活体猪模型在高阶内镜治疗技术培训中的应用价值

目的通过活体猪模型实验,进一步证实和明确其在高阶内镜治疗技术培训中的应用价值。 方法选取6名受训者接受活体猪模型培训,之后6名受训者与6名对照者均进行手把手教学培训。随后,对于受训者接受活体猪模型和手把手培训的差异性,以及受训者和对照者关于是否接受活体猪模型培训的差异性分别进行对比。 结果所有活体猪模型和手把手培训手术均未出现术中大出血及术后迟发性出血,两种培训手术术中各有2例局部微小穿孔,以组织夹可有效封闭,均无术后迟发性穿孔;所有实验动物及患者未出现其他严重并发症。所有手术均完整剥离了病变,仅少数需上级带教医师接手后完成。接受活体猪模型培训后,受训者自身的剥离时间和剥离速度明显改善(P< 0.05);相比于对照者,受训者的手术时间(包括各步骤时间)、剥离速度以及手术完成度评分、注射评分、切开评分均明显改善(P< 0.05)。 结论活体猪模型用于高阶内镜治疗技术的培训是安全有效的,其对于改善初学者的学习曲线及有效应对并发症均有所帮助。     

离体猪胃模型应用于内镜模拟手术培训的初步探讨

目的对离体猪胃模型应用于内镜模拟手术培训进行初步探讨。方法对消化科专科医师进行为期6个月的培训,共操作胃ESD 6例及POEM3例,此培训在北京平谷医院动物实验基地进行。进行基础理论知识学习、记录ESD总体操作时间、创面范围、操作部位、操作速度(创面面积/时间)、POEM总体操作时间、隧道长度,并应用李克特量表调查问卷检测学员培训前后的变化。数据应用SPSS25.0统计软件进行分析。结果在胃窦及胃体部位进行ESD操作时间无明显差异,且操作时间与创面大小比较差异不具有统计学意义。POEM成功1例。随着培训次数的增加,学员的操作速度逐渐提高。通过李克特量表调查问卷,发现在对适应症及禁忌症的把握、操作器械的熟悉情况、操作过程的熟悉情况、操作并发症的处理、操作的自信心程度方面均有所提高。结论离体猪胃模型应用于内镜黏膜下剥离术的模拟培训是可行的。     

隧道法内镜黏膜下剥离术在食管早期癌及癌前病变中应用的研究

目的 探讨隧道法黏膜下剥离术治疗食管早期癌或癌前病变的应用价值及操作技术要领.方法 2010年1月～ 2011年10月在我科内镜中心通过胃镜活检及超声胃镜诊断食管早期癌及上皮内瘤变、深度未超过黏膜下层者7例,应用隧道法ESD(病变黏膜下层建立隧道)治疗.结果 7例病变均一次性完整切除,病变直径2.0～4.0cm,手术时间为37 ～ 110 min,经病理证实基底部及切缘未见病变累及,2例出现术中出血量较多,均内镜下成功止血,无迟发性出血者,所有病例均无穿孔者,术后3个月及半年复查创面愈合良好,均无复发.结论 隧道法ESD是治疗早期食管癌及癌前病变的良好方法,隧道法ESD与传统ESD相比,缩短了内镜手术时间,简化了操作步骤,使得内镜手术更安全更快捷.     

内镜黏膜下隧道法剥离术治疗早期食管癌伴黏膜下层纤维化的临床观察

目的评价内镜黏膜下隧道法剥离术（endoscopic submucosal tunnel dissection,ESTD）治疗早期食管癌伴黏膜下层纤维化的效果和安全性。方法2015年6月—2018年2月间,在江苏省苏北人民医院消化内科采用ESTD或内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗,术后病理证实病灶＜1/3食管管周,且伴有黏膜下层纤维化的早期食管癌病例87例纳入回顾性分析,按纤维化程度分成轻度纤维化60例（ESTD 31例、ESD 29例）和重度纤维化27例（ESTD 16例、ESD 11例）,比较同一纤维化程度时两种手术方式的剥离速度、整块切除率、完全切除率,以及出血、肌层损伤、穿孔、颈部皮下气肿和术后狭窄的发生率。结果对于伴有轻度黏膜下层纤维化的早期食管癌患者,ESTD的整块切除率[96.8%（30/31）比82.8%（24/29）,P＜0.05]和完全切除率[96.8%（30/31）比75.9%（22/29）,P＜0.05]明显高于ESD,固有肌层损伤发生率明显低于ESD[6.5%（2/31）比17.2%（5/29）,P＜0.05],剥离速度、术中出血发生率、穿孔发生率、术后狭窄发生率与ESD比较差异均无统计学意义（P均＞0.05）,两种手术方式均无术后迟发性出血和颈部皮下气肿发生。对于伴有重度黏膜下层纤维化的早期食管癌患者,ESTD的剥离速度快于ESD[（12.3±2.8）mm2/min比（7.1±3.2）mm2/min],整块切除率、完全切除率、术后狭窄发生率与ESD相近,术中出血发生率[12.5%（2/16）比54.5%（6/11）]、固有肌层损伤发生率[18.8%（3/16）比54.5%（6/11）]、穿孔发生率[6.3%（1/16）比27.3%（3/11）]、颈部皮下气肿发生率[6.3%（1/16）比27.3%（3/11）]低于ESD,两种手术方式均无术后迟发性出血发生。术后12个月2例行ESD和1例行ESTD患者局部复发,术后24个月1例行ESTD患者发生异时癌。结论ESTD能安全、有效切除伴有黏膜下层纤维化的早期食管癌。对于伴有轻度黏膜下层纤维化者,ESTD的优势主要体现在治疗效果方面;对于伴有重度黏膜下层纤维化者,ESTD的优势主要体现在治疗安全性方面。     

