内镜下黏膜切除术治疗食管平滑肌瘤42例的临床观察

目的探讨内镜下黏膜切除术(EMR)治疗食管平滑肌瘤的疗效和应用价值。方法回顾性分析2009年1月-2011年1月我院消化内镜中心行EMR治疗且经病理证实的42例食管平滑肌瘤患者的临床资料。结果 42例患者均经微探头超声内镜检查确定其食管病变的解剖层次及起源后,行EMR完整切除病变组织。3例手术中出血患者经金属夹夹闭出血点后成功止血,1例手术后迟发性出血患者经内镜下氩离子血浆凝固术(APC)止血成功。无穿孔、感染等严重并发症发生,术后随访6个月,无瘢痕狭窄等术后并发症发生。结论 EMR治疗食管平滑肌瘤是一种安全、有效的微创治疗方法,具有重要的临床应用价值。     

经黏膜下隧道内镜切除术治疗食管黏膜下肿瘤5例临床分析

背景:随着胃镜检查的普及和超声内镜(EUS)技术的成熟,食管黏膜下肿瘤(SMTs)的检出率逐年上升。目的:评估经黏膜下隧道内镜切除术(STER)治疗食管SMTs的疗效和安全性。方法:5例于2012年1～6月于昆山市中医医院接受STER治疗的食管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:5个病灶均由STER一次性完整切除,病灶长径0.8～2.0 cm,黏膜切开至黏膜切口完整缝合时间为45～95 min。术后病理诊断平滑肌瘤1例,间质瘤4例,切缘均为阴性。术后无出血、穿孔等并发症发生。出院后3个月内镜复查未见病变残留、复发。结论:STER治疗来源于固有肌层的食管SMTs安全、有效,可一次性完整切除病变,提供完整的病理信息,并避免出血、穿孔等并发症,有望成为食管SMTs的主要治疗选择。     

内镜下黏膜切除术治疗食管黏膜隆起肿瘤30例临床分析

目的探讨内镜下黏膜切除术治疗食黏膜管隆起肿瘤的治疗效果及安全性。方法30例胃镜检查发现食管黏膜隆起肿瘤,其中食管黏膜下隆起病变的患者接受超声内镜检查确诊病变源于黏膜肌层,确定无手术禁忌后,进行EMR切除病变,术后病变标本送病理检查。结果30例患者顺利完成EMR切除病变,耗时20—45min,平均为（25±4．7）min。2例患者发生急性出血,予药物喷洒、电凝等治疗后出血停止。所有治疗病例均无急性或延迟性食管穿孔及食管狭窄等并发症出现。结论EMR可有效、安全地切除食管黏膜隆起肿瘤,有较好的临床应用价值。     

食管早期癌和癌前病变超声内镜诊断及内镜下食管黏膜切除术的临床研究

目的探讨食管早期癌和癌前病变超声内镜诊断价值及内镜下食管黏膜切除术的临床治疗价值。方法 61例食管早期癌和癌前病变行超声内镜检查探测病变浸润深度,位于黏膜层及黏膜肌层的食管早期癌和癌前病变行内镜下食管黏膜切除术（EMR）,位于黏膜下层的食管早期癌行外科手术治疗。EMR术28例,外科手术33例。比较超声内镜和术后病理判断病变浸润深度。结果超声内镜判断食管黏膜内癌的特异性和敏感性为94.1%（48/51）、98.0%（48/49）;黏膜下癌的特异性和敏感性为80.0%（8/10）、72.7%（8/11）;鉴别黏膜内癌及黏膜下癌浸润深度准确率为91.8%（56/61）。28例EMR术后病理：14例食管早期癌和12例食管黏膜中重度异型增生完全切除,完全切除成功率为92.9%（26/28）,观察3～45个月无复发。结论超声内镜能较准确鉴别食管早期癌和癌前病变浸润深度,黏膜切除术治疗食管早期癌和癌前病变是安全有效的内镜治疗方法。     

