内镜经黏膜下隧道肿瘤切除术与内镜黏膜下剥离术治疗食管固有肌层肿瘤的多中心随机对照研究

目的分析内镜经黏膜下隧道肿瘤切除术(STER)与内镜黏膜下剥离术(ESD)治疗食管固有肌层肿瘤的多中心随机对照结果。方法选择2014年12月至2015年12月中国人民解放军第四五一医院、中国人民解放军第三二三医院、陕西省人民医院这3个试验中心收治的204例食管固有肌层肿瘤患者,按随机数表法分为对照组和研究组,每组各102例。对照组予以ESD治疗,研究组予以STER治疗。比较两组患者的手术情况、并发症及创面愈合情况。结果研究组患者的手术时间、整块切除率高于对照组,而住院费用、住院时间低于对照组,差异具有统计学意义(P0.05)。研究组和对照组的完全切除率分别为100%和96.08%,两组比较差异无统计学意义(P0.05)。两组均有皮下气肿、迟发性出血、胸腔积液、剧烈疼痛发生,但研究组的并发症发生率低于对照组,且研究组的创面完全愈合率高于对照组(95.09%比32.35%),差异均有统计学意义(P均0.05)。结论 STER和ESD治疗食管固有肌层肿瘤均可起到较好的临床效果,但STER的整块切除率更高,并发症更少,且创面愈合更快,可能更适用于治疗食管固有肌层肿瘤。     

内镜黏膜下挖除术治疗食管固有肌层肿瘤

目的探讨内镜黏膜下挖除术（ESE）治疗食管固有肌层肿瘤的临床价值。方法回顾性分析2008年12月至2010年12月27例行ESE治疗的食管固有肌层肿瘤患者的资料,评价治疗的可行性、安全性和疗效。结果27例患者共29个病灶,病变直径0．5—3．0cm,平均（1．25±0．70）cm。切除率96．3％（26／27）,1例患者中转手术治疗。中位手术时间74（30～120）min。术后病理诊断平滑肌瘤26例,间质瘤1例。2例术中穿孔伴气胸,金属夹夹闭创面后予胸腔闭式引流,未行开胸手术修补。中位随访时间12（3～27）个月,未见复发病例。结论对于直径小于3．0cm、腔内生长为主的食管固有肌层肿瘤,ESE治疗具有安全、有效的特点,并可提供完整的病理学诊断资料,进一步扩大了内镜治疗的范围。     

内镜黏膜下剥离术治疗消化道固有肌层肿瘤

目的 探讨内镜黏膜下剥离术(ESD)治疗来源于消化道固有肌层黏膜下肿瘤(SMT)的疗效和安全性.方法 对内镜发现的消化道SMT进行超声检查,对来源于固有肌层的SMT应用头端弯曲的针形切开刀进行ESD治疗:(1)黏膜下注射生理盐水;(2)预切开病变周围黏膜;(3)剥离黏膜下层组织显露病变,一次性完整切除病变.结果 来源于固有肌层的消化道SMT 10例,术后病理诊断为食管平滑肌瘤1例,胃平滑肌瘤1例,胃间质瘤6例,直肠平滑肌瘤和间质瘤各1例.病变最大直径0.5～3.0 cm(平均1.4 cm).9例病变一次性完整剥离,1例创面肿瘤残留接受外科手术.ESD手术时间30～150 min(平均73.5 min).1例术中出现消化道穿孔,应用金属夹成功闭合,未转开腹手术修补.术中平均出血量约40 ml,术后均未出现出血,亦未出现其他并发症.结论 ESD治疗来源于固有肌层的消化道SMT安全、有效,大多可以一次性完整切除病变,提供完整的病理学诊断资料,达到外科手术同样的治疗效果.     

