类弹性蛋白多肽粘膜下注射在黏膜剥离术中应用的实验研究

目的将类弹性蛋白多肽(ELP)作为一种黏膜下注射液应用于内镜黏膜下剥离术(ESD),对其有效性进行评估,为临床应用提供依据。方法 54只雄性SD大鼠随机分为3组(n=18)。第一组观察不同注射液分离组织的有效性。根据注射不同的注射剂随机分为3个亚组(n=6),暴露胃后壁分别黏膜下注射ELP、透明质酸钠(SH)和生理盐水(NS)0.2mL,观察并记录药物注射后0、5、10、30及60min局部黏膜隆起厚度及黏膜表面的改变;第2组观察注射不同注射液后30min黏膜隆起的组织学表现(n=6);第3组观察黏膜下剥离时不同注射液对出血的影响。根据注射不同注射剂随机分为3个亚组(n=6)。给予上述注射剂处理后,用无菌手术刀片完整切除黏膜下注射后形成的隆起部位,测定黏膜切除20min内的出血量。结果注射药物后60min内黏膜隆起厚度比较:ELP组分别与SH和NS组相比差异有显著性(P<0.05),即ELP维持黏膜隆起厚度明显大于SH和NS;SH与NS组相比差异有显著性(P<0.05),即SH维持黏膜隆起厚度大于NS。组织学观察ELP注射部位的周围组织中未见明显的炎性细胞浸润及坏死。黏膜切除时的出血量:ELP组、SH组、NS组分别为(854.0±98.9)、(726.3±104.8)和(1144.0±112.4)mg,ELP、SH组分别与NS组相比差异有显著性(P<0.05),应用ELP与SH较NS可明显减少出血量。结论黏膜下注射ELP后,ELP在黏膜下组织中的弥散明显延缓,在黏膜下形成较持久的液体垫维持黏膜厚度,有利于黏膜组织的剥离切除,并可以减少出血量,因此ELP有可能作为ESD中较为理想的黏膜下注射剂应用于临床。     

内镜黏膜下剥离术治疗消化道巨大隆起性病变

目的 探讨内镜黏膜下剥离术(ESD)治疗消化道巨大隆起性病变的疗效及安全性.方法 自2006年10月～2007年10月,对胃镜和肠镜发现的消化道直径大于2 cm的隆起病变行ESD治疗:在病灶周围标记、黏膜下注射、切开病灶周围黏膜、剥离病灶、处理创面.结果 28例患者,8例病灶位于食管内,11例位于胃内,9例位于结直肠内,病灶直径20～35 mm(平均24 mm),病灶均位于黏膜层或黏膜下层.食管内病灶,平滑肌瘤(起源于黏膜肌层)4例,食管囊肿2例,食管早期鳞癌2例.胃内病灶位于胃窦5例,胃底2例,胃体4例.其中增生性息肉4例,异位胰腺1例,管状腺瘤伴轻一中度不典型增生3例,管状腺瘤伴高度不典型增生1例,早期胃癌侵犯黏膜肌层1例,间质瘤1例.结肠内病灶位于直肠4例,乙状结肠5例,其中绒毛状腺瘤2例.绒毛状管状腺瘤伴轻-中度不典型增生3例,绒毛状管状腺瘤伴高度不典型增生1例,绒毛状腺瘤伴局部癌变1例,类癌1例,平滑肌瘤1例.ESD时间50～120 rain,病灶整块切除26例,分块切除2例.食管及胃内病灶ESD术后平均住院3.5 d.结直肠病灶ESD术后平均住院4.6 d.所有患者术中有少量出血,给予电凝或氩气止血,有1例胃窦管状腺瘤ESD术后出血,电凝、氩气止血无效,给予2枚钛夹止血.有1例直肠病灶ESD术后出现小穿孔,保守治疗16 d后康复出院.术后2个月复查胃镜和肠镜,创面愈合良好,有1例胃窦增生性息肉有少量残留,给予圈套切除,余未出现复发.结论 ESD治疗消化道巨大隆起性病变是安全有效的,其创伤小,恢复快,并发症发生率低,能维持正常的生理结构,可使该类患者免于剖腹手术之苦.     

