内镜黏膜下剥离术在早期胃癌诊疗中的应用

内镜黏膜下剥离术(endoscopic mucosal dissection,ESD)在早期胃癌(early gastric carcinoma,EGC)诊疗中的应用越来越广泛。ESD可整块切除病灶,术后大块病理能精确的对病灶进行组织学分型,协助诊断。随着技术的进步,ESD治疗EGC的适应证不断扩大。其作为一种内镜微创技术,治愈性切除率、5年总生存率可达86%与92.6%。与外科手术相比,ESD并发症少,出血、穿孔常见;但由于保留了胃完整的解剖结构,异时性癌的发生率较高。并且对于同时性多原发癌、早期胃管癌、早期残胃癌及老年人EGC等特殊人群,ESD也可作为新的选择。除此,ESD还能明显提高患者的生活质量,减少住院花费等。本文现就ESD在EGC诊疗中的应用进展作一综述。     

内镜与外科手术治疗符合内镜黏膜下剥离术扩大适应证的老年单发早期胃癌的疗效对比

目的对比内镜与外科手术治疗符合内镜黏膜下剥离术(ESD)扩大适应证的老年单发早期胃癌的临床疗效与安全性。方法老年单发早期胃癌病人104例,根据治疗方法不同分为两组,内镜组72例,采用经内镜手术治疗,外科组32例,行外科手术治疗。两组病人均满足ESD扩大适应证。对比两组病人的手术时间、住院时间、术后病灶残留、复发、5年存活率及并发症等情况。结果内镜组的手术时间、术后禁食时间、住院时间和住院费用与外科组比较,差异有统计学意义(P0.05);两组的短期并发症总发生率接近(P0.05),但内镜组的长期并发症总发生率显著低于外科组(P0.05);内镜组与外科组的治愈性切除率、整块切除率、病灶残留率、复发率比较,差异均无统计学意义(P0.05);两组病人均获得随访,内镜组5年完全生存率、无病生存率分别为100%(72/72)和95.83%(69/72),外科组分别为96.88%(31/32)和93.75%(30/32),组间比较差异无统计学意义(P0.05)。结论符合ESD扩大适应证的老年单发早期胃癌病人,实施内镜手术与外科手术治疗的疗效接近,但前者手术耗时短、长期并发症少、术后恢复快。     

内镜隧道式黏膜下剥离术治疗大面积早期食管癌的安全性和有效性评价

目的评价内镜隧道式黏膜下剥离术(endoscopic submucosal tunnel dissection,ESTD)用于治疗大面积早期食管癌的安全性和有效性。 方法回顾性分析2018年1月至2019年8月于解放军总医院第一医学中心消化内科接受内镜下手术治疗的共68例大面积早期食管癌患者资料,根据手术方式不同,分为内镜下黏膜剥离术(endoscopic submucosal dissection,ESD)组45例和ESTD组23例。对比分析ESD组与ESTD组在术中出血、穿孔、剥离速度、治愈性切除率的表现。 结果安全性,ESD组1例(2.2%)术后出现迟发性出血,ESTD组2例(8.7%)发生迟发性出血,该3例出血患者通过热止血钳电凝处理均成功止血,两组相比,差异无统计学意义(P＝0.545)。ESD组无穿孔出现;ESTD组1例发生术中穿孔,以钛夹及生物蛋白胶有效封堵穿孔,两组相比,差异无统计学意义(P＝0.730)。有效性,ESD组40例(88.9%)实现治愈性切除,ESTD组21例(91.3%)达到治愈性切除,两组相比,差异无统计学意义(P＝1.000)。ESD组病变剥离速度为(33.2±13.4)mm²/min,ESTD组病变剥离速度为(41.8±17.3)mm²/min,两组相比,ESTD组要显著快于ESD组(P＝0.027)。 结论与传统ESD相比,ESTD对于病变黏膜剥离速度更快,是一种安全有效的治疗大面积早期食管癌的内镜下切除术式。     

消化道类癌三种内镜治疗方法的比较

目的比较普通圈套器电切、内镜黏膜切除术(EMR)和内镜黏膜下剥离术(ESD)治疗消化道类癌的有效性和安全性。 方法回顾性分析2006年1月至2015年6月病理符合消化道类癌患者的临床资料,比较普通圈套器电切治疗(普通圈套器电切组,12例)、内镜黏膜切除术治疗(EMR组,47例)和内镜黏膜下剥离术治疗(ESD组,39例)的组织学完全切除率、并发症,以及术后随访6～36个月观察其疗效。 结果内镜治疗消化道类癌的组织学完全切除率为78.57%(77/98)。普通圈套器电切组的组织完全切除率为66.67% (8/12),EMR组为82.98% (39/47),ESD组为76.92% (30/39),差异均无统计学意义 (P＝0.463)。仅1例ESD治疗后发生穿孔,其他患者未出现并发症。所有患者随访6～36个月,均未复发。 结论内镜治疗对病变未超过黏膜下层的小的消化道类癌是一种安全有效的方法。     