内镜超声辅助下隧道式内镜黏膜下剥离术治疗食管固有肌层肿瘤30例

对于起源于食管固有肌层的肿瘤,传统的治疗方式为胸外科手术,但是创伤较大。过去也有尝试应用ESD切除食管固有肌层肿瘤的报道,但其操作难度大、风险较大。近几年出现了隧道式ESD治疗食管固有肌层肿瘤的报道,但该方法也存在术中无法找到病灶的问题,甚至可能误伤大血管。我们尝试采用内镜超声辅助下隧道式ESD来治疗食管固有肌层肿瘤,取得了较满意的疗效。     

经食管黏膜下隧道内镜治疗胃底贲门固有肌层肿物的价值

目的 探讨经食管黏膜下隧道治疗胃底贲门部固有肌层起源肿物的的应用价值.方法 2011年1月至2011年12月间经超声内镜诊断胃底贲门固有肌层起源肿物18例,行经食管黏膜下隧道法内镜切除术,随访观察治疗效果.结果 18例患者治疗均取得成功,剥离病变大小0.7～7.2cm,平均大小约(2.43 ± 1.91)cm,病变均完整切除.术中出现腹膜后、纵隔、皮下气肿2例,3d后自行吸收.术后24h内出现发热1例,伴有WBC升高,抗炎对症处理后第2天完全缓解.无严重出血、穿孔及死亡病例.所有病例术后3d可正常进流质食,1周后复查食管隧道愈合创面形成.结论 内镜经食管黏膜下隧道技术是胃底贲门部固有肌层起源肿物剥离切除安全有效的方法,能有效降低内镜切除胃底贲门部固有肌层病变的难度.     

内镜经黏膜下隧道肿瘤切除术治疗上消化道固有肌层肿瘤的临床价值

目的:探讨内镜经黏膜下隧道肿瘤切除术(submucosal tunneling endoscopic resection,STER)治疗上消化道固有肌层肿瘤的可行性和安全性,以及术前超声内镜(endoscopic ultrasonography,EUS)检查的价值.方法:对经EUS证实的24例固有肌层肿瘤患者行STER(STER组),另取15例外科手术患者作为对照(外科手术组),分析两组的治疗情况.结果:术中发现,STER组有3例肿瘤位于黏膜肌层,改用其他治疗方式;余21例切除的肿瘤平均直径与外科手术组相比差异无统计学意义(P0.05),食管肿瘤治疗所需手术时长两组比较差异无统计学意义(P0.05),胃部肿瘤治疗所需手术时长STER组短于外科手术组(P0.01),STER组术后平均住院天数短于外科手术组(P0.01),住院花费亦比其少(P0.05).术前EUS的诊断符合率为92.3%.结论:STER治疗上消化道固有肌层肿瘤安全且高效.术前EUS检查对肿瘤的层次定位和治疗方式的选择具有重要的提示作用.     

食管巨大平滑肌瘤内镜下开窗剥离术治疗一例

食管平滑肌瘤是食管良性肿瘤之一,随着瘤体不断增大,可严重影响患者生活质量。其治疗从外科手术逐步发展至内镜下微创治疗。本文报道1例巨大食管平滑肌瘤行开窗式内镜黏膜下剥离术,瘤体完整切除,患者预后良好。     

内镜诊治食管黏膜肌层平滑肌瘤22例

在食管的黏膜下肿块（submucosal tumor，SMT）中，有一部分为来源于食管黏膜肌层的平滑肌瘤，可行胃镜下黏膜切除术（endoscopic mueosal resection，EMR）治疗。我院行该项治疗22例，报道如下。     

内镜黏膜下挖除术治疗胃固有肌层问质瘤

目的探讨内镜黏膜下挖除术（endoscopicsub—mucosalexcavation,ESE）治疗胃固有肌层间质瘤的疗效和安全性。方法对内镜超声（EUS）发现的源于胃固有肌层的黏膜下肿瘤（submucosaltumor,SMT）行ESE治疗：黏膜下注射生理盐水抬高病变,切开病变周围黏膜,剥离病变周围组织,完整切除病变。结果17例源于胃固有肌层的黏膜下肿瘤均成功挖除,2例ESE治疗中发生穿孔．应用金属止血夹成功夹闭。术后病理诊断为间质瘤,其中胃底8例,胃体8例,胃窦1例。病变最大直径0．7～4,3（平均1．5）cm。全组未出现ESE术后出血,随访2～30个月,恢复良好,未出现复发或转移。结论ESE治疗小的胃固有肌层间质瘤安全、有效,能一次性完整切除病变,提供完整的病理诊断资料。且术后恢复快。     