内镜黏膜下隧道法剥离术治疗胃角巨大黏膜病变的多中心回顾性研究

目的 评估内镜黏膜下隧道法剥离术（ESTD）在治疗胃角巨大黏膜病变中的应用价值。 方法 回顾性分析2014年7月至2016年7月在6家中心接受ESTD或内镜黏膜下剥离术（ESD）治疗的87例胃角大面积黏膜病变患者资料,其中ESTD组32例,ESD组55例。比较2组剥离时间、剥离速度、整块切除率、治愈性切除率、并发症及复发情况。 结果 ESTD组剥离时间较ESD组短［（87.3±32.6）min比（136.7±64.5）min,P＜0.01］,剥离速度明显快于ESD组［（0.18±0.07）cm2／min比（0.08±0.05）cm2／min,P＜0.01］,ESTD组较ESD组整块切除率［100％（32／32）比87.3％（48／55）,P=0.035］及治愈性切除率［100％（32／32）比85.5％（47／55）,P=0.024］高。ESD组术中均有出血发生,有8例出现肌层损伤;而ESTD组术中出血率仅59.4％（19／32）,且无肌层损伤发生（P均＜0.05）。2组复发率比较差异无统计学意义［0（0／32）比1.9％（1／54）,P=0.443］。 结论 ESTD在治疗胃角巨大黏膜病变时具有更高的剥除效率,同时可有效降低手术风险,减少并发症的出现,值得临床推广。     

内镜黏膜下剥离术在消化道肿瘤治疗中的应用

目的探讨内镜黏膜下剥离术（ESD）在治疗消化道肿瘤中的应用价值。方法收集近2年电子胃肠镜发现的15例胃与大肠黏膜及黏膜下肿瘤,内镜超声检查和/或病理活检进一步明确病灶大小,位置及性质,ESD操作步骤;黏膜下注射液体以抬高病灶,接着预切开病灶周围黏膜,之后使用Hook刀或IT刀沿病灶黏膜下层完整剥离病灶。结果 15例患者均顺利完成ESD治疗,病变直径1.0～3.5cm,平均2.3cm,ESD手术时间30～175min,平均73min,ESD治疗过程中创面均有少量出血,均经电凝或金属钛夹止血,无术后延迟出血发生,穿孔发生率为6.7%（1/15）,术后随访1～8个月,未见肿瘤残留或复发。结论 ESD作为一种内镜微创治疗,能实现较大病灶的完全剥离,为临床提供完整的病理学资料,也为消化道早期黏膜及黏膜下肿瘤的治疗开辟了新的治疗途径。     

消化内镜微创手术机器人系统的研发及其辅助离体猪胃内镜黏膜下剥离术的可行性评估

目的初步评估新型柔性、双臂、主从操作的消化内镜微创手术机器人——DREAMS(dual-arm robotic endoscopic assistant for minimally invasive surgery)系统辅助内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)的可行性。方法选用新鲜剥离的健康猪胃作为模型, 设计不同大小的类圆形病变10个(胃窦和胃体各5个), 由2名内镜医生(甲和乙)独自完成内镜下剥离操作, 观察DREAMS系统辅助下的剥离效果(黏膜下剥离速度)、安全性(肌层损伤、穿孔发生率)和操作性能(抓取效率:用每个病变需要夹钳夹取的次数来评估)。结果 10例机器人辅助下的ESD均顺利完成, 10个病变均实现整块切除, 病变直径(22.34±2.39)mm, 剥离时间(15.00±8.90)min, 剥离速度(141.79±79.12)mm2/min, 平均每个病变需要夹取4.2次, 共有4例(40.0%)ESD出现肌层损伤, 无一例穿孔发生。结论初步动物实验结果显示, DREAMS系统辅助ESD安全、可行。     