内镜黏膜下剥离术对食管胃黏膜下病变的诊疗价值

目的探讨内镜黏膜下剥离术对食管胃黏膜下病变的安全性及临床疗效。方法将2008年1月至2011年12月我院同期收治的43例经超声内镜确诊为食管胃黏膜下病变的患者随机分为内镜黏膜下剥离术(ESD)组(n=20)和内镜黏膜下切除术(EMR)组(n=23)进行手术,对比分析两组的临床资料。结果 ESD组与EMR组在性别、年龄、肿瘤部位和肿瘤大小之间差异无统计学意义(P>0.05)。ESD组术后发生出血1例(2.0%);EMR组术后发生并发症3例(6.25%),其中出血2例,穿孔1例。两组比较其差异具有统计学意义(P<0.05)。ESD组无切缘阳性者,EMR组术后切缘阳性者有2例(4.17%)(P<0.05)。ESD组患者均无复发,EMR组术后仅1例复发(2.08%)(P<0.01)。结论 ESD创伤性小;安全性高;切除病灶     

超声内镜对上消化道黏膜下隆起型病变的诊断价值

目的比较超声内镜(EUS)、电子胃镜和CT检查对上消化道黏膜下隆起型病变的诊断价值。方法 137例患者行EUS、电子胃镜和(或)CT检查,并经内镜下黏膜剥离术(ESD)或高频电凝切除术获取病变标本,送病理组织学检查,以病理结果作为金标准比较EUS、电子胃镜和CT的诊断准确率。结果食管黏膜下隆起型病变中以平滑肌瘤最常见(98.1%),胃黏膜下以间质瘤最常见(56.6%)。137例患者中,125例黏膜下隆起型病变(食管内<2.0cm、胃内<3.0cm)行ESD或高频电凝切除术,12例病变较大者行外科治疗。对于平滑肌瘤、间质瘤、囊肿和血管瘤,EUS的诊断准确率(83.2%)明显高于电子胃镜(45.2%)(P<0.05),而且EUS能清晰地显示出食管和胃的组织结构,可较准确地判断出隆起起源的层次;CT的诊断准确率(35.4%)明显低于EUS和电子胃镜,但在显示消化道黏膜下肿瘤并远处淋巴结转移方面,CT优于EUS和电子胃镜。结论 EUS可较好地对上消化道黏膜下隆起型病变的起源、范围及大小作出准确判断,对上消化道黏膜下肿瘤治疗方案的选择具有重要的指导价值。     

内镜黏膜下剥离术在上消化道相关病变的应用

目的探讨内镜黏膜下剥离术(ESD)治疗上消化道黏膜及黏膜下病变的疗效和安全性。方法经胃肠镜及超声内镜检查确诊为上消化道黏膜及黏膜下病变患者26例(其中6例为黏膜病变、20例为黏膜下病变),应用内镜黏膜下剥离术治疗,并对病理、治疗效果进行评估,术后内镜随访1周～2年不等。结果 26例入选病例中食管9例,胃15例,残胃1例,十二指肠球部1例。治疗情况:22例完整剥离,4例部分剥离。术中4例少量出血、1例食管轻度穿孔经术中及术后保守治疗均有效,1例出血较大予以外科手术治疗。病理:平滑肌瘤8例,间质瘤1例,纤维瘤1例,异位胰腺3例,脂肪瘤2例,潴留囊肿1例,异型增生7例,癌变3例。完成随访10例,其中1例早期食管癌复发,其余愈后良好。结论 ESD治疗上消化道黏膜及黏膜下病变安全、有效,术前严格评估及术中对切除范围及深度严密把握对减少病灶残留和病变复发、降低并发症发生率尤为重要。     

磁性水凝胶黏膜下注射辅助离体猪食管内镜黏膜下剥离术的可行性研究

目的 探讨基于磁锚定技术的磁性水凝胶辅助内镜黏膜下剥离术（ESD）的可行性。方法 以新鲜离体猪食管为模型，在黏膜下注射自行配置的海藻酸钠-四氧化三铁微粒溶液和交联剂，使两者发生反应形成磁性水凝胶。在食管外放置锚定磁体后，黏膜下的磁性水凝胶被吸引，连同病变黏膜一起被抬起，可辅助完成ESD。结果 在锚定磁体的磁场力作用下，磁性水凝胶被锚定磁体吸引，可充分显露黏膜剥离面术野并形成足够的组织张力，改善术者操作体验，提高整块黏膜切除率。结论 黏膜下注射磁性水凝胶在食管ESD中具有可行性，后续将进一步优化磁性水凝胶性能并进行验证。该技术有望应用于临床。     

