消化内镜切除技术中黏膜下注射液的研究进展

近十几年, 内镜切除技术不断发展普及, 在消化道癌前病变与早期癌变的治疗中应用广泛。内镜切除技术主要包括息肉切除术、内镜黏膜切除术(endoscopic muscosal resection, EMR)、内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)。其中ESD及多数EMR术中都需要黏膜下注射这一重要操作, 通过该操作使病灶与肌层分离, 这对黏膜的完整切除及预防出血穿孔等都非常重要, 同时也促进了内镜技术的推广应用。如何选择合适的黏膜下注射液值得关注, 本文就目前黏膜下注射液的研究现况进行阐述, 并展望了未来黏膜下注射液的发展方向。     

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.     

内镜黏膜下剥离术治疗胃肠间质瘤的疗效分析

[目的]探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗胃肠间质瘤(gastrointestinal stromal tumors,GIST)的疗效。[方法]回顾性分析运用ESD治疗的27例GIST患者的临床资料。[结果]27例均为单发肿瘤,直径为5~30(16±8)mm,其中位于胃底部13例,胃体8例,胃窦部3例,贲门部2例,直肠1例。27例均内镜下成功完成手术,手术时间为35~180(75±43.6)min,术中出血量较少,平均(10±8.2)ml,4例术中出现穿孔,其中1例主动穿孔行内镜下胃壁全层切除术,均予金属夹成功夹闭。术后病理提示26例为GIST,1例为平滑肌瘤。术后随访6~24个月,所有患者未见肿瘤复发及转移。[结论]ESD治疗GIST是安全、有效的。     

直肠类癌内镜黏膜下剥离治疗的临床研究

[目的]探讨超声内镜(endoscopic ultrasonography,EUS)诊断、内镜黏膜下剥离(endoscopic submucosal dissection,ESD)治疗直肠类癌的临床疗效及安全性。[方法]对经EUS证实并行ESD治疗的12例直肠类癌患者的临床资料进行回顾性分析。12例均在内镜下标识预切除范围、黏膜下多次注射、黏膜切开、病变剥离及创面钛夹处理。[结果]12例直肠类癌直径0.6~1.8cm,均一次性切除,病灶基底与周缘无类癌组织累及。随诊6~25个月无复发。[结论]经EUS证实行ESD治疗直径2cm,未浸及固有肌层、无远处转移的直肠类癌疗效确切、安全性好,适宜开展。     

超声内镜辅助胃食管间叶源性肿瘤的内镜治疗25例

目的 探讨在超声内镜(endoscopicultrasonography,EUS)辅助下,针对胃及食管间叶源性肿瘤的个性化治疗方法.方法 患者选择标准:(1)最大直径＜ 2.0 cm起源于黏膜肌层的黏膜下肿瘤(submucosal tumor,SMT).(2)最大直径＜1.2 cm起源于固有肌层的SMT.(3)肿瘤向腔内生长.(4)无肿瘤转移的其他影像学证据.入选病例25例,其中男15例,女10例.采用内镜下黏膜切除术(endoscopic mucosal resection,EMR)方法治疗黏膜肌层的肿瘤,固有肌层的肿瘤采用结扎方法.结果 6例病变位于胃固有肌层的SMT(胃底4例,胃体1例,胃窦1例)采取内镜下结扎方法治疗;19例食管黏膜肌层SMT采取内镜下EMR治疗.25例治疗过程中均未发生出血及穿孔,术后复查超声内镜创面愈合,病变无残留.结论 EUS在选择间叶源性肿瘤治疗方式方面具有积极的作用,可为病人选择个性化治疗,使内镜下治疗更安全、有效.起源于固有肌层的肿瘤,采用内镜下结扎治疗,与内镜下剥离治疗相比,创伤小、并发症少,不失为一种好的治疗办法.     

牙线辅助内镜黏膜下剥离术治疗消化道早期病变的临床研究

目的探讨牙线辅助内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗消化道早期病变的疗效和安全性。方法应用牙线辅助ESD治疗消化道早期病变15例和传统ESD方法治疗22例,比较手术时间、并发症发生率等方面的差异。结果牙线辅助ESD法手术平均时间为(45.11±3.14)min,并发症2例(2例均为术后出血);传统ESD法手术平均时间为(61.36±5.11)min,并发症5例(4例出血、1例穿孔);两组手术时间比较,差异有统计学意义(P0.05),并发症发生率比较,差异无统计学意义(P0.05)。结论牙线辅助ESD与传统ESD相比明显减少手术操作时间,但术后并发症发生率未见明显差异。     