内镜下黏膜切除术在治疗食管黏膜肌层肿瘤中的应用

食管黏膜肌层肿瘤属于食管黏膜下肿瘤的一部分，而对于食管黏膜下肿瘤的治疗，传统的方法主要以手术治疗为主，随着超声内镜和内镜介入技术的发展，选择具有一定适应证的食管黏膜下肿瘤进行内镜下切除，已可替代部分外科手术治疗。我们对2年来在我院行内镜下黏膜切除术（endoscopic mucosal resection，EMR）治疗的食管黏膜下肿瘤患者的临床资料进行回顾性分析，以探讨其治疗效果。     

Submucosal tunneling endoscopic resection: An effective and safe therapy for upper gastrointestinal submucosal tumors originating from the muscularis propria layer

AIM To evaluate the effectiveness and safety of submucosal tunneling endoscopic resection(STER) and compare its outcomes in esophageal and cardial submucosal tumors(SMTs) of the muscularis propria(MP) layer.METHODS From May 2012 to November 2017, 173 consecutive patients with upper gastrointestinal(GI) SMTs of the MP layer underwent STER. Overall, 165 patients were included, and 8 were excluded. The baseline characteristics of the patients and SMTs were recorded. The en bloc resection rate, complete resection rate,residual rate, and recurrence rate were calculated to evaluate the effectiveness of STER, and the complication rate was recorded to evaluate its safety. Effectiveness and safety outcomes were compared between esophageal and cardial SMTs.RESULTS One hundred and twelve men and 53 women with a mean age of 46.9 ± 10.8 years were included. The mean tumor size was 22.6 ± 13.6 mm. Eleven SMTs were located in the upper esophagus(6.7%), 49 in the middle esophagus(29.7%), 46 in the lower esophagus(27.9%), and 59 in the cardia(35.7%). Irregular lesions accounted for 48.5% of all lesions. STER achieved an en bloc resection rate of78.7%(128/165) for GI SMTs with an overall complication rate of 21.2%(35/165).All complications resolved without intervention or were treated conservatively without the need for surgery. The en bloc resection rates of esophageal and cardial SMTs were 81.1%(86/106) and 72.1%(42/59), respectively(P = 0.142), and the complication rates were 19.8%(21/106) and 23.7%(14/59), respectively,(P =0.555). The most common complications for esophageal SMTs were gas-related complications and fever, while mucosal injury was the most common for cardial SMTs.CONCLUSION STER is an effective and safe therapy for GI SMTs of the MP layer. Its effectiveness and safety are comparable between SMTs of the esophagus and cardia.     

Submucosal tunneling endoscopic resection for simultaneous esophageal and cardia submucosal tumors originating from the muscularis propria layer (with video)

Submucosal tunneling endoscopic resection (STER) is a new treatment technique for upper gastrointestinal submucosal tumors (SMT) originating from the muscularis propria (MP) layer. In contrast to conventional endoscopic resection, the new therapy can maintain the mucosal integrity of the digestive tract, which effectively prevents mediastinitis and peritonitis. STER, although a known method, has not been widely adopted because of technical difficulties. Here, we describe the case of a 30‐year‐old patient presenting with two separate SMT originating from the esophageal and cardia MP layer. A 2‐cm longitudinal mucosal incision was made approximately 5 cm proximal to the esophageal SMT, and the esophageal and cardia SMT were dissected successively in the same submucosal tunnel. In the relevant literature, this is the first case of STER for resecting esophageal and cardia SMT using the same submucosal tunnel.     