内镜下黏膜下肿块切除对食管胃黏膜下病变的诊疗价值

目的探讨内镜下黏膜下切除治疗食管胃黏膜下隆起性病变的诊断、治疗价值及安全性。方法今年以来该科内镜检查发现食管胃黏膜下隆起性病变20例，结合超声内镜检察结果，在内镜下确定食管胃黏膜下隆起性病变可移动后，于病变基底部注射1：10000肾上腺素盐水，使病变基底部与胃壁基层分离，用圈套器套取病变，采用混合电凝电切切除隆起性病变。结果18例病人获得有效的病理诊断，大多数患者病变获得有效切除。结论对于食管、胃黏膜下隆起性病变行胃镜下切除术具有良好的诊断与治疗价值，特别对恶性和潜在恶性问质瘤的早期诊断与治疗，安全性较好。     

磁锚定技术辅助内镜下胃黏膜剥离术的实验研究

目的探讨磁锚定技术(MAT)在内镜下胃黏膜剥离术中应用的可行性。方法自行设计加工适用于胃内镜黏膜下剥离术(ESD)的磁锚定装置。以Beagle犬离体胃为实验模型,胃镜下利用软组织夹将靶磁体(TM)钳夹固定于假定的病变黏膜边缘,胃体外放置锚定磁体(AM),用来吸引牵拉TM,改变牵拉方向,并维持足够的组织张力,从而完成ESD。结果成功设计并加工出AM和TM。通过胃镜的钳道,利用软组织夹可将TM固定于病变黏膜边缘,钳夹方便,固定牢靠。胃体外AM能够灵活牵引TM,改变AM位置能灵活调节TM来控制黏膜牵拉力的方向和大小,可以清晰显示黏膜剥离面。整个操作过程顺利,未出现黏膜撕脱现象。结论MAT可用于胃ESD,能够为黏膜剥离面提供足够的组织张力,并充分显露剥离面术野,该技术操作简单,具有极大的临床应用潜力。     

内镜黏膜下剥离术在食管肿瘤中的应用

目的 探讨内镜黏膜下剥离术(ESD)处理食管黏膜下肿瘤(SMT)的疗效和安全性.方法 以2009年2月～2010年2月内镜发现的食管黏膜下病灶作为入选对象,通过超声内镜(EUS)检查明确病灶大小、位置、性质,进行ESD治疗.观察其疗效和并发症情况.结果 共计20例,18例(90%)完整剥离,2例ESD术后创面仍有肿瘤残留且病理报告低度恶性,后行外科手术扩大切除治疗.病灶直径0.4～2.9 cm(平均1.3 cm),手术时间30～190 min(平均55 min).其中1例穿孔经保守治愈.术后随访1～12个月,18例完整剥离患者均未见复发.结论 ESD作为一种微创治疗方法,对食管的SMT具有可完整剥离病灶、创伤小、术后恢复快等优点,值得推广.     

内镜黏膜下剥离术治疗消化道隆起性病变的护理

[目的]总结内镜黏膜下剥离术(ESD)治疗消化道黏膜及黏膜下隆起性病变的护理。[方法]对33例消化道黏膜及黏膜下隆起性病变病人行ESD治疗,术前进行完善的术前准备,术中进行严密的配合,术后进行细致的观察及护理。[结果]33例病人ESD治疗均成功。1例胃间质瘤术后出血约800 mL,经氩离子凝固术(APC)、钛夹等内镜下止血;1例胃底平滑肌瘤术后出血约1 000mL,经禁食、输血及药物内镜下治疗后止血;1例发生胃穿孔,经胃肠减压、禁食禁水、药物等治疗恢复。[结论]完善的术前准备、术中严密的配合及术后细致的护理,有利于手术成功,保证良好的治疗效果。     

Is blood the ideal submucosal cushioning agent? A comparative study in a porcine model

