早期结直肠肿瘤内镜黏膜下剥离术非治愈性切除的危险因素研究进展

结直肠癌是消化道常见的恶性肿瘤之一.内镜黏膜下剥离术(ESD)已广泛应用于早期结直肠肿瘤的治疗.早期结直肠肿瘤ESD非治愈性切除的危险因素已在多项研究中得到证实.本文就早期结直肠肿瘤ESD非治愈性切除危险因素的研究进展作一综述.     

结直肠息肉癌变的内镜下表现、治疗及癌变因素分析

目的探讨结直肠息肉癌变的内镜下表现,分析癌变相关因素和治疗策略。方法回顾性分析经电子结肠镜检查或治疗的77例结直肠癌变息肉患者的临床、内镜及病理资料,探讨影响结直肠息肉癌变的相关因素及其内镜下治疗策略。结果77例癌变结直肠息肉中,9例伴发结肠癌。60例有临床症状,症状发生率为77．9％（60／77）。息肉癌变主要分布在乙状结肠,多发生于年龄超过60岁的老年患者,绒毛状腺瘤癌变率最高。行电子结肠镜电切法切除44例,其中完全切除38例。结论年龄〉60岁患者和乙状结肠息肉癌变发生率明显增高,选择性对属于原位癌或早期浸润癌的癌变息肉行电子结肠镜下切除是安全有效的。     

结直肠息肉切除后并发出血的研究进展

随着我国经济社会的发展,结直肠癌的发病率和死亡率在我国呈现出逐年上升的趋势,目前是我国发病率第四位的肿瘤。结直肠镜检查及内镜下息肉切除术是降低结直肠癌发病率和死亡率的重要手段]。出血、术后电凝综合征、穿孔和腹部不适是内镜下结直肠息肉切除术的主要并发症,其中以出血最常见。结直肠息肉切除后出血会引起一系列不良事件,包括：病人急诊观察、再次入院、重复内镜检查、内镜下止血、输血、血管造影栓塞甚至外科手术结直肠切除,对医院及患者而言均是较大的负担,本文对结直肠息肉切除后并发出血的研究进展做一综述,重点讨论结肠息肉切除后出血的流行病学、出血相关危险因素、出血后处置方法及预防出血措施,以期加深临床医师对此种并发症的认识,从而更好的指导临床工作。     

内镜下切除结直肠侧向发育型肿瘤的 临床结果研究

目的比较分析内镜黏膜切除术(EMR)、预切开EMR(EMR-P)、内镜黏膜下剥离术(ESD)和圈套器辅助ESD(ESD-S)4种内镜下切除方法治疗结直肠侧向发育型肿瘤(LSTs)的安全性和有效性。方法以2016年1月至2018年3月在解放军总医院第一医学中心接受内镜下治疗的146例结直肠LSTs病例为研究对象,回顾性分析患者基本信息、内镜下切除结果、术后组织病理学结果和随访结果。结果146例结直肠LSTs中,23例行EMR治疗,29例行EMR-P治疗,50例行ESD治疗,44例行ESD-S治疗。中位病变直径2.5 cm(1.2~10.0 cm)。EMR、EMR-P、ESD和ESD-S整块切除率分别为73.9%(17/23)、72.4%(21/29)、96.0%(48/50)、65.9%(29/44),差异有统计学意义(P<0.001);R0切除率分别为65.2%(15/23)、69.0%(20/29)、94.0%(47/50)、63.6%(28/44),差异有统计学意义(P=0.002)。ESD组整块切除率和R0切除率高于其他3组(P均<0.05)。4组术中穿孔率分别为0,0,6.0%(3/50),9.1%(4/44),差异无统计学意义(P=0.269);迟发性出血率分别为4.3%(1/23),0,2.0%(1/50),2.3%(1/44),差异无统计学意义(P=0.768)。117例(80.1%)患者术后进行了肠镜随访,中位随访时间10.0个月(3.0~26.0个月),其中局部复发7例(6.0%)。结论ESD是结直肠LSTs最理想的治疗方法;EMR可作为直径<20 mm结直肠LSTs的治疗方法;EMR-P和ESD-S作为改良的内镜下切除方法,在治疗LSTs上具有自身特殊的优势。     