经黏膜下隧道内镜肿瘤切除术治疗源于固有肌层的上消化道黏膜下肿瘤初探

目的探讨经黏膜下隧道内镜肿瘤切除术（STER）治疗来源于上消化道固有肌层黏膜下肿瘤（SMTs）的疗效和安全性。方法对26例经超声内镜和CT诊断为来源于固有肌层的上消化道SMTs患者全麻下行STER治疗：（1）内镜寻找到肿瘤,并准确定位;（2）建立黏膜下隧道,显露肿瘤;（3）内镜直视下完整切除肿瘤;（4）缝合黏膜切口。结果来源于固有肌层的上消化道SMTs患者26例中,食管14例,贲门7例,胃5例。来源于固有肌层浅层者11例,深层者15例,其中2例胃SMTs与浆膜层粘连,密不可分。STER成功切除所有黏膜下肿瘤,完整切除率100％,切除病变直径1．0～3．2cm（平均1．9cm）。黏膜切开至黏膜切口完整缝合时间25～145min,平均68．5min;完整缝合创面所用金属夹4—6枚,平均5枚。术后病理诊断为平滑肌瘤17例,间质瘤7例,血管球瘤1例,神经鞘膜瘤1例;切缘均为阴性。发生皮下气肿2例,左侧气胸伴皮下气肿1例,气腹2例,均予保守治疗痊愈。术后无一例出现迟发性消化道出血、消化道漏和胸腔腹腔继发感染,无一例发生黏膜下隧道内积血积液和继发感染。随访3～9个月,无一例病变残留或复发。结论STER治疗来源于固有肌层的上消化道SMTs安全、有效,可以一次性完整切除病变,提供完整的病理学诊断资料,并可避免消化道漏和胸腔腹腔继发感染。     

Endoscopic full thickness resection for gastric tumors originating from muscularis propria

AIM: To do systematic review of current literature for endoscopic full thickness resection(EFTR) technique for gastric tumors originating from muscularis propria.METHODS: An extensive English literature search was done till December 2015; using Pub Med and Google scholar to identify the peer reviewed original and review articles using keywords-EFTR, gastric tumor, muscularis propria. Human only studies were included. The references of pertinent studies were manually searched to identify additional relevant studies. The indications, procedural details, success rates, clinical outcomes, complications and limitations were considered. For the purpose of review, data from individual studies was combined to calculate mean. No other statistical test was applied.RESULTS: A total of 9 original articles were identified. Four articles were from same institute and the time frames of these studies were overlapping. To avoid duplication of data, only the study with patients over the longest time interval was included and other three were excluded. In total six studies were included in the final review. In our systematic review, the mean success rate for EFTR of gastric tumors originating from muscularis propria was 96.8%. The mean procedure time varied from a minimum of 37 min to a maximum of 105 min. There was no reported mortality from the technique itself. The most common histological diagnosis was gastrointestinal stromal tumors and leiomyoma. Gastric wall defect closure by either metallic clips or over the scope clip(OTSC) had similar outcomes although experience with OTSC was limited to smaller lesions(3cm).CONCLUSION: EFTR is a minimally invasive technique to resect gastric submucosal tumors originating from muscularis propria with a high success rate and low complication rate.     

EFR治疗胃固有肌层肿物25例

目的探讨内镜全层切除术(EFR)治疗源于固有肌层的胃黏膜下肿物(SMT)的疗效和安全性。方法 25例于2011年1月至2013年9月于我院接受EFR治疗的胃SMT患者纳入研究,肿瘤经EUS和增强CT检查诊断为来源于固有肌层。对其治疗结果、并发症发生情况、近期随访结果等进行回顾性分析。结果 25例均完整切除病灶,病灶长径1.0~5.5 cm,黏膜切开至黏膜切口完整缝合时间为60~180 min,使用止血夹5~30枚,住院天数3~9 d,医疗费用8 000~20 000元。术后病理诊断间质瘤22例,平滑肌瘤2例,神经鞘瘤1例,切缘均为阴性。术后无出血,1例出现腹膜炎。出院后3个月内镜复查未见病变残留、复发。结论 EFR治疗来源于固有肌层的胃SMT安全、有效,可成为胃SMT的治疗选择。     