超声内镜辅助内镜治疗源于胃固有肌层间质瘤的价值探讨

目的探讨超声内镜辅助内镜下治疗源于胃固有肌层间质瘤的价值及安全性。方法收集本院所有内镜下治疗黏膜下肿瘤的患者资料,筛选出2010年12月至2013年10月33例经病理证实为源于胃固有肌层的间质瘤,详细记录临床病理表现、超声所见、内镜切除的方法、并发症发生率以及术后随访资料。结果 33例患者其中22例接受内镜黏膜下剥离术(ESD),11例接受内镜下全层切除术(EFR)。其中ESD治疗中有5例穿孔,气胸1例,均内镜下处理以及保守治疗后好转。2例EFR患者因穿孔大转行腹腔镜手术治疗。33例患者术后均接受了3~36月随访,无局部复发以及远处转移。结论超声内镜辅助内镜下治疗源于固有肌层胃间质瘤是安全、有效的。     

内镜下全层切除术的研究进展

随着内镜诊治技术和相关器械的发展及应用,内镜下黏膜切除术(EMR)、内镜黏膜下剥离术(ESD)技术广泛应用于临床中.ESD对于早期消化道肿瘤有一定优势,而对于病变较大、基底广泛粘连和侵及肌层及浆膜层等情况,有复发及穿孔风险.在此基础上针对消化道全层"主动穿孔"的内镜下全层切除术(EFTR)一经提出,就引起国内外同行学者...     

内镜黏膜剥离术治疗消化道黏膜及黏膜下病变

目的探讨内镜下黏膜剥离术(endoscopic gubmucosal disseetion,ESD)治疗消化道黏膜及黏膜下病变的疗效、安全性及并发症防治。方法回顾性分析ESD方法治疗37例消化道黏膜及黏膜下病变的内镜下手术情况、并发症及治疗、预后情况。结果术中出血3例,术后出血2例,均内镜下成功止血;术中穿孔2例,均予内镜下金属夹夹闭后内科保守治疗成功,未有中转外科手术;l例直肠类癌及1例食管重度异型增生术后切缘病变组织残留,2~6月后复查未见明显复发迹象。结论 ESD治疗消化道黏膜及黏膜下病变安全、有效,可以一次性完整切除较大病变,提供完整的病理学资料,且术后不易复发。     

内镜黏膜下剥离术治疗消化道肿瘤的安全性及手术操作体会

[目的]探讨消化道肿瘤行内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗的安全性及手术操作体会。[方法]选取行ESD治疗的消化道黏膜层及黏膜下层肿瘤患者10例,对镜下手术方法及并发症进行总结。[结果]10例患者均完整剥离病灶,平均手术时间65(40~90)min,平均住院时间9(7~15)d。所有病例术中仅有少量渗血,经喷洒及电凝即可止血;1例穿孔,经保守治疗后痊愈。[结论]ESD治疗消化道黏膜层及黏膜肌层肿瘤是相对安全有效的,大部分患者的手术并发症可保守治愈。     

Development of a novel endoscopic manipulation system: The Endoscopic operation robot

AIM: To develop and evaluate the endoscopic operation robot (EOR). The EOR is a robot system designed specifically for remote manipulation of the scope during gastrointestinal endoscopy by a seated endoscopist. METHODS: Total colonoscopy examinations using a colonoscopy training model were performed compared conventional insertion by manual manipulation and remote-controlled insertion, using the EOR. The author investigated the time taken for each of the 50 examinations. RESULTS: The median insertion time (in minutes) for each 10 examinations (EOR vs manual manipulation) was 73.70 ± 25.37 vs 3.77 ± 1.34 in the first group, 38.40 ± 6.24 vs 3.40 ± 0.97 in the second group, 27.6 ± 4.01 vs 2.70 ± 0.95 in the third group, 23.8 ± 3.65 vs 3.10 ± 0.88 in the fourth group, and 22.9 ± 5.02 vs 2.60 ± 1.08 in the fifth group.CONCLUSION: The study suggested the possibility of the clinical application of the EOR.     

Endoscopic mucosal resection and endoscopic submucosal dissection for early gastric cancer: Current and original devices

Compared with endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) is easier to perform and requires less time for treatment. However, EMR has been replaced by ESD, because achieving en bloc resection of specimens > 20 mm in diameter is difficult with EMR. The technique of ESD was introduced to resect large specimens of early gastric cancer in a single piece. ESD can provide precise histological diagnosis and can also reduce the rate of recurrence, but has a high level of technical difficulty, and is consequently associated with a high rate of complications, a need for advanced endoscopic techniques, and a lengthy procedure time. To overcome disadvantages in both EMR and ESD, various advances have been made in submucosal injections, knives, other accessories, and in electrocoagulation systems.     