放大色素内镜在结直肠肿瘤内镜黏膜切除治疗中的应用

目的 评估内镜黏膜切除术(EMR)结合放大色素内镜诊治结直肠肿瘤的有效性和安全性.方法 收集结肠镜检查患者中符合EMR指征的无蒂型或平坦、凹陷型病灶.观察病灶形态学与EMR术后组织学结果 的相关性,评估放大色素内镜判断病灶浸润深度的准确性.结果 81例患者经EMR切除病灶90个(无蒂型25个,平坦、凹陷型65个).组织学显示低级别上皮内瘤变(LGD)58个,高级别上皮内瘤变(HGD)20个,腺癌12个.其中HGD和癌变病灶直径大于LGD病灶[(1.4±0.5)cm和(1.6±0.5)cm比(1.05:0.4)cm],但组间差异无统计学意义(P>0.05).平坦、凹陷型病灶较无蒂型病灶更易出现HGD或癌,但差异亦无统计学意义[41.5%(27/65)比20.0%(5/25),P=0.084].病灶表面有凹陷者出现HGD或癌的比例显著高于无凹陷者[51.0%(25/49)比17.1%(7/41),P<0.01)].放大色素内镜判断病灶浸润深度的准确性为97.8%(88/90).完整的组织学切除占所有病灶的95.6%(86/90).结论 凹陷型和平坦型伴中央凹陷的结直肠病变的恶性倾向高.应用放大色素内镜能准确判断病灶浸润深度,从而使EMR治疗更安全有效.     

结直肠肿瘤内镜诊治新技术的应用进展

近年随着内镜诊治往术的不断发展,一些常规内镜下不易发现的病灶,如结直肠微小扁平状腺癌和锯齿状腺癌的诊断率不断提高;对一些结直肠肿瘤也常采用内镜下治疗。本文主要对国内临床刚开展应用的内镜诊治新技术：变焦扩大电子结肠镜、内镜金属夹结扎蒂性大息肉和氩离子束血浆凝固（APC）术作一简要综述。一、结直肠肿瘤的变焦结肠境检查新型变焦结肠镜不仅具有常规电子结肠镜的所有功能,还具有变焦放大功能,可根据需要将病灶放大100～150倍,以细致观察结直肠粘膜腺管开口,即凹窝的形态。将色素内镜与变焦结肠镜相结合,在内镜直观了…     

结直肠黏膜下肿瘤的内镜治疗现状

随着居民健康体检意识的增强和消化内镜诊疗技术的发展普及,结直肠黏膜下肿瘤（submucosal tumor, SMT）的检出率明显提高,但病理类型和生物学行为的多样性使其诊疗难度依旧较大。内镜切除术因微创、标本完整和费用低等优点而广受关注和认可,目前被用于病变无淋巴结或远处转移且能够耐受内镜手术的患者。消化道SMT的内镜下切除方式主要有内镜圈套切除术、内镜黏膜下挖除术、经黏膜下隧道内镜肿瘤切除术和内镜全层切除术等,本文即对结直肠SMT的这4种治疗方式进行综述。     

内镜黏膜下剥离术治疗结直肠浅表性肿瘤性病变的术后随访

[目的]探讨结直肠浅表性肿瘤性病变行内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)后临床病理特征、术后并发症及非治愈性ESD的相关危险因素及追加手术的必要性.[方法]回顾性分析本院因结直肠浅表性肿瘤性病变行ESD治疗的383例患者的临床资料,分析其一般临床特点、病理特征及预...     