内镜黏膜下剥离术治疗早期结直肠癌及癌前病变的非整块切除影响因素分析

目的 探讨内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)治疗结直肠肿瘤发生非整块切除的影响因素。方法 回顾性收集2011年1月～2022年12月结直肠ESD临床病理资料,经病理证实为腺瘤、锯齿状病变、早期结肠癌共1251例患者1312个病变,比较整块切除组与非整块切除组的临床病理特征,采用单因素及多因素logistic回归分析ESD非整块切除的影响因素。结果 1312个病变长径(25.8±16.3)mm。腺瘤728个(55.5%),锯齿状病变193个(14.7%),腺癌391个(29.8%)。1306个病变完成ESD治疗,因穿孔或操作困难中止切除6个。病变整块切除率89.5%(1174/1312),完全切除率73.8%(968/1312),治愈性切除率70.6%(926/1312)。多因素logistic分析显示,病变长径≥40 mm(OR=6.329,95%CI:4.278～9.384,P<0.001)、抬举征阴性(OR=2.384,95%CI:1.424～3.903,P=0.005)、瘢痕部位病变(OR=2.997,95%CI:...     

经黏膜下隧道内镜剥离术治疗食管浅表肿瘤的临床研究

目的评价经黏膜下隧道内镜剥离术(ESTD)治疗食管浅表性肿瘤的效率及安全性。方法 74例食管浅表性肿瘤患者按病灶周径(1/3周,1/3~2/3周,2/3周)分层随机分为内镜黏膜下剥离术(ESD)组(36例)和ESTD组(38例),分别行ESD及ESTD治疗,比较各组的剥离面积、手术时间、剥离速度、整块切除率、治愈性切除率和出血、穿孔及术后狭窄等并发症情况。结果各组剥离面积无差异(P0.05)。在病灶周径1/3周时,两组的手术时间、剥离速度、整块切除率及治愈性切除率均差异无统计学意义(P0.05),在病灶周径1/3~2/3周及2/3周时,ESTD组的手术时间[(50.7±21.3)min及(61.7±29.8)min]明显短于ESD组[(79.8±19.5)min及(119.8±35.4)min](P0.05)、剥离速度[(21.1±5.6)mm~2/min及(28.8±6.1)mm~2/min]明显快于ESD组[(14.5±3.7)mm~2/min及(15.2±5.1)mm2/min](P0.05)。在病灶周径1/3~2/3周时,两组整块切除率及治愈性切除率均无差异(P0.05),在周径2/3周时,ESTD组整块切除率及治愈性切除率均高于ESD组(P0.05)。ESD组中,术中出血6例,术后迟发性穿孔2例,术后狭窄10例;ESTD组中,术中出血5例,术后狭窄13例,无穿孔发生。结论 ESTD能安全有效地切除食管浅表肿瘤,大面积食管肿瘤同传统ESD相比,具有手术时间短、剥离速度快、治愈性切除率高的优势。     

ESD治疗早期结直肠癌及癌前病变疗效观察

探讨内镜黏膜下剥离术(ESD)治疗早期结直肠癌(CC)及癌前病变(PL)(早期CC～PL)的疗效。2014年1月—2016年12月,CC～PL患者146例,随机分为内镜黏膜下剥离术(ESD)组与内镜黏膜下切除术(EMR)组各73例,分别行ESD治疗和EMR治疗。观察手术时间、术中出血量、术中穿孔、出血与住院时间,病灶切除情况:基底病灶残余、组织治愈性切除、整块切除,术前、术后3月血清T细胞,CD3~+、CD4~+、CD8~+、CD4~+/CD8~+;术前、术后3月CEACAM-1、微血管密度值(MVD),两组术后并发症及1年复发、存活情况。结果显示,ESD组手术时间、术中出血量与住院时间均大于EMR组(P0.05)。ESD组整块切除率(97.26%)、治愈性切除率(68.49%)均高于EMR组整块切除率(75.34%)、治愈性切除率(46.58%)(P0.05)。ESD组基底病灶残余率(2.74%)与EMR组(4.11%)无差异(P0.05);两组切缘阳性率均为0。术后3月,ESD组血清CD3~+、CD4~+、CD4~+/CD8~+均高于EMR组,血清CD8~+及MVD低于EMR组(P0.05)。ESD组术后并发症发病率、一年复发率均低于EMR组(P0.05)。两组一年生存率差异无统计学意义(P0.05)。结果表明,ESD治疗早期CC～PL病灶切除效率高,可有效降低CEACAM-1水平,弱化其致癌功能,促进细胞免疫功能恢复,抑制肿瘤血管形成,有助于患者康复。     