BACKGROUND AND STUDY AIMS: Creation of a submucosal cushion before endoscopic mucosal resection (EMR) significantly reduces perforation risk. We evaluated six solutions as cushioning agents in live pigs. MATERIAL AND METHODS: 5 ml of normal saline, normal saline plus epinephrine, albumin 12.5 %, albumin 25 %, hydroxypropyl methylcellulose, and the pig's own whole blood were endoscopically injected into the porcine esophageal submucosa. Blood was obtained from a peripheral vein immediately before injection. Injections were made every 4 cm from the gastroesophageal junction. The time from completion of the injection to disappearance of the cushion was recorded. Endoscopy was repeated at 48 hours post injection. Two EMRs were performed after blood injection. Statistical analysis employed one-way analysis of variance followed by pairwise T test comparisons using the Bonferroni correction. RESULTS: Five animal experiments were completed. The mean time to dissipation of the submucosal cushion was shortest for saline plus epinephrine sites (2.87 minutes, SD 2.21) followed by the saline (4.8 minutes, SD 1.56), albumin 12.5 % (5.68 minutes, SD 3.48), albumin 25 % (7.83 minutes, SD 2.02), hydroxypropyl methylcellulose (9.77 minutes, SD 1.55), and blood sites (38.6 minutes, SD 6.07). Injection of blood resulted in significantly longer mucosal elevation than any other solution ( P < 0.0007). Blood from the cushion did not hamper visualization and facilitated EMR. CONCLUSION: Blood produces the most durable cushion compared with standard agents, also having the advantages of being readily available and without cost. Albumin 25 % provides as durable a cushion as hydroxypropyl methylcellulose.     

Comparison of various submucosal injection solutions for maintaining mucosal elevation during endoscopic mucosal resection

BACKGROUND AND STUDY AIMS: One of the major complications of endoscopic mucosal resection (EMR) for gastrointestinal tumors is perforation, and the most effective way of preventing perforation is to elevate the lesion sufficiently by endoscopic injection of fluid into the submucosa. MATERIALS AND METHODS: In order to compare the lesion-lifting properties of several different solutions, 1 ml of each of the following solutions was injected into the submucosa of the resected porcine stomach: normal saline, 3.75 % NaCl, 20 % dextrose water, 10 % glycerin with 0.9 % NaCl plus 5 % fructose, and two sodium hyaluronate (SH) solutions. RESULTS: Significantly higher initial elevation was produced by both SH solutions, and it remained higher than that achieved by the other solutions at all times. Hypertonic solutions, especially 10 % glycerin with 0.9 % NaCl plus 5 % fructose, tended to produce and maintain greater mucosal elevation than normal saline, but the difference was not significant. CONCLUSIONS: SH solutions were the most suitable ones for producing and maintaining long-term mucosal elevation, while the superiority of hypertonic solutions over normal saline was not clearly demonstrated.     

内镜黏膜下剥离术治疗直肠类癌的临床价值

目的探讨内镜下对直肠类癌的诊断与治疗的临床价值。方法肠镜发现直肠黏膜下肿块后进行微探头超声检查,对诊断为类癌的患者应用头端弯曲的针形切开刀进行内镜黏膜下剥离术（ESD）治疗：黏膜下注射生理盐水抬高病灶,使病灶与肌层分离;预切开病灶周围黏膜;剥离病变下方黏膜下层结缔组织,完整切除病灶。结果ESD手术时间（自黏膜下注射至完整剥离病变）25～55min;术中创面出现少量出血,均经电凝、氩离子血浆凝固和止血夹成功止血,不需再次肠镜下止血。术后全部经病理确诊,基底和切缘未见病变累及。1个月后肠镜复查,创面基本愈合。结论ESD是治疗直肠类癌的一种新方法,以往需要外科手术切除的肿瘤通过ESD可以达到同样的治疗效果。     