内镜黏膜下剥离术后溃疡愈合影响因素的研究进展

内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)作为消化道早癌及癌前病变的标准治疗方式已被广泛接受,相较于传统手术,有微创、显效、美观、并发症少等优点。ESD术后溃疡是指ESD后创面形成的医源性溃疡,可导致狭窄、穿孔、出血等并发症,严重者需再次行内镜下治疗或转外科进行手术治疗。本文就ESD术后溃疡愈合的相关影响因素及药物治疗作一概述。     

内镜微创治疗食管黏膜下肿瘤的效果和安全性

目的探讨内镜治疗术对食管黏膜下肿物治疗的安全性。方法选择99例食管黏膜下肿物患者采用内镜黏膜下剥离术(ESD)、内镜黏膜下挖除术(ESE)、内镜经黏膜下隧道肿瘤切除术(STER)等方法治疗,通过良好的术前、术中及术后处理,观察手术效果及安全性。结果本组99例患者黏膜下肿物的完整切除率为98.99%(98/99),穿孔发生率为2.02%(2/99),出现气胸及皮下气肿2例,经保守治疗后痊愈。术后内镜复查时间为3个月,均临床治愈,无术后迟发性出血或穿孔。结论内镜微创治疗食管黏膜下肿物安全有效。     

三维消化内镜研制及在活体动物内镜手术的初步应用（含视频）

目的　研制三维（three‑dimensional,3D）消化内镜,并通过动物实验初步探讨用于胃部内镜黏膜下剥离术（endoscopic submuscular dissection,ESD）的效果和安全性。方法　荷兰小香猪2只,由郑州大学动物实验中心提供。ESD手术操作由2位高年资内镜医师完成,1人完成1例,一位术中佩戴3D眼镜,另一位术中佩戴3D高清头戴式显示器。记录ESD手术是否成功（手术步骤完成,拟定病灶全部剥离,术中及术后止血成功）、成功次数,有无穿孔、穿孔次数,术者（内镜医师及助手）术中立体感体验情况,术者术中、术后有无眼部不适症状（眼疲劳、眼痛、视物模糊）,内镜医师对机械操作的信任度及内镜使用过程中存在的问题。结果　2例ESD均成功,无穿孔事件发生。术者反馈：术中3D消化内镜成像清晰,立体感强,进行内镜治疗时有明显的距离感和层次感,对出血点的判定更加精准,有2D图像无法比拟的层次感;术中及术后无眼部不适。内镜医师对3D消化内镜信任程度较高,但反映存在摄像头距离消化道管壁<10 mm时图像模糊的问题。结论　初步结果显示,3D消化内镜能够提供良好的立体成像,在活体动物的胃ESD操作过程中定位更加精准,安全性好,且不会明显增加术者的眼部不适,但存在摄像头与消化道管壁距离过近时的图像模糊尚待改进。     

25例消化道病变ESD治疗体会

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)处理消化道病灶的实用性及安全性。方法对7例消化道早期癌肿及18例深度未超过黏膜下层的黏膜下肿瘤共25例行ESD治疗。结果 25例患者均一次性完整切除病灶。所有治疗中均伴有术中出血,用ESD专用热止血钳、APC、金属止血夹成功止血,未发生术后迟发出血。术中穿孔1例,穿孔率为4%(1/25),以金属夹成功夹闭,无术后迟发穿孔。术后随访20例(包括7例消化道早期癌肿及13例黏膜下肿瘤),随访期为7～17个月(平均12.2个月),随访创面均完全愈合,未见复发病灶。结论ESD作为一种微创治疗方法,对于浸润深度不超过黏膜下层的病灶可以一次性大块剥离,从而获得完整的病理学诊断资料,安全性较好。但操作过程复杂,技术难度高。     

Future directions of duodenal endoscopic submucosal dissection

Endoscopic therapies for lesions of the duodenum are technically more difficult than those for lesions of the other parts of the gastrointestinal tract due to the anatomical features of the duodenum, and the incidence rate of complications such as perforation and bleeding is also higher. These aforementioned trends were especially noticeable for the case of duodenal endoscopic submucosal dissection(ESD). The indication for ESD of duodenal tumors should be determined by assessment of the histopathology, macroscopic morphology, and diameter of the tumors. The three types of candidate lesions for endoscopic therapy are adenoma, carcinoma, and neuroendocrine tumors. For applying endoscopic therapies to duodenal lesions, accurate preoperative histopathological diagnosis is necessary. The most important technical issue in duodenal ESD is the submucosal dissection process. In duodenal ESD, a short needle-type knife is suitable for the mucosal incision and submucosal dissection processes, and the Small-caliber-tip Transparent hood is an important tool. After endoscopic therapies, the wound should be closed by clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. At present, the criteria for selection between ESD and EMR vary among institutions. The indications for ESD should be carefully considered. Duodenal ESD should have limitations, such as the need for its being performed by experts with abundant experience in performing the procedure.     