内镜超声指导食管黏膜下肿瘤的黏膜切除术

目的探讨内镜超声指导食管黏膜下肿瘤黏膜切除术的有效性和安全性。方法对1992年至2005年间656例疑为上消化道黏膜下肿瘤患者进行内镜超声检查，其中97例食管病变内镜超声显示病变来源于黏膜肌层，有43例经知情同意后行内镜下黏膜切除术。切除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，EUS准确地判断肿瘤所在的层次；通过黏膜切除术切除所有病变，无一例发生并发症。结论内镜超声检查能准确判断黏膜肌层来源的肿瘤，可用于指导黏膜切除术。     

超声内镜联合EMR或ESD在食管表浅隆起性病变诊断和治疗中的作用

目的：探讨超声内镜（EUS）联合内镜下黏膜切除术（EMR）或内镜下黏膜剥离术（ESD）在食管表浅隆起性病变诊断和治疗中的价值。方法对35例经EUS检查拟诊为食管表浅隆起性病变患者进行EMR或ESD治疗的病例资料进行回顾性研究,分析病变部位的EUS图像、病理诊断结果及随访治疗效果。结果35例中21例经EMR治疗,14例经ESD治疗。经病理组织学检查确诊为早期食管癌9例,重度不典型增生5例,良性间质瘤3例,腺瘤性息肉4例,非腺瘤性息肉6例,平滑肌瘤8例。经EUS及病理证实病变均起源于黏膜层、黏膜肌层和黏膜下层。34例分别于术后1、3、6月复查EUS随访,术后1个月后伤口均完全愈合,无出血、食管狭窄及局部复发现象发生。结论联合应用EUS和EMR或ESD技术,不仅可以提高食管表浅隆起性病变早期的确诊率,而且是一种微创、有效、安全、快速的治疗措施。     

内镜下黏膜切除术治疗消化道肿瘤

目的 探讨内镜下黏膜切除术(EMR)对消化道肿瘤的治疗价值。方法 利用染色、放大内镜及超声内镜探测病变范围及侵犯深度,对位于黏膜层及黏膜肌层的早期癌、癌前病变、黏膜下肿瘤、侧向发育型息肉、无蒂或亚蒂巨大息肉、息肉癌变等病变行EMR治疗。结果 病灶最大直径6cm。2例早期食管癌、1例早期贲门癌、1例早期大肠癌及2例胃中、重度异型增生经EMR及透明帽负压吸引EMR切除,观察3-18个月无复发;31例黏膜下肿瘤经EMR和透明帽负压吸引EMR,均完全切除;对13例侧向发育型息肉及21例亚蒂和无蒂大息肉及局部癌变息肉采用EMR或分片黏膜切除术切除。术中出血5例,出血率7.04％,经内镜治疗停止。1例4.5 cm腺瘤术后3个月复发。结论 在超声内镜、色素内镜及放大内镜的指导下,采用内镜下黏膜切除术治疗部分消化道早期癌、癌前病变、侧向发育型及无蒂或亚蒂臣大息肉、局部癌变息肉及黏膜肌层的肿瘤,足一项安全有效的内镜治疗疗法。     

内镜下黏膜切除术治疗消化道平坦型病变103例分析

目的回顾分析内镜下黏膜切除术（EMR）对消化道平坦型病变的治疗效果，并讨论其并发症和操作方法。方法103例共114处消化道平坦型病变，以注射法或透明帽辅助法行黏膜切除治疗，记录其操作方法、并发症、术后病珲类型及随访情况。结果113处病变经EMR或EPMR完整切除，治愈率99．12％。并发症：术中出血7例（6．80％），以APC止血成功。术后迟发出血1例（0．97％），内科保守治疗成功，无穿孑L发生。术后病理：良性腺瘤73处，黏膜肌层平滑肌瘤5处，乳头状瘤2处，增生性息肉11处，炎性息肉17处，黏膜内癌（m癌）3处，黏膜下层癌（sml癌）2处，同有肌层癌（nap癌）1处。sml癌追加外科肠段切除，手术标本未见肿瘤残存或浸润。mp癌行黏膜下注射后抬举征可疑阳性，术后追加外科肠段切除，可见肠旁淋巴结转移（1／6）。癌变病例随访3～9月，未见病变残留或复发。结论镜下黏膜切除术可安全有效切除大多数消化道平坦型病变。〉10min病变术后应常规作病理检查。采用纯切模式，较大功率有助于保持标本完整性。     

