内镜黏膜切除术治疗直肠类癌的价值评估

目的 探讨内镜下十二指肠乳头括约肌切开术（EST）治疗胆总管结石患者的远期治疗效果,评估EST术后胆囊切除的必要性.方法 对2006年1月至12月因胆总管结石而行EST治疗257例患者进行随访,所有患者平均随访时间为34.8个月（26～48个月）.根据不同病情和处理情况分为3组进行比较,合并有胆囊结石的患者EST术后行胆囊切除为A1组,EST术后未行胆囊切除为A2组;B组为未合并胆囊结石者.结果 出现远期并发症者31例（12.1%）,胆总管结石复发25例（9.7%）,胆管炎27例（10.1%）,胰腺炎2例（0.8%）,胆管癌1例（0.4%）;A2组患者远期并发症发生率、胆总管结石复发率均高于A1组（P均〈0.05）.结论 从远期疗效来看,EST是治疗胆总管结石的安全、有效的方法,对于合并有胆囊结石的患者EST术后行胆囊切除是有必要的.     

直肠类癌的内镜超声诊断和内镜黏膜下切除

目的 研究内镜超声对直肠类癌的诊断价值，探讨内镜下黏膜切除术治疗直肠类癌的应用价值。方法 应用微超声探头对结肠镜发现的黏膜正常的大肠隆起性病灶进行超声检查，对诊断直肠类癌病例应用套扎器对准病灶负压吸引进行圈套结扎，再在皮圈根部连皮圈电切病灶。比较内镜超声诊断和病理检查结果，观察切除标本基底有无肿瘤累及。结果 126例黏膜正常的大肠隆起性病灶经内镜超声诊断，25例直肠类癌全部得到病理证实。直肠类癌表现为黏膜下层的边界清晰、回声欠均匀的低回声肿块。全部类癌病例无固有肌层和血管浸润，行内镜黏膜下切除无一例出现出血和穿孔，切除标本边缘和基底无肿瘤累及。结论 内镜超声可以明确直肠类癌的肠壁来源、大小、内部回声性质、边界、有无肌层和周围血管浸润，内镜下黏膜切除术治疗直肠类癌疗效确切。     

Endoscopic resection of superficial gastrointestinal tumors

Therapeutic endoscopy plays a major role in the management of gastrointestinal （GI） neoplasia. Its indications can be generalized into four broad categories; to remove or obliterate neoplastic lesion, to palliate malignant obstruction, or to treat bleeding. Only endoscopic resection allows complete histological staging of the cancer, which is critical as it allows stratification and refinement for further treatment. Although other endoscopic techniques, such as ablation therapy, may also cure early GI cancer, they can not provide a definitive pathological specimen. Early stage lesions reveal low frequency of lymph node metastasis which allows for less invasive treatments and thereby improving the quality of life when compared to surgery. Endoscopic mucosal resection （EMR） and endoscopic submucosal dissection （ESD） are now accepted worldwide as treatment modalities for early cancers of the GI tract.     

经内镜切除消化道黏膜下肿瘤

目的 探讨内镜切除消化道黏膜下肿瘤(SMT)的疗效、安全性以及切除前内镜超声检查(EUS)的价值。方法 SMT71例中食管36例，胃29例，十二指肠和直肠各3例，64例(90．1％)治疗前行EUS检查。SMT大小6～20mm，平均14．2mm。55例用双活检管道内镜行黏膜切除术(EMR)，把持钳剥离SMT后，将其切除；6例先用圈套器在SMT基底部勒紧，再注入生理盐水，切除SMT；10例≤10mm的用透明帽吸引法切除。结果 71例SMT中68例(95．8％)内镜下完全切除；2例(1例异位胰腺、1例胃平滑肌瘤)病变残留(4周时胃镜发现)；l例直肠平滑肌瘤，未能切除改行外科手术。67例平均随访18．7个月未见复发。组织学诊断平滑肌瘤51例(71．8％)，颗粒细胞瘤、纤维瘤、异位胰腺、脂肪瘤、间质瘤和类癌共15例(21．1％)，5例(7．0％)间叶肿瘤未做免疫染色，不能确定组织来源。并发症：9例局部少量出血，1例胃间质瘤切除后胃穿孔。结论 内镜切除SMT是一种较安全、有效的方法，并可获得组织学诊断，EUS对内镜治疔SMT选择适应证有重要的价值。     

Endoscopic resection for gastrointestinal neuroendocrine tumors

Gastrointestinal (GI) and neuroendocrine tumors (NETs) can be treated by mini-invasive endoscopic resection when localized in the superficial layers of the bowel wall and their size is <20 mm. Endoscopic diagnosis of NETs is usually incidental or suspected after clinical, laboratory or imaging findings. Endoscopic mucosal resection is the most commonly used technique for NET removal, endoscopic submucosal dissection is indicated in selected cases, while papillectomy is feasible for ampullary lesions. Histopathologic assessment of the resection margin (circumferential and deep) is important for staging. Incidence of endoscopic mucosal resection-/endoscopic submucosal dissection-related complications for removal of GI NETs are similar to those reported for other GI lesions. Endoscopic follow-up is based on histopathologic characteristics of the resected NETs and its site. NETs >20 mm in size, with penetration of the muscle layer and/or serosa are at high risk for metastases and surgical approach is recommended when feasible.     