黏膜下注射生理盐水在食管、胃、结肠无蒂息肉内镜治疗中的应用

目的探讨黏膜下注射生理盐水与肾上腺素生理盐水,在食管、胃、结肠无蒂息肉内镜治疗中的疗效和安全性方面的差异。方法在内镜下治疗食管、胃、结肠无蒂息肉时,采用随机对照设计,设试验组和对照组,分别使用生理盐水和肾上腺素生理盐水（1∶10 000）进行黏膜下注射,随后用高频电刀切除病灶,在疗效和并发症方面进行对比研究。结果黏膜下注射生理盐水和肾上腺素生理盐水都可以有效地减少创面出血,且治疗效果确切,试验组和对照组无出血率分别为89.39%和92.31%,组间比较差异无统计学意义（P〉0.05）,对照组黏膜下注射后有8例心率增快、5例血压升高,两组比较差异有统计学意义（P〈0.05）。结论在食管、胃、结肠无蒂息肉的内镜治疗中单纯使用生理盐水作为黏膜下注射液,既能有效预防穿孔,又能减少出血,尚可避免肾上腺素的并发症,可以取代肾上腺素生理盐水。     

Endoscopic Submucosal Dissection in the Era of Proton Pump Inhibitors

Endoscopic submucosal dissection (ESD) has the advantage over endoscopic mucosa resection, permitting removal of gastrointestinal neoplasms en bloc, but is associated with relatively high risk of complications. Indications for early gastric cancer (EGC) are expanded: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings ≤3 cm in diameter; and minute submucosal invasive cancer ≤3 cm in size. The indications for early esophageal cancer (EEC) are the tumors confined to the two-third layer of the lamina propria. The EEC lesions spreading more than three-quarter of circumference of the esophagus are at frequent risk of stenosis. The procedures include marking, submucosal injection, circumferential mucosal incision and exforiation of the lesion along the submucosal layer. Complete ESD can achieve a large one-piece resection, allowing precise histological assessment to prevent recurrence. Clinical outcomes of gastric and esophageal ESD have been promising, and the prognosis of EGC patients treated by ESD is likely to be excellent, though further longer follow-up studies are warranted. Notification of perforation risk is essential in particular for esophageal ESD. Bleeding during ESD can be managed with coagulation forceps, and postoperative bleeding may be reduced with routine use of the stronger acid suppressant, proton pump inhibitors.     

Evaluation of dextrose 50 % as a medium for injection-assisted polypectomy

BACKGROUND AND STUDY AIMS: Injection-assisted polypectomy (IAP) is traditionally carried out by using normal saline as the submucosal fluid cushion. However, normal saline, being isotonic, does not maintain the elevation of the mucosa for prolonged periods. It was hypothesized that dextrose 50 %, as a hypertonic solution, might be an ideal medium for IAP. This study evaluated the efficacy and safety of dextrose 50 % for performing IAP. PATIENTS AND METHODS: All patients undergoing IAP during gastroscopy or colonoscopy were randomly assigned on a prospective basis to receive either normal saline or dextrose 50 % as the submucosal fluid cushion. The endoscopist was blinded to the type of solution injected. The volume of solution and number of sites injected to elevate the lesion, the number of times IAP was interrupted to inject more fluid to maintain elevation, the rates of en bloc and complete resections, and the complication rates were compared in the two groups. The mean follow-up period was 10 months. RESULTS: Fifty-two sessile lesions were removed in 50 patients. In comparison with normal saline, smaller volumes (median 7 ml vs. 5 ml; P = 0.02) and fewer injections (median 2 vs. 1; P = 0.003) were required to perform IAP when dextrose 50 % was used. The en bloc resection rate was higher with dextrose 50 % than with normal saline (82 % vs. 44 %; P = 0.01). Elevation of the submucosal area persisted even after completion of IAP in 96 % of the patients randomly assigned to dextrose 50 %, compared with 20 % of those receiving normal saline ( P < 0.001). There were no significant differences in the rates of complete resection or complications between the two groups. CONCLUSIONS: Dextrose 50 % is superior to normal saline as a submucosal fluid cushion, as it allows better en bloc resection during injection-associated polypectomy.     