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。     

早期结直肠癌及其癌前病变内镜黏膜下剥离术非治愈性切除的危险因素分析

背景：目前国内尚缺乏内镜黏膜下剥离术（ESD）非治愈性切除早期结直肠癌及其癌前病变的危险因素的大宗临床研究。目的：分析ESD治疗早期结直肠癌及其癌前病变的疗效,探索影响非治愈性切除的危险因素。方法：收集2016年9月—2021年9月北京医院行ESD治疗的早期结直肠癌及其癌前病变患者共229例,分析患者的临床病理特征、ESD疗效。采用单因素分析和Logistic多因素回归分析评估影响ESD非治愈性切除的危险因素。结果：共发现255处病变,整块切除率为90.2%,R0切除率为87.8%,治愈性切除率为83.5%,并发症发生率为2.7%。单因素分析结果显示非治愈性切除组腔内突出型肿瘤检出率（61.0%对24.4%,P<0.05）、黏膜下层重度纤维化率（24.4%对2.4%,P<0.05）显著高于治愈性切除组,而抬举征阳性率明显降低（80.5%对95.1%,P<0.05）。Logistic多因素回归分析结果显示腔内突出型肿瘤（OR=4.087,95%CI:1.523～10.968,P=0.005）、黏膜下层重度纤维化（OR=9.609,95%CI:1.107～83.439,P...     

JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection

Colorectal endoscopic submucosal dissection (ESD) has become common in recent years. Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also many types of precarcinomatous adenomas. It is important to establish practical guidelines in which the preoperative diagnosis of colorectal neoplasia and the selection of endoscopic treatment procedures are properly outlined, and to ensure that the actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with the guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society has recently compiled a set of colorectal ESD/endoscopic mucosal resection (EMR) guidelines using evidence‐based methods. The guidelines focus on the diagnostic and therapeutic strategies and caveat before, during, and after ESD/EMR and, in this regard, exclude the specific procedures, types and proper use of instruments, devices, and drugs. Although eight areas, ranging from indication to pathology, were originally planned for inclusion in these guidelines, evidence was scarce in each area. Therefore, grades of recommendation were determined largely through expert consensus in these areas.     

Colorectal endoscopic submucosal dissection: present status and future perspective,including its differentiation from endoscopic mucosal resection

Endoscopic submucosal dissection (ESD) allows en bloc resection of a lesion, irrespective of the size of the lesion. ESD has been established as a standard method for the endoscopic ablation of malignant tumors in the upper gastrointestinal (GI) tract in Japan. Although the use of ESD for colorectal lesions has been studied via clinical research, ESD is not yet established as a standard therapeutic method for colorectal lesions because colorectal carcinoma has unique pathological, organ specific characteristics that differ radically from those of the esophagus and stomach, and scope handling and control is more difficult in the colorectum than in the upper GI tract. Depending on the efficacy of endoscopic mucosal resection (EMR) and the clinicopathological characteristics of the colorectal tumor, the proposed indications for colorectal ESD are as follows: (1) lesions difficult to remove en bloc with a snare EMR, such as nongranular laterally spreading tumors (particularly the pseudo depressed type), lesions showing a type VI: pit pattern, and large lesions of the protruded type suspected to be carcinoma; (2) lesions with fibrosis due to biopsy or peristasis; (3) sporadic localized lesions in chronic inflammation such as ulcerative colitis; and (4) local residual carcinoma after EMR. Colorectal ESD is currently in the development stage, and a standard protocol will be available in the near future. We hope that colorectal tumors will be efficiently treated by a treatment method appropriately selected from among EMR, ESD, and surgical resection after precise preoperative diagnosis based on techniques such as magnifying colonoscopy.     

Treatment outcomes of endoscopic resection for rectal carcinoid tumors: an analysis of the resectability and long-term results from 46 consecutive cases

Aim: In Japan, most of colorectal carcinoid tumors developed in rectum. The choice of treatment is important because surgical treatment may need to construct artificial anus. Although curative endoscopic resection (ER) is desirable from the point of quality of life, sufficient evidence of endoscopic treatment for rectal carcinoid tumors is not fully obtained.