静脉麻醉内镜下黏膜切除术的疗效观察

[目的]观察静脉麻醉内镜下黏膜切除术(EMR)的疗效.[方法]对经超声内镜检查确诊未侵犯黏膜下层的40例消化道隆起和平坦型病变进行静脉麻醉EMR,术后所有病例均留标本再次行病理检查,并内镜随访.[结果]40例均完全切除,无一例出现大出血、迟发出血、穿孔等不良并发症,术后1、3、6、12个月复查内镜,除2例肠息肉患者息肉复发再次给予EMR治疗外,余患者未见病灶残留或复发.[结论]EMR是安全、有效、简便实用的,配合静脉麻醉效果更好,适用范围更大,值得临床推广.     

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。     

硬化治疗后曲张静脉内镜和超声内镜表现的演变

目的研究食管胃底静脉曲张硬化治疗后曲张静脉变化的规律。方法肝炎后肝硬化、食管胃静脉曲张出血患者行内镜下硬化剂注射治疗后止血并接受连续治疗、完成首期疗程、食管胃静脉曲张消失或减轻至Ⅱ期以下的进入随访,要求随访时间5年。共386例进入随访,随访过程中记录内镜和超声内镜表现,并探讨其演变的规律。结果190例完成了5年随访,失访196例,平均失访时间(3】.7±14.7)月。硬化治疗后食管的曲张静脉管腔闭塞,形成白色纤维条索残留于食管壁。随时间延长,食管内静脉逐渐再现,再现有2种方式:一是在食管壁内逐渐出现一些再生的小静脉(362/386,93.8％),二是原曲张血管再通(24/386,6.2％)。硬化治疗前无胃静脉曲张的病例中有5.3％出现胃静脉曲张。随访中还见到罕见的十二指肠静脉曲张。超声内镜表现进一步证实了静脉管腔闭塞后再生并逐渐扩张的过程。结论硬化治疗静脉曲张消失后静脉会逐渐再现,要保持硬化治疗的长期效果,必须定期复查并有针对性地给予治疗。     

EVS、EVS+EVL续贯EVS和EVL续贯EVS治疗食管静脉曲张的疗效比较

目的:比较内镜下食管静脉曲张硬化治疗(EVS)、EVS EVS加套扎(EVL)续贯EVS和EVL续贯EVS治疗食管静脉曲张的疗效.方法:乙型病毒性肝炎肝硬化食管静脉曲张破裂出血患者130例,随机分为EVS治疗组50例,EVS EVL续贯EVS组40例,EVL续贯EVS组40例,比较3组食管静脉曲张的消失率、并发症、硬化剂总用量,患者住院天数和远期复发出血率.结果:三组患者治疗后食管静脉曲张消失率无差异;EVS组硬化剂应用总量、治疗次数和住院天数都高于EVS EVL续贯EVS组,EVL续贯EVS组(95.64±37.51 mL vs 55.90±38.93 mL,32.15±26.97 mL;3.64±1.32 vs 1.85±1.18,1.35±0.88;25.92±8.69 vs 20.6±5.00 d,17.55±4.62 d;P均<0.05),而后两组之间没有差异;EVL续贯EVS组食管静脉曲张复发率高于另外两组(45% vs 12%,20%,P<0.05),而后两组间没有差异.3组间再出血发生率及并发症的发生率没有差别.结论:EVL续贯EVS和EVS EVL续贯EVS在食管静脉曲张的治疗上优于单纯EVS,尤其后者兼具EVL和EVS的优点.     