Technical tips for endoscopic ultrasound-guided hepaticogastrostomy

Interventional procedures using endoscopic ultrasound (EUS) have recently been developed. For biliary drainage, EUS-guided trans-luminal drainage has been reported. In this procedure, the transduodenal approach for extrahepatic bile ducts is called EUS-guided choledochoduodenostomy, and the transgastric approach for intrahepatic bile ducts is called EUS-guided hepaticogastrostomy (EUS-HGS). These procedures have several effects, such as internal drainage and avoiding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, and they are indicated for an inaccessible ampulla of Vater due to duodenal obstruction or surgical anatomy. EUS-HGS has particularly wide indications and clinical impact as an alternative biliary drainage method. In this procedure, it is necessary to dilate the fistula, and several devices and approaches have been reported. Stent selection is also important. In previous reports, the overall technical success rate was 82% (221/270), the clinical success rate was 97% (218/225), and the overall adverse event rate for EUS-HGS was 23% (62/270). Adverse events of EUS-biliary drainage are still high compared with ERCP or PTCD. EUS-HGS should continue to be performed by experienced endoscopists who can use various strategies when adverse events occur.     

Does endoscopic ultrasound-guided biliary drainage really have clinical impact?

The well established, gold standard method for treatment of obstructive jaundice involves biliary drainage under endoscopic retrograde cholangiopancreatography(ERCP) performed by pancreatobiliary endoscopists. Recently, interventions using endoscopic ultrasound(EUS) have been developed not only for obtaining cytological and histological diagnosis, but also for biliary drainage as alternative method. EUS-guided biliary drainage(EUSBD) was first reported by Giovannini et al. EUS-BD broadly includes EUS-guided rendezvous technique, EUS-guided choledochoduodenostomy, and EUS-guided hepaticogastrostomy. More recently, EUS-guided antegrade stenting and EUS-guided gallbladder drainage have also been reported. many case reports, series, and retrospective studies on EUS-BD have been reported. However, because prospective studies and comparisons between the different biliary drainage methods have not been reported, the technical success, functional success, adverse events, and stent patency with long-term follow up of EUS-BD are still unclear. Therefore, prospective, randomized controlled studies addressing these issues are needed. Despite this, EUSBD undoubtedly is clinically useful as an alternative biliary drainage method. EUS-BD has the potential to be a first-line biliary drainage method instead of ERCP if results of clinical trials are favorable and the technique is simplified.     

超声内镜对食管静脉曲张结扎术前后侧枝循环变化的临床研究

目的 应用Fujinon SP-701小探头超声内镜观察食管静脉曲张结扎术(EVL)前后曲张静脉及侧枝循环的变化，分析影响疗效的原因。选择合理的治疗方法。方法 对60例单纯食管静脉曲张出血患者依超声检查结果分为3组：Ⅰ组为单纯食管静脉曲张(EV)；Ⅱ组为合并有食管旁静脉(PEV)，但无交通枝(PV)；Ⅲ组合并有食管旁静脉及交通枝。患者EVL术后4、8、12周行超声内镜检查，观察及测量EV、PEV、PV的变化情况，分析影响疗效的原因。结果 Ⅰ组显效率75％，复发率16％，疗效最佳；Ⅲ组显效率0％，复发率100％，疗效最差。Ⅰ组24例中出现PEV者12例；Ⅱ组20例PEV全部增宽，11例出现PV；Ⅲ组全部有PEV增宽、PV增多增宽表现。结论 超声内镜对食管静脉曲张出血治疗方法的选择有指导意义。单纯食管静脉曲张EVL可获得满意疗效，但是伴PEV及PV者不是EVL适应证，建议采用其他方法治疗。     

ERCP结合EPT对胆囊切除术后患者诊治价值的探讨

目的 回顾性研究逆行性胰胆管造影（ERCP）结合乳头肌切开术（EPT）对胆囊切除术后患者的诊治价值。方法 170例胆囊切除术后症状再发或反复发作患者，接受ERCP检查和EPT等治疗，诊断结果与B超作对照。同时动态观察内镜下介入诊治术后临床表现的改变。不良反应及血清淀粉酶的变化及高淀粉酶血症的分布情况。结果 经ERCP结合EPT等术后患者临床症状显著改善；与B超对照ERCP对胆囊切除术后胆总管残余结石的诊断率显著提高（P＜0．001），对胆总管扩张程度的诊断价值显著优于B超（P＜0．05），并能发现许多B超检查不能发现的胆胰病变；术后主要不良反应表现为出血、高淀粉酶血症，ERCP结合EPT等治疗组高淀粉酶的发生率显著高于单纯ERCP操作组（P＜0．01）。经积极地处理后短期内出血控制，血清淀粉酶多在3日内转为正常。结论 对胆囊切除术后患者，ECRP结合EPT不失为一项非常有价值、安全的诊治措施。     