Methods: Between April 2001 and August 2013, 46 rectal carcinoid tumors in 46 patients who underwent either with endoscopic mucosal resection with a ligation device (EMR-L) or endoscopic submucosal dissection (ESD) were analyzed retrospectively. The rates of en bloc resection, positive for lateral and/or vertical margin, curative resection, local recurrence, additional treatments, overall and disease-specific survival rate after ER were evaluated during follow-up (median observation period 61.6 months).

Results: Twenty-two lesions were treated by EMR-L and 24 lesions were treated by ESD. Both groups had similar mean tumor size (EMR-L: 6.2?mm, ESD: 6.0?mm). The rate of en bloc resection, negative for both lateral and vertical margins, and curative resection were, respectively, 73%, 63%, and 50% for EMR-L, 100%, 100%, and 83% for ESD. These results suggested that the rate of resectability and curability for ESD was significantly higher than EMR-L (p?Conclusion: The long-term outcomes of ER for rectal carcinoid tumors were excellent. ESD has advantage for resectability and curability compared with EMR-L; therefore, ESD is more favorable procedure as treatment for rectal carcinoid tumors.     

Current status of endoscopic full-thickness resection with the full-thickness resection device

Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD) is an integral part of diagnostic and therapeutic endoscopy. Since its market launch in Europe in 2014, its safety and effectiveness have been proven in numerous studies. Adaptations in design as well as new techniques, such as hybrid EFTR, expand the spectrum of the FTRD system. The following review is intended to provide an overview of the clinical application and current evidence of EFTR with the FTRD system.     

Endoscopic resection of submucosal tumors

Submucosal gastrointestinal tumors represent a unique, diverse and challenging group of lesions found in modern medical practice. While management has traditionally been surgical, the development of advanced endoscopic techniques is challenging this approach. This review aims to investigate the role of endotherapy in treatment pathways, with a focus on carcinoid and gastrointestinal stromal tumors. In particular, we will discuss which lesions can be safely treated endoscopically, the evidence base behind such approaches and the limitations of the current evidence. The review will consider how these techniques may change the management of submucosal tumors in the future.     

改良内镜黏膜切除术治疗结肠扁平息肉的临床应用

目的 评价改良内镜黏膜切除术(M-EMR)治疗结肠扁平息肉疗效。方法 将276例297枚结肠扁平息肉患者随机分成两组：EMR组136例共152枚息肉,M-EMR组140例共145枚息肉。病灶黏膜下注射生理盐水后,EMR组一次性切除病灶,M-EMR组在病灶周边用圈套器头端切开周边黏膜后一次性切除病灶,回收全部标本送病理检查。比较术后两组并发症发生率,手术时间,完整切除率,术后复发率。结果 全部息肉一次性切除。EMR组1例迟发出血,1例穿孔,1例电凝综合征,并发症发生率2.0%(3/152);M-EMR组1例迟发出血,1例电凝综合征,并发症发生率1.4%(2/145)。EMR组息肉切除时间平均(5.6±2.0)min;M-EMR组息肉切除时间平均(5.7±2.1)min,2组无显著差异(p>0.05)。EMR组息肉完整切除率92.1％(140／152),M-EMR组息肉完整切除率100％(145／145),2组显著差异(p<0.05)。术后病理：管状腺瘤135例,绒毛状腺瘤40例,绒毛管状腺瘤57例,增生性息肉29例,炎性息肉34例。腺瘤伴高级别类瘤变8例,其中EMR组1例息肉残留,后行肠段切除,6个月后8例复查无复发。M-EMR组2例黏膜内癌,完整切除,6个月后复查无复发。EMR组12例术后残留,1例手术,11例APC处理后,1例6个月复发,复发率0.66%(1／152),M-EMR组无复发。结论 M-EMR组较EMR组治疗结肠扁平息肉更有效。     

Cold snare endoscopic resection of nonpedunculated colorectal polyps larger than 10 mm: a systematic review and pooled-analysis

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