EMR和ESD在消化道肿瘤治疗中的应用

考虑到外科手术的风险和改善患者生活质量等问题,内镜下粘膜切除术(EMR)和内镜下粘膜剥离术(ESD)在日本已成为消化道早期粘膜癌的常规治疗方法,并逐渐被西方等国家认同。现就EMR、ESD在消化道肿瘤治疗中的应用现状和进展作一综述。     

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。     

Endoscopic mucosal resection in the upper gastrointestinal tract

Endoscopic mucosal resection （EMR） is a technique used to locally excise lesions confined to the mucosa. Its main role is the treatment of advanced dysplasia and early gastrointestinal cancers. EMR was originally described as a therapy for early gastric cancer. Recently its use has expanded as a therapeutic option for ampullary masses, colorectal cancer, and large colorectal polyps. In the Western world, the predominant indication for EMR in the upper gastrointestinal tract is the staging and treatment of advance dysplasia and early neoplasia in Barrett＇s esophagus. This review will describe the basis, indications, techniques, and complications of EMR, and its role in the management of Barrett＇s esophagus.     

Upper gastrointestinal carcinoid tumors incidentally found by endoscopic examinations

AIM: This study shares Asian clinical experiences of carcinoid tumors that originated in the upper gastrointestinal tract. METHODS: From May 1987 to June 2002, we had found only 13 cases of histologically confirmed carcinoid tumors in the upper gastrointestinal tract by endoscopic examinations. There were eight males and five females. The mean age was 53.16±20.51 years that ranged from 26 to 82 years. Each of their clinical presentations, locations, tumor morphology, and size and the treatment outcome were analyzed and discussed. RESULTS: One patient had a polypoid lesion at the lower esophagus, nine were stomach lesions and three located at the duodenum. All patients with polypoid and submucosal tumor types were of small size (<1.7 cm) and all patients survived after simple excision or polypectomy. Four of the five patients in tumor mass forms died and the tumors were more than 2.0 cm in size. CONCLUSION: Carcinoid tumors rarely originated from the upper gastrointestinal tract and are usually found accidentally after endoscopic study. Bigger size (more than 2 cm) tumor masses may indicate a more severe disease and poor prognosis.     

Endoscopic resection of tumors in the lower digestive tract

As endoscopic technology has developed and matured,the endoscopic resection of gastrointestinal tract polyps has become a widely used treatment. Colorectal polyps are the most common type of polyp, which are best managed by early resection before the polyp undergoes malignant transformation. Methods for treating colorectal tumors are numerous, including argon plasma coagulation, endoscopic mucosal resection, endoscopic submucosal dissection, and laparoscopic-endoscopic cooperative surgery. In this review, we will highlight several currently used clinical endoscopic resection methods and how they are selected based on the characteristics of the targeted tumor. Specifically, we will focus on laparoscopic-endoscopic cooperative surgery.     

Endoscopic resection with a two-channel videoendoscope for gastric carcinoid tumors

BACKGROUND/AIMS: Endoscopic resection has been used to treat hypergastrinemia-associated early carcinoid tumors of the stomach. However, indications for endoscopic treatment of these tumors have not been established. Moreover, endoscopic resection of these tumors is often difficult with conventional polypectomy, because these tumors are often located in the submucosal layer. To completely remove these tumors, we used a two-channel videoendoscope with which both grasping forceps and a polypectomy snare could be used simultaneously. METHODOLOGY: At Osaka Medical Center for Cancer and Cardiovascular Diseases, eight carcinoid tumors in six patients were removed with a two-channel videoendoscope. Reports of early carcinoid tumor in Japanese literature were reviewed to analyze the relationship between lymph node metastasis and the size and depth of involvement of these tumors. RESULTS: Six carcinoid tumors were completely removed "en bloc", but two tumors were incompletely removed. In these two patients, submucosal tumor invasion was observed on the excision line. To completely remove these tumors, the oral side, but not the top, of the tumor should be strongly grasped and pulled toward the center of the lumen as far as possible by the grasping forceps, which had been passed through the snare loop. Endoscopic follow-up studies showed no local recurrence in any patients with and without complete tumor resection during the average observation period of 30 months. A review of histological reports in Japanese literature showed that lymph node metastasis did not occur when the tumors were less than 10 mm in diameter, and could be completely removed by an endoscope. CONCLUSIONS: Endoscopic resection with a two-channel videoendoscope is a useful and safe method for resection of small carcinoid tumors of the stomach.     