内镜下圈套结扎在治疗上消化道小平滑肌瘤中的应用

目的 探讨应用内镜下皮圈结扎的方法来治疗上消化道的小平滑肌瘤，并评价这种方法的安全性和疗效。方法 通过内镜、内镜超声及内镜超声下穿刺细胞学检查确定了59例上消化道小平滑肌瘤患者，共发现64处平滑肌瘤。在这64处平滑肌瘤中，50处为食管平滑肌瘤，12处为胃平滑肌瘤，2处为十二指肠平滑肌瘤。对所有平滑肌瘤进行皮圈套扎治疗，术后2周开始，每周做胃镜检查观察结扎处的变化，直至创面完全愈合。结果 64处病变中50处食管平滑肌瘤被完全去除，创面的平均愈合时间为3．1周。12处胃平滑肌瘤中9处被完全去除，其余3例由于结扎不彻底，仍有残余瘤组织，平均愈合时间为4.5周。2例十二指病变被完全去除，平均愈合时间4．5周。全部患者无一例发生出血、穿孔。结论 内镜下圈套结扎术是治疗上消化道小平滑肌瘤安全、有效的方法。     

Endoscopic treatment of gastro-oesophageal reflux disease (GORD): a systematic review

Gastro-oesophageal reflux disease represents an extremely common disorder which has a substantial impact on patients' quality of life and use of health care resources. Gastro-oesophageal reflux disease is a chronic relapsing disease for which a lifelong solution is needed. Until now the two competing therapeutic modalities have been the medical and surgical therapies. Quite recently a third option has become available. A number of endoscopic anti-reflux procedures have been described, with the common goal of creating an anti-reflux barrier, thus obviating long-term proton pump inhibitors and the cost and potential risk of laparoscopic Nissen fundoplication. In this review the different techniques are thoroughly examined and the results are critically evaluated, giving special emphasis to efficacy, safety and durability of these new anti-reflux procedures. Available data show that these anti-reflux techniques produce significant improvement in gastro-oesophageal reflux disease symptomatology and quality of life as well as reduce the use of anti-reflux medication, without causing serious morbidity or mortality. However, the majority of these techniques have failed to adequately control oesophageal acid reflux. Endoscopic anti-reflux therapies therefore sound very attractive-being less invasive than surgery-and show a significant promise, but are still in the early stages of assessment. Large-scale randomized multi-centre trials comparing control groups with sham procedures are essential to confirm their efficacy. Further studies are also necessary to determine what modifications these techniques require in order to produce maximum clinical efficacy and durability. However, considering that current therapies (both medical and surgical) of gastro-oesophageal reflux disease are highly effective, the need for such new endoscopic modalities may be questionable. Moreover, appropriate trials in dedicated centres should be carried out to assure that the enthusiasm commonly associated with new technology is justified and can be generalized to open-access endoscopists.     

Endoscopic Ultrasound-Guided Hepaticogastrostomy: Technical Review and Tips to Prevent Adverse Events

Most patients who require biliary drainage can be treated by endoscopic retrograde cholangiopancreatography (ERCP)-guided procedures. However, ERCP can be challenging in patients with complications, such as malignant duodenal obstruction, or a surgically-altered anatomy, such as a Roux-en-Y anastomosis, which prevent advancement of the duodenoscope into the ampulla of Vater. Recently, endoscopic ultrasound (EUS)-guided biliary drainage via transhepatic or transduodenal approaches has emerged as an alternative means of biliary drainage. Typically, EUS-guided gallbladder drainage or choledochoduodenostomy can be performed via both approaches, as can EUS-guided hepaticogastrostomy (HGS). EUS-HGS, because of its transgastric approach, can be performed in patients with malignant duodenal obstruction. Technical tips for EUS-HGS have reached maturity due to device and technical developments. Although the technical success rates of EUS-HGS are high, the rate of adverse events is not low, with stent migration still being reported despite many preventive efforts. In this review, we described technical tips for EUS-HGS related to bile duct puncture, guidewire insertion, fistula dilation, and stent deployment, along with a literature review. Additionally, we provided technical tips to improve the technical success of EUS-HGS.