内镜套扎切除术和内镜黏膜下挖除术治疗固有肌层起源小胃肠间质瘤的疗效分析

本研究采集2016年1月—2018年12月在中国人民解放军联勤保障部队第九〇九医院消化内镜中心经内镜治疗的长径≤1.2 cm胃肠间质瘤（gastrointestinal stromal tumor,GIST）病例43例,按术式分为内镜套扎切除术（endoscopic ligation resection,ELR）组27例和内镜黏膜下挖除术（endoscopic submucosal excavation,ESE）组16例,比较两组患者的一般资料、围手术期资料和随访资料。结果显示,两组患者的一般资料差异无统计学意义,具有可比性。手术时间,ELR组20.0（18.0,25.0） min,ESE组27.5（23.0,37.5） min,组间比较差异有统计学意义（U=92.5,P=0.001）。整块切除率,ELR组100.0%（27/27）,ESE组81.3%（13/16）,组间比较差异有统计学意义（P=0.045）。术后住院时间,ELR组3（2,4） d,ESE组5（4,6） d,组间比较差异有统计学意义（U=125.5,P=0.020）。两组的术中出血率和出血量、术中穿孔率,止血夹数量以及术后出血、发热、腹膜炎等并发症发生情况,差异均无统计学意义（P>0.05）。两组随访均未见间质瘤复发和转移。可见对于病变长径≤1.2 cm的小GIST,ELR和ESE均可安全有效切除,ELR手术时间、术后住院时间更短,整块切除率更高。     

Endoscopic full-thickness resection for gastric submucosal tumors arising from the muscularis propria layer

AIM: To evaluate the efficacy, safety and feasibility of endoscopic full-thickness resection (EFR) for the treatment of gastric submucosal tumors (SMTs) arising from the muscularis propria.METHODS: A total of 35 gastric SMTs arising from the muscularis propria layer were resected by EFR between January 2010 and September 2013. EFR consists of five major steps: injecting normal saline into the submucosa; pre-cutting the mucosal and submucosal layers around the lesion; making a circumferential incision as deep as the muscularis propria around the lesion using endoscopic submucosal dissection and an incision into the serosal layer around the lesion with a Hook knife; a full-thickness resection of the tumor, including the serosal layer with a Hook or IT knife; and closing the gastric wall with metallic clips.RESULTS: Of the 35 gastric SMTs, 14 were located at the fundus, and 21 at the corpus. EFR removed all of the SMTs successfully, and the complete resection rate was 100%. The mean operation time was 90 min (60-155 min), the mean hospitalization time was 6.0 d (4-10 d), and the mean tumor size was 2.8 cm (2.0-4.5 cm). Pathological examination confirmed the presence of gastric stromal tumors in 25 patients, leiomyomas in 7 and gastric autonomous nerve tumors in 2. No gastric bleeding, peritonitis or abdominal abscess occurred after EFR. Postoperative contrast roentgenography on the third day detected no contrast extravasation into the abdominal cavity. The mean follow-up period was 6 mo, with no lesion residue or recurrence noted.CONCLUSION: EFR is efficacious, safe and minimally invasive for patients with gastric SMTs arising from the muscularis propria layer. This technique is able to resect deep gastric lesions while providing precise pathological information about the lesion. With the development of EFR, the indications of endoscopic resection might be extended.     

经口双镜联合切除来源于固有肌层的胃黏膜下肿瘤的临床初探

目的 探讨经口双镜联合切除来源于固有肌层的胃黏膜下肿瘤的疗效和可行性.方法 对2013年3月经辅助检查明确诊断为起源于固有肌层的胃黏膜下肿瘤患者2例,在静脉麻醉下行经口双镜联合切除治疗,辅助镜提拉肿瘤和固有肌层,主镜完整切除病变和牢固夹闭固有肌层创面,观察治疗效果.结果 2例胃黏膜下肿瘤,经口双镜联合成功完整切除.术后病理1例为胃间质瘤,1例为平滑肌瘤;病变直径2 cm.手术时间分别为48 min和66 min.术后无一例出现感染、穿孔及出血等并发症.住院时间为8d和6d.结论 经口双镜联合切除来源于固有肌层的胃黏膜下肿瘤是可行的,具有一定的优势.