内镜下切除十二指肠非壶腹部病变的临床应用分析

目的回顾性分析内镜下切除十二指肠非壶腹部病变(non-ampullary duodenal lesions, NADLs)的安全性和有效性。 方法以在解放军总医院第一医学中心接受内镜下切除NADLs的72例患者为研究对象,对患者的基本资料、手术相关资料和术后随访资料进行回顾性分析。 结果72例患者中,36例行内镜下黏膜切除术、22例行内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)、14例行改良ESD术。整块切除率为83.3%,R0切除率为79.2%。其中6例(8.3%)病变发生穿孔、5例(6.9%)发生迟发出血。68例(94.4%)进行了术后随访,其中8例(11.1%)术后复查时病变局灶复发并再次接受内镜下治疗。 结论内镜下治疗NADLs是可行的、有效的。但是由于十二指肠特殊的解剖学特点,其手术并发症发生率高,需要通过有效的预防措施来降低其发生率。     

早期胃癌内镜黏膜下剥离术相关并发症及其处理原则

正早期胃癌由于淋巴转移和远处转移率很低,故其预后明显优于进展期胃癌。近年来随着内镜技术的发展,内镜黏膜切除术(EMR)和内镜黏膜下剥离术(ESD)已广泛应用于早期胃癌的治疗。ESD治疗适用范围较EMR扩大,提高了整块切除率,减少病灶残留,降低了复发率,提高了对消化道病变的治愈率。因此目前ESD是早期胃癌主要的内     

内镜下黏膜切除术及黏膜剥离术治疗早期胃癌和癌前病变的疗效对比研究

目的对比分析内镜下黏膜切除术（EMR）和内镜下黏膜剥离术（ESD）对治疗早期胃癌（EGC）和癌前病变的效果和安全性。 方法选取2015年1月至2016年1月无锡市第二人民医院收治的60例EGC和癌前病变患者为研究对象,根据治疗方式分为EMR组（32例）和ESD组（28例）,对比分析两组患者的手术时间、禁饮禁食时间、术中出血情况、术后病理、整块切除率、治愈性切除率、肿瘤局部复发率、肿瘤残留率和术中、术后不良反应及预后情况。 结果ESD组患者手术时间长于EMR组［（53.35±7.12）min vs（34.23±5.74）min,t=2.009,P=0.043］,术中出血量多于EMR组［（10.26±3.42）ml vs（3.35±0.71）ml,t=2.511,P=0.018］,差异有统计学意义。ESD组患者病灶整块切除率（92.9% vs 62.5%,χ²=7.693,P=0.006）及治愈性切除率（78.6% vs 43.8%,χ²=7.545,P=0.006）均高于EMR组患者,差异有统计学意义。ESD组不良反应率为14.3%（4/28）,高于EMR组的3.1%（1/32）,差异有统计学意义（χ²=8.765,P=0.001）。两组患者术后2年总生存率比较,差异无统计学意义（χ²=0.643,P=0.423）。 结论与EMR相比,ESD可能是治疗EGC及癌前病变的一种较为安全有效的手术方式。     

Validation of the application of the Japanese curative criteria for superficial adenocarcinoma at the esophagogastric junction treated by endoscopic submucosal dissection: a long-term analysis

Background

A few studies have shown promising results with endoscopic submucosal dissection (ESD) for adenocarcinoma at the esophagogastric junction (EGJAC). However, curative criteria on the histology of EGJAC have not been developed, and long-term clinical results are lacking. The purpose of this study was to validate the application of the Japanese curative criteria to EGJAC after ESD.

Methods

Between September 2002 and March 2009, 1,350 superficial gastric neoplasms in 1,181 patients were treated by ESD at a single tertiary cancer center. For this retrospective cohort study, 49 patients with 50 superficial EGJACs were extracted from our database. Complications, en bloc resection rate, curative resection rate, overall survival, and cause-specific survival were evaluated in all patients. For assessment of curability, curative criteria proposed by the Japanese Gastric Cancer Association for early gastric carcinoma after endoscopic resection were used.

