块剥离后发生术后穿孔,追加腹腔镜下局部修补手术,术后患者恢复良好出院,其余患者均无并发症发生,效果良好。结论 对于十二指肠黏膜的癌前病变及十二指肠早期癌,内镜微创切除治疗是一种重要的治疗方法,疗效确定,术后迟发性穿孔是主要并发症。     

Pneumothorax following endoscopic submucosal dissection of a rectal tumor

Endoscopic submucosal dissection is a useful alternative to endoscopic mucosal resection and surgery for en bloc resection of colorectal tumors. However, the technique is considered to be difficult, and potential complications include perforation and postoperative bleeding. In this case report, we present a case of a 63-year-old woman who developed pneumothorax after endoscopic submucosal dissection of a rectal tumor.     

Aggressive endoscopic mucosal resection in the upper GI tract — Hook knife EMR method —

Summary

We have developed a new EMR method, the ‘Hook knife’ method, for the en-bloc resection of larger lesions. First, we placed marks around the lesion with a coagulation tip. Next, 10% glycerol diluted epinephrine solution was injected into the submucosal layer to separate the mucosa from the muscular layer proper. Then, we cut the mucosa around the lesion with a needle knife. Finally, we cut the submucosal fibers and vessels using a hook-type knife and resected the lesions. A large en-bloc resection, ≥70 mm in size, was possible with this new EMR method. Because of this, the histological examination for both the range of lateral spreading and the depth of invasion can be made more precisely. Aggressive endoscopic mucosal resection is established by this new EMR method.     

Indications, Knives, and Electric Current: What's the Best?

Endoscopic submucosal dissection (ESD) was developed to overcome the limitations of conventional endoscopic mucosal resection (EMR), and ESD has been also applied for large colorectal neoplasms. Since colorectal ESD is still associated with higher perforation rate, a longer procedure time, and increased technical difficulty, the indications should be strictly considered. Generally, colorectal tumors without deep submucosal invasion or minimal possibility of lymph node metastasis, for which en bloc resection using conventional EMR is difficult, are good candidates for colorectal ESD. The ideal knife for colorectal ESD should avoid making perforations but can make a clean cut of optimal depth at one time. The ideal current for ESD differs depending on the procedure used, the surgical devices used, the tissue to be dissected, and the operator's preference. Application of the optimal indications and improvements in the technical skill and surgical devices are required for easier and safer colorectal ESD.     

直肠神经内分泌肿瘤的内镜下诊断与治疗

目的分析直肠神经内分泌肿瘤(R-NENs)的临床病理学特征,并探讨R-NENs内镜下的诊断特点及内镜下治疗的效果及安全性。方法回顾性分析2010年1月-2019年9月就诊于新疆医科大学第一附属医院并行常规结肠镜检查的76例R-NENs患者的临床资料,均经组织标本活检或手术切除瘤体病理检查明确诊断为R-NENs。结果肿瘤位于低位直肠段32例(42.11%),中段25例(32.89%),下段19例(25.00%)。36例行超声内镜(EUS)检查,其中27例EUS下诊断为R-NENs,2例诊断为间质瘤,6例诊断为脂肪瘤,1例诊断为平滑肌瘤,与病理结果诊断符合率达75.00%(27/36)。29例病例行内镜黏膜下剥离术(ESD),22例行内镜下黏膜切除术(EMR),20例行内镜经黏膜下隧道肿物剥离术(STER),2例行电凝电切术,3例因不同原因未通过上述内镜手术方式进行治疗。所有患者中69例行病理学检查及免疫组化检查,结果证实G1级最多见,共62例,占所有病例的81.58%(62/76)。结论R-NENs以男性多见,好发于中低位直肠段,其中G1级最为常见;EUS技术的成熟运用能够对病变性质及组织学起源进行较准确的判断,但也存在一定的误诊率,最终还应以病理结果为金标准;早期G1、G2级R-NENs经内镜治疗是安全有效的,并且能够提供较完整的病理学资料。     

超声内镜指导下食管间质瘤黏膜切除术

目的探讨超声内镜指导下食管间质瘤黏膜切除术的意义。方法对2005年～2007年5月76例疑为消化道黏膜下肿瘤的患者进行超声内镜检查,其中34例食管病变超声内镜显示病变来源于黏膜下层,有24例经知情同意后行超声内镜下黏膜切除术。切除的病变经过病理检查明确病变的层次和病变性质。结果通过与病理结果对照表明,超声内镜检查能准确地判断肿瘤所在层次;通过黏膜切除术切除所有的病变,无1例发生并发症。结论超声内镜指导食管间质瘤黏膜切除术既准确又安全。     

Endoscopic mucosal resection.

Endoscopic mucosal resection (EMR) is a major advance in endoscopy for treatment of patients with superficial esophageal, gastric, or colonic lesions, providing a nonsurgical treatment option for management of these lesions. With the assistance of endoscopic ultrasonography, it is now possible to obtain an accurate histologic diagnosis, confirm the depth of the lesion, and in many cases resect submucosal tumors. The main goal of EMR using the advances in endosonography is to detect early gastrointestinal cancers and successfully resect them, offering an outpatient, nonsurgical treatment option. Although popular in the Orient, where there is a high incidence of superficial neoplasia, limited data are available on the use of EMR in the United States. Gastrointestinal (GI) endoscopy nurses and assistants play important roles in successful EMR. This article informs GI staff on the indications for EMR, the procedure and accessories needed, the different resection methods, possible complications, and nursing care.     

内镜黏膜下剥离术治疗老年早期上消化道肿瘤的效果

目的 探讨内镜黏膜下剥离术治疗老年上消化道早期肿瘤的疗效.方法 收集安徽医科大学附属安庆医院消化内科2017年3月至2019年10月收治的67例老年上消化道早期肿瘤患者的临床资料,患者入院后均行内镜黏膜下剥离术(ESD),术后跟踪随访,评估内镜治疗的术前术后病理结果、并发症发生率、病灶整块切除率、住院时间、术后残留及复...