Different mixtures of sodium hyaluronate and their ability to create submucosal fluid cushions for endoscopic mucosal resection

BACKGROUND AND STUDY AIMS: Sodium hyaluronate (SH) is a promising submucosal injection solution during endoscopic mucosal resection, but its high cost is an obstacle to more widespread use. The aim of this study was to identify an appropriate low-cost SH solution by varying the molecular weight of SH and mixing various solutions with it. MATERIALS AND METHODS: The viscoelasticity of various SH solutions was first measured. The concentrations of two 1 % SH preparations with different molecular weights (800 kDa and 1900 kDa) were adjusted to 0.5 %, 0.25 %, and 0.125 %, using 0.9 %/3.75 % normal saline (NS), 5 %/20 % dextrose water (DW), and a glycerin solution (Glyceol): 10 % glycerin with 0.9 % normal saline plus 5 % fructose. The ability of these SH solutions to create submucosal fluid cushions (SFCs) was then investigated in the stomachs of two live minipigs. RESULTS: The 0.25 % 1900 kDa SH/NS solution and the 0.125 % 1900 kDa SH/20 % DW solution created a similar viscoelasticity to that of the 0.5 % 800 kDa SH/NS solution. The ability of these solutions to create SFCs was also similar. In addition, the 0.125 % 1900 kDa SH/Glyceol solution created similar SFCs, with a synergistic effect of increased viscoelasticity and the hypertonic nature of glycerin. CONCLUSIONS: A mixture of higher molecular weight sodium hyaluronate with a sugar solution (particularly 20 % dextrose), with or without glycerin, should be regarded as a cost-effective option for creating SFCs instead of the conventional SH solution made with the same amount of a 1 % 800 kDa SH preparation and normal saline.     

消化道无蒂隆起性病变的内镜黏膜切除术和内镜黏膜下剥离术治疗分析

目的探讨内镜下粘膜切除术(EMR)和内镜粘膜下剥离术(ESD)治疗消化道无蒂隆起性病变包括早癌的疗效和安全性。方法对行EMR和ESD的43例消化道无蒂隆起性病变患者做回顾性分析。结果 43例无蒂隆起性病变食管11例,胃底4例,胃体8例,胃窦8例,贲门11例,直肠1例。EMR32例,ESD 11例。EMR病变长径、手术时间均明显低于ESD;EMR术后1例出血,无穿孔,ESD术后1例出血,2例穿孔,皆保守治疗后治愈。术后病理提示间质瘤6例,息肉23例,1例异位胰腺,7例上皮内瘤变,6例早癌。基底和切缘均未见病变累及。术后2月、6月随访,创面愈合,无病变残留和复发。结论 EMR和ESD治疗消化道无蒂隆起性病变安全有效,可以提供完整的病理诊断学资料。EMR和ESD可用于治疗消化道早癌。     

简易离体猪胃模型在内镜黏膜下剥离术培训中的应用效果

目的设计一种简易离体猪胃模型,通过举办8期胃内镜黏膜下剥离术(ESD)培训班来评估其应用效果。方法前瞻性研究2018年12月-2020年10月重庆医科大学附属第一医院消化内科设计的一种简易离体猪胃模型,探讨其在ESD学员培训中的应用效果。共举办8期猪胃ESD手把手教学培训班,选用12个猪胃,共培训学员72例,其中公立医院46例、私立医院26例。将当天新鲜购买未经冷冻的重量在0.6～0.9 kg的猪胃洗净后,用民用缝衣针线或医用外科缝合针线将猪胃缝合完整,仅保留食管入口,再将猪胃固定于厚度为2 cm的珍珠棉泡沫板上(长60 cm,宽40 cm),每个猪胃需要固定5个点,猪胃与泡沫板之间预先放置手术电刀所需的电极板,胃镜通过食管入口后,用外科止血钳夹闭食管入口处,防止漏气。将上述装置平放于手术平台上,尽量防止移动。ESD手术流程参照传统ESD操作流程进行,通过评估手术操作时间、完整切除率、完成率、成功率和后期能否独立开展ESD工作等来判断该模型的应用效果。结果所有学员在培训当天使用该模型独立完成1例ESD操作,多采用口袋法完成ESD,完成时间为30～50 min,平均(38.6±5.3) min,完整切除率为95%,完成率为98%,成功率为98%,整个过程中医生和助手均不需要对模型进行按压或校正,胃腔始终能保持扩张状态。部分学员熟练操作后,甚至可以在没有助手辅助的情况下独立完成整个ESD。通过培训,学员返回自己医院后,可以独立制作该模型进行反复的ESD练习,有3名医生通过培训后,能独立进行临床ESD工作。结论简易离体猪胃模型设计简单,所需材料容易获得,缝合方式可靠,基本不会漏气,视野清晰,手术操作流畅,可以良好地模拟ESD操作,值得临床推广应用。