Results

Delayed bleeding and postoperative stenosis each occurred in three (6 %) patients but were managed endoscopically. No other major complications were observed related to ESD. The en bloc resection rate was 98 % (49/50), and the curative resection rate was 72 % (36/50). With a median follow-up period of 47 (range 22–97) months, the overall survival rates and cause-specific survival rates at 5 years were 86.2 % [95 % confidence interval (CI) 76–97] and 100 % (95 % CI 91–100), respectively.

Conclusions

Endoscopic submucosal dissection with application of the Japanese curative criteria may be a feasible and effective treatment for curative intent in patients with superficial EGJAC.     

Comparing Laparoscopic to Endoscopic Resections for Early Gastric Cancer in a High Volume North American Center

Endoscopic submucosal dissection as an organ sparing option for early gastric cancer is becoming increasingly accepted as an alternative to laparoscopic gastrectomy. Given the very limited North American data, we sought to compare outcomes between endoscopic and laparoscopic resection of gastric malignant and premalignant tumors. Patients undergoing laparoscopic gastrectomy or endoscopic submucosal dissection from 2007 to 2014 for adenocarcinoma or dysplasia at the McGill University Health Center were identified from a prospectively collected database and dichotomized according to the surgical approach. Patient demographics, tumor characteristics, stage, oncologic outcome, length of stay, and postoperative complications were recorded. Of 155 patients with gastric cancer identified, 67 were treated by laparoscopic gastrectomy (n?=?37) or endoscopic submucosal dissection (ESD) (n?=?30). There were significantly more invasive lesions in the laparoscopic group and patients subject to ESD harbored more T1 lesions. No significant difference in the rate of R0 resection or overall complications was observed between the groups. Accordingly, length of stay was significantly shorter in the ESD group. There were no significant differences in terms of overall and disease-free survival. In selected patients, ESD is associated with improved short-term outcomes and provides an appropriate oncologic resection option in a North American patient cohort.     

The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis

Background  

Endoscopic submucosal dissection (ESD) allows en bloc resection of the entire lesion, permitting a higher curative resection rate and increased quality of life by minimizing the resection size compared with that of endoscopic mucosal resection (EMR). Although ESD has been implemented at most university hospitals in Korea, potential complications of ESD such as bleeding and perforation raise doubts in the therapeutic decision on use of the ESD procedure for early gastric cancer patients and in reimbursement decision making. This systematic review aimed to address both the effectiveness and safety outcomes of ESD versus EMR for early gastric cancer.     

内镜下黏膜切除术与内镜黏膜下剥离术对早期胃癌疗效的Meta分析

目的：系统评价内镜下黏膜切除术（EMR）与内镜黏膜下剥离术（ESD）治疗早期胃癌（EGC）的疗效及安全性。 方法：检索多个国内外数据库,收集相关临床研究文献,筛选出符合纳入标准的合格文献后行Meta分析。 结果：最终纳入15个临床病例对照研究,共4 673例患者,其中ESD组2 154例,EMR组2 519例。Meta分析显示,ESD组的手术时间长于EMR组,但整块切除率、完整切除率、治愈切除率均高于EMR组（均P<0.05）;并发症方面,两组出血的发生率差异无统计学意义（P>0.05）,但ESD组的穿孔发生率高于EMR组（P<0.05）;ESD组术后局部复发率低于EMR组（P<0.05）。 结论：ESD治疗EGC切除率高、局部复发率低,但手术时间长、穿孔率高,但以上结论还需要大样本、高质量的研究进一步证实。     

The modern treatment of early gastric cancer: our experience in an Italian cohort

Background  Endoscopic submucosal dissection (ESD) has been developed as treatment for early gastric cancer (EGC) by Japanese authors. However, there are no reports about its possible implementation in the Western setting. The aim of the present work is to determine the safety and efficacy of the endoscopic treatments for EGC in an Italian cohort. Methods  Forty-five patients for a total of 48 gastric lesions were enrolled in the study. Thirty-six EMR procedures were performed with the strip biopsy technique using a double-channel endoscope. En bloc resection refers to resection in one piece, while piecemeal refers to resections in which the lesion was removed in multiple fragments. A total of 12 ESD were performed and completed with IT knife. We define as curative treatment lateral and vertical margins of the resected specimens free of cancer and repeat endoscopic finding of no recurrent disease. Results  Out of 36 EMR procedures, 10 were piecemeal resections (28%), while 26 were en bloc (72%). ESD led to en bloc resection in 11/12 cases (92%). Histological assessment of curability in the EMR group was achieved in 56% of the cases, and in 92% of the ESD group. Mean follow-up period was 31 months (range: 12–71 months). There was no local recurrence or distant metastasis in the curative group patients. Conclusions  These results seem to confirm the safety and the clinical efficacy of the ESD procedure in the Western world too.     

