内镜粘膜下剥离胃食管连接部上皮内瘤变的有效性及安全性研究

背景：在胃不同部位内镜粘膜下剥离（ESD）中胃食管连接部手术技术难度最大。Siewert将胃食管连接部腺癌依据起源分为三种类型。目前仅有日本学者报道了胃食管连接部Siewert’s二型病变ESD研究，尚未见将三种类型病变ESD治疗效果统一分析的报道。Objective：评价应用ESD切除胃食管连接部上皮内瘤变的有效性和安全性。方法： 2008年10月至2013年1月期间，73例患者应用ESD技术切除胃食管连接部病上皮内瘤变。本研究前瞻性的评估ESD技术的可行性，短期结果，完整切除率，治愈性切除率，并发症，以及ESD术后的补充治疗及随访结果。结果：73例患者中，68例 (93.2%) 完整切除。切除粘膜最大径平均33.7mm。达到治愈性切除标准的61例患者中，成功随访57例(93.4%)。随访时间为1-56个月，平均24.1个月。1例患者出现高级别上皮内瘤变的再发。12例患者未达到治愈性切除。其中有3例水平切缘残留，1例垂直切缘有残留，4例存在印戒细胞癌或未分化的腺癌，1例病人存在脉管或淋巴管浸润，垂直切除残留印戒细胞癌的有1例，未分化腺癌且合并脉管或淋巴管浸润的有2例。在非治愈性切除患者中，1例失访，7例病人补充外科手术，4例病人定期随访未发现复发及远端转移。3例出现并发症仅为延迟出血，经过保守治疗或内镜下止血后治愈。结论：ESD是治疗胃食管连接部上皮内瘤变的安全有效方法，完整切除以及治愈性切除是完全可行的，且在一定程度上可以避免局部复发。

The effectiveness and safety of endoscopic submucosal dissection for intraepithelial neoplasia of the esophagogastric junction

Background: Endoscopic submucosal dissection(ESD) of the esophagogastric junction(EGJ) is the most difficult form of dissection throughout the stomach and esophagus. Currently, none of the reports of ESD for Siewert type II carcinoma of the EGJ has compared the outcomes of ESD for all three Siewert types of adenocarcinoma. To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for intraepithelial neoplasia of the esophagogastric junction (EGJ). Methods: From October 2008 to June 2013, 73 patients underwent ESD for intraepithelial neoplasia of the EGJ. The patients were evaluated prospectively as to the executability of the technique, the short-term results of the procedure, en bloc resection rate, curative resection rate, complications and additional treatment after ESD and follow-up outcomes. Results: Of 73 patients, 68 patients (93.2%) had en bloc resection; the mean maximum diameter of specimen was 33.7mm. In 61 curative resection patients, 57(93.4%) were successfully followed-up for 1-56 months with an average of 24.1 months. Local recurrence was found in one patient with High-grade intraepithelial neoplasm (HIN). Non-curative