Treatment for superficial non-ampullary duodenal epithelial tumors

Because of the low prevalence of non-ampullary duodenal epithelial tumors (NADETs), standardized clinical management of sporadic superficial NADETs, including diagnosis, treatment, and follow-up, has not yet been established. Retrospective studies have revealed certain endoscopic findings suggestive of malignancy. Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery. The use of endoscopic treatment including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for the treatment for superficial NADETs is increasing. EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection. ESD provides an excellent complete resection rate, however it remains a challenging method, considering the high risk of intraoperative or delayed perforation. Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment. Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion, which presents a risk of lymph node metastasis. Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory. Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.     

Endoscopic submucosal tunnel dissection for large superficial esophageal squamous cell neoplasms

Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial esophageal squamous cell neoplasms (SESCNs) with no risk of lymphatic metastasis. However, for large SESCNs, especially when exceeding two-thirds of the esophageal circumference, conventional ESD is time-consuming and has an increased risk of adverse events. Based on the submucosal tunnel conception, endoscopic submucosal tunnel dissection (ESTD) was first introduced by us to remove large SESCNs, with excellent results. Studies from different centers also reported favorable results. Compared with conventional ESD, ESTD has a more rapid dissection speed and R0 resection rate. Currently in China, ESTD for large SESCNs is an important part of the digestive endoscopic tunnel technique, as is peroral endoscopic myotomy for achalasia and submucosal tunnel endoscopic resection for submucosal tumors of the muscularis propria. However, not all patients with SESCNs are candidates for ESTD, and postoperative esophageal strictures should also be taken into consideration, especially for lesions with a circumference greater than three-quarters. In this article, we describe our experience, review the literature of ESTD, and provide detailed information on indications, standard procedures, outcomes, and complications of ESTD.     

Two traction methods that can facilitate esophageal endoscopic submucosal dissection

Different traction devices that can provide a visual field and attain appropriate tension at the dissection plane during endoscopic submucosal dissection(ESD) have been developed. Clip-with-line(CWL) is a classic traction device that can offer per-oral traction toward the direction where the line is drawn. A multicenter randomized controlled trial(CONNECT-E trial) comparing the conventional ESD and CWL-assisted ESD(CWL-ESD) for large esophageal tumors was conducted in Japan. This study showed th...     

离体猪胃黏膜下隆起性病变模型的建立及其在内镜黏膜下剥离术中的应用研究

目的 探讨离体猪胃黏膜下隆起性病变模型的制作方法及其在内镜黏膜下剥离术（ESD）中的应用。方法 应用硅橡胶印模材料和直径1 cm、2 cm、3 cm钢球制成半球形阴模,将生牛肉糜放进阴模,两个阴模对合固定,置入100℃水中煮沸20 min后制成球形肿物模型。选取离体猪胃6只,将球形肿物模型经猪胃浆膜层切口置入黏膜下层,每只离体猪胃的胃底、胃体、胃窦部各置入1枚,直径分别为1 cm、2 cm、3 cm。应用胃镜及内镜超声对模型进行观察,并对黏膜下隆起性病变行ESD。结果 6只猪胃共置入肿物模型18枚,其中17枚成功置入,1例失败。置入的17枚肿物模型在内镜下均表现为明显向腔内凸起的占位改变,表面黏膜与周边黏膜对比无明显改变。内镜超声下表现为位于黏膜下层的混合回声占位。对肿物模型进行ESD,与实际ESD操作过程基本一致,未出现肿物模型脱出、破碎等影响操作的情况。结论 本方法制作的胃黏膜下隆起性病变模型可较好复制疾病状态,为胃黏膜下隆起性病变内镜治疗方法研究及内镜医师培训提供了一个较为合适的模型。     

Delayed perforation after endoscopic submucosal dissection for early gastric cancer: Clinical features and treatment

Perforation is an important procedural complication of endoscopic submucosal dissection (ESD) for early gastric cancer. Although the incidence of delayed perforation after ESD is low, extreme caution is necessary because many cases require surgical intervention. Among 1984 lesions of early gastric cancer treated in our hospital by ESD in 1588 patients from September 2002 through March 2015, delayed perforation developed in 4 patients (4 lesions, 0.25%). A diagnosis of delayed perforation requires prompt action, including surgical intervention when required.     

Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade

Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.