Endoscopic submucosal dissection versus transanal endoscopic surgery for the treatment of early rectal tumor: a systematic review and meta-analysis

Minimally invasive treatment of early-stage rectal lesion has presented good results, with lower morbidity than surgical resection. Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) are the main methods of transanal surgery. However, endoscopic submucosal dissection (ESD) has been gaining ground because it allows en bloc resections with low recurrence rates. The aim of this study was to analyze ESD in comparison with transanal endoscopic surgery. We searched MEDLINE, EMBASE, SciELO, Cochrane CENTRAL, and Lilacs/Bireme with no restrictions on the date or language of publication. The outcomes evaluated were recurrence rate, complete (R0) resection rate, en bloc resection rate, length of hospital stay, duration of the procedure, and complication rate. Six retrospective cohort studies involving a collective total of 326 patients—191 in the ESD group and 135 in the transanal endoscopic surgery group were conducted. There were no statistically significant differences between the groups for any of the outcomes evaluated. For the minimally invasive treatment of early rectal tumor, ESD and surgical techniques do not differ in terms of local recurrence, en bloc resection rate, R0 resection rate, duration of the procedure, length of hospital stay, or complication rate, however, evidence is very low.     

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目的 总结和分析残胃癌的临床诊治特点。方法 回顾性分析1996年2月至2003年11月收治的14例残胃癌病人。结果 手术切除率为78．6％，根治切除率57．1％，5年生存率21．4％；根治性切除者的2年生存率达87．5％。结论 根治性外科治疗及病期是决定残胃癌预后的关键。     

Endoscopic submucosal dissection using a carbon dioxide laser with submucosally injected laser absorber solution (porcine model)

Background

Recently, endoscopic submucosal dissection (ESD) has been performed to treat early gastric cancer. The en bloc resection rate of ESD has been reported to be higher than that of conventional endoscopic mucosal resection (EMR), and ESD can resect larger lesions than EMR. However, ESD displays a higher complication rate than conventional EMR. Therefore, the development of devices that would increase the safety of ESD is desired. Lasers have been extensively studied as a possible alternative to electrosurgical tools. However, laser by itself easily resulted in perforation upon irradiation of the gastrointestinal tract. We hypothesized that performing ESD using a CO₂ laser with a submucosal laser absorber could be a safe and simple treatment for early gastric cancer. To provide proof of concept regarding the feasibility of ESD using a CO₂ laser with submucosally injected laser absorber solution, an experimental study in ex vivo and in vivo porcine models was performed.

Methods

Five endoscopic experimental procedures using a carbon dioxide (CO₂) laser were performed in a resected porcine stomach. In addition, three endoscopic experimental procedures using a CO₂ laser were performed in living pigs.

Results

In the ex vivo study, en bloc resections were all achieved without perforation and muscular damage. In addition, histological evaluations could be performed in all of the resected specimens. In the in vivo study, en bloc resections were achieved without perforation and muscular damage, and uncontrollable hemorrhage did not occur during the procedures.

Conclusions

Endoscopic submucosal dissection using a CO₂ laser with a submucosal laser absorber is a feasible and safe method for the treatment of early gastric cancer.     

Long-term outcome after laparoscopic wedge resection for early gastric cancer

Background  Laparoscopic wedge resection (LWR) can be applied for the management of early gastric cancer without the risk of lymph node metastasis. Although LWR for early gastric cancer is one of the minimally invasive procedures, its radicality in cancer therapy is controversial. This study aimed to evaluate the long-term outcomes after LWR. Methods  Data on 43 consecutive cases of LWR performed for preoperatively diagnosed mucosal gastric cancer were analyzed retrospectively in terms of long-term outcomes. Results  No postoperative deaths occurred after LWR. Histologically, resected specimens showed submucosal invasion in 11 cases (26%) and positive surgical margins for cancer in 4 cases (9%). Three patients (7%) showed local recurrence near the staple line, and one patient (2%) died due to the local recurrence, but no lesional lymph node or distant recurrence occurred. The overall 5-year survival rate was 88%. The gastric remnant after LWR developed metachronous multiple gastric cancer in five cases (12%). Conclusions  The findings show a relatively high incidence of positive surgical margin, local recurrence, and gastric remnant cancer after LWR. Although LWR can be performed for properly selected patients, periodic postoperative endoscopic examination is necessary to detect metachronous multiple gastric cancer and local recurrences.