Metastatic tumors to the upper gastrointestinal tract: endoscopic experience.

Metastatic tumors to the upper gastrointestinal tract were identified by esophagogastroduodenoscopy in 14 patients. Malignant melanoma, breast cancer, and lung cancer were the most common primary cancers in four, three, and three patients, respectively. Osteogenic sarcoma, renal cell carcinoma, Meckel cell carcinoma of the skin, and germ-cell tumor were the primary cancer in the remaining four. The esophagus was involved in three patients, the stomach in 13, duodenum in four, and papilla of Vater in one. Upper gastrointestinal bleeding and anemia were the most common presenting features. There was correlation between symptoms and endoscopic findings in all patients. Involvement of gastrointestinal tract at endoscopy was the initial and only evidence of metastases in all patients without evidence of metastases elsewhere, as evidenced by other diagnostic tests in any of these patients. Endoscopic biopsies and/or brush cytology provided histologic diagnosis in all 14 patients. The endoscopic and nonendoscopic literature regarding metastases to the upper gastrointestinal tract is reviewed.     

Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device

BACKGROUND: Local endoscopic mucosal resection of rectal carcinoid tumors is often associated with margin involvement that requires further intervention. The efficacy of resection of these tumors with endoscopic submucosal resection with a ligation device (ESMR-L) was evaluated. METHODS: Fourteen rectal carcinoid tumors were treated by ESMR-L between 1999 and 2002. ESMR-L was performed with a conventional colonoscope with an attached band-ligator device. For comparison, 14 rectal carcinoid tumors, treated by either endoscopic mucosal resection or polypectomy between 1990 and 1997, were evaluated as historical controls. All tumors were estimated to be 1 cm or less in diameter. OBSERVATIONS: There were no differences between the 2 groups in terms of age, gender, or tumor size. For 6 (43%) patients in the control group, there was tumor involvement at the margin of the resection specimen, whereas all tumors removed by ESMR-L had histopathologically proven negative margins (p < 0.05). The mean vertical resection margin also was significantly deeper in the ESMR-L group (p < 0.05). There was no complication of any procedure. CONCLUSIONS: ESMR-L is technically simple, minimally invasive, and safe for treatment of small rectal carcinoid tumors contained within the submucosa. ESMR-L provides a deeper resection margin compared with that obtained with conventional endoscopic mucosal resection or polypectomy.     

Endoscopic mucosal resection with circumferential mucosal incision of duodenal carcinoid tumors

Duodenal carcinoids are a rare form of neuroendocrine tumors, and tend to invade the submucosa during the early stage. Endoscopic treatment is generally recommended for duodenal carcinoids less than 10 mm in diameter. Although a few reports have described the use of endoscopic resection of duodenal carcinoids, there are no published studies on endoscopic mucosal resection with circumferential mucosal incision (EMR-CMI). We performed EMR-CMI for 5 cases of duodenal carcinoids in the duodenal bulb. The mean tumor diameter was 4.6 ± 1.8 mm. Although all of the tumors were located in the submucosa, R0 resection was performed without complication in each case. EMR-CMI may thus be a safe and effective treatment for duodenal carcinoids less than 10 mm in diameter.     

Endoscopic resection of small duodenal carcinoid tumors with strip biopsy technique

Background: Most cases of duodenal carcinoid have conventionally been treated by surgical resection. The aim of our study was to explore the feasibility of endoscopic resection in small duodenal carcinoids. Methods: The study population consisted of seven patients with small duodenal carcinoids. The diagnosis was confirmed by preoperative biopsies. The depth of tumor invasion was evaluated by endosonography. Results: The carcinoid was detected by endosonography in all cases. Size ranged ultrasonographically from 1.5 mm to 7 mm. Tumor invasion was confined to the submucosa in all patients. Endoscopic resection was performed with the strip biopsy technique using a two-channel endoscope. In six patients, the specimens were resected without severe complications. Five of them were confirmed histologically to be typical carcinoids. In one patient, carcinoid was not detected histologically in the specimen. In the remaining patient, a perforation occurred. However, the huge ulcer was managed conservatively. Follow-up endoscopy revealed no evidence of recurrent or residual tumor in any patient. Conclusion: Small duodenal carcinoids confined to the submucosa can be resected endoscopically and preoperative endosonography is necessary for the determination of endoscopic resectability. (Gastrointest Endosc 1998;47:466-70.)