结直肠侧向发育型肿瘤内镜诊断与治疗

目的探讨结直肠侧向发育型肿瘤(LST)内镜诊断方法,经内镜黏膜切除术(EMR)、分片切除术(EPMR)、内镜黏膜下剥离术(ESD)方法治疗LST的疗效、安全性。方法 LST经色素染色放大内镜或NBI-ME观察病变形态、腺管开口分型(pit)及表面微血管分型(MP),分别进行EMR、EPMR、ESD或外科手术治疗,并分析LST的病理特点。结果在399例病人检出有LST,共407个病变。LST大小在10～80mm。LST部位在直肠128个(31.4%),乙状结肠97个(23.8%),降结肠54个(13.3%),横结肠67个(16.5%),升结肠21个(5.2%),盲肠36个(8.8%),回肠末段4例(1.0%)。LST形态呈颗粒均一型145个,结节混合型161个,扁平隆起型63个,假凹陷型38个。LST腺管开口分型以ⅢL和Ⅳ为多。405个LST经肠镜微创电切治疗,228个行EMR切除,165个行EPMR切除,12个行ESD切除,均在内镜下成功电切,另2例LST行外科手术治疗。出血发生率4.0%,术中即刻出血4例,术后3天迟发出血12例,无肠穿孔发生。LST病理结果:管状腺瘤46个(11.3%),管状绒毛状腺瘤146个(35.9%),绒毛状腺瘤181个(44.5%),增生性息肉10个(2.5%),高级别上皮内瘤变19个(4.7%),黏膜内癌3个(0.7%),黏膜下癌2个(0.4%)。术后复查肠镜无复发。结论色素染色放大内镜或NBI-ME方法有利于检出LST,EMR、EPMR、ESD是内镜下治疗LST安全有效的方法。

Diagnosis and treatment of colorectal laterally spreading tumor by endoscopy

Objective To evaluate the power of endoscopic diagnosis and treatment of laterally spreading tumor（LST）.Methods LST was detected by chromoendoscopy and NBI combined with magnifying endoscopy（NBI-ME） technique.The site,size,morphological features,pit pattern,and microvascular patterns（MP） on the surface of LST were observed with staining with indigo carmine magnifying endoscopy or NBI-ME.The LSTs were resected by EMR,EPMR,ESD or surgical operation,respectively.The histopathological feature of the specimen of LST was analyzed.Results Four handred and seven of LSTs were detected in 399 patients,the diameter range of LSTs was 10-80 mm,the largest lesion was 80 mm × 80 mm,and the smallest one was 10 mm × l0 mm.The site of 128 LSTs was in rectum（31.4%）,97 LSTs in sigmoid colon（23.8%）,54 LSTs in descending colon（13.3%）,67 LSTs in transverse colon（16.5%）,21 LSTs in ascending colon（5.2%）,36 LSTs in cecum（8.8%）,and 4 LST in terminal ileum（1.0%）.Morphology of 145 LSTs were homogeneous granular type（LST-G）,161 LSTs were mixed non-granular type（LST-NG）,63 LSTs were flat elevated type,and 38 LSTs were pseudo-depressed type.Most of the pit patterns of LST were type ⅢL or type Ⅳ.Four handred and five LSTs were treated by endoscopic minimally invasive surgery.Among them,228 LSTs were resected by EMR,165 LSTs by EPMR,12 LSTs by ESD,en bloc resection of all cases were successful,other 2 LSTs were treated by surgical operation.The rate hemorrhage was 4.0%,4 cases were bleeding during the operation,12 cases were late onset 3 days after operation,no perforation was happened.The histopathological diagnoses of LST included 46 tubular adenoma（11.3%）,146 villous-tubular adenoma（35.9%）,181 villous adenoma（44.5%）,10 hyperplastic polyps（2.5%）,19 advanced intraepithelial tumor（4.7%）,3 intramucosal carcinoma（0.7%）,2 slightly invaded submucosal cancer（0.4%）.No recurrence was found after resection.Conclusion Mucosal staining with magnifying endoscopy and NBI-ME were very useful in detecting LST,the resection of LST with minimally invasive treatment such as EMR,EPMR,ESD was effective and safe.