内镜黏膜切除术在切除大肠息肉中的应用

目的观察内镜黏膜切除术在切除大肠息肉中的应用价值。方法收集173例经结肠镜诊断的大肠息肉,用内镜黏膜切除术法予以摘除,观察创面情况和患者并发症发生率。结果 173例患者均顺利摘除,无出血和穿孔发生,且创面较常规电凝摘除浅。结论内镜黏膜切除术用于切除大肠息肉是安全、有效的。     

Propofol use in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

Compared to standard endoscopy,endoscopic retrograde cholangiopancreatography(ERCP)and endoscopic ultrasound(EUS)are often lengthier and more complex,thus requiring higher doses of sedatives for patient comfort and compliance.The aim of this review is to provide the reader with information regarding the use,safety profile,and merits of propofol for sedation in advanced endoscopic procedures like ERCP and EUS,based on the current literature.     

The endoscopic transilluminator: an endoscopic device for identification of the proximal jejunum for transgastric endoscopic gastrojejunostomy

BACKGROUND: Localization of the proximal jejunum is important for creation of gastrojejunal anastomosis to palliate gastric outlet obstruction or for treatment of obesity with gastric bypass. OBJECTIVE: To facilitate identification of the proximal jejunum during transgastric endoscopic gastrojejunostomy with the use of an endoscopic transilluminator (ET). DESIGN AND SETTING: Acute experiments in a live porcine model. INTERVENTIONS: The ET is a 3500-mm long, 6F radio-opaque tube with a fiberoptic core that lights up at its distal end. When situated in the intestinal lumen, it transilluminates the bowel wall. With the animal under general anesthesia with endotracheal intubation, a colonoscope was advanced to the proximal jejunum. A plastic tube (3500-mm long, 3.5 mm in diameter) was passed through the biopsy channel and placed into the small bowel. The colonoscope was withdrawn, leaving the tube in place. The ET was introduced into the jejunum through the tube. A gastric wall incision was made and the endoscope was advanced to the peritoneal cavity. The transilluminated loop of the proximal jejunum was identified and gastrojejunal anastomosis was made by use of a previously reported endoscopic technique. MAIN OUTCOME MEASUREMENTS: Identification of the proximal jejunum. RESULTS: Eleven pigs (average weight 55 kg) had ET placement. In all of the pigs, placement of the ET was performed easily to the proximal small bowel, and the proximal jejunum was successfully localized by either direct visualization of the transilluminated loop only or with the aid of fluoroscopy. The tip of the ET was usually located about 50 to 70 cm distal to the ligament of Treitz. There were no complications related to the use of ET. LIMITATIONS: The device has not yet been evaluated in humans. CONCLUSIONS: The ET is a safe instrument and can be used to identify the proximal jejunum to facilitate endoscopic gastrojejunostomy.     

Evolving endoscopic surgery

Since the days of Albukasim in medieval Spain, natural orifices have been regarded not only as a rather repugnant source of bodily odors, fluids and excreta, but also as a convenient invitation to explore and treat the inner passages of the organism. However, surgical ingenuity needed to be matched by appropriate tools and devices. Lack of technologically advanced instrumentation was a strong deterrent during almost a millennium until recent decades when a quantum jump materialized. Endoscopic surgery is currently a vibrant and growing subspecialty, which successfully handles millions of patients every year. Additional opportunities lie ahead which might benefit millions more, however, requiring even more sophisticated apparatuses, particularly in the field of robotics, artificial intelligence, and tissue repair (surgical suturing). This is a particularly exciting and worthwhile challenge, namely of larger and safer endoscopic interventions, followed by seamless and scarless recovery. In synthesis, the future is widely open for those who use together intelligence and creativity to develop new prototypes, new accessories and new techniques. Yet there are many challenges in the path of endoscopic surgery. In this new era of robotic endoscopy, one will likely need a virtual simulator to train and assess the performance of younger doctors. More evidence will be essential in multiple evolving fields, particularly to elucidate whether more ambitious and complex pathways, such as intrathoracic and intraperitoneal surgery via natural orifice transluminal endoscopic surgery (NOTES), are superior or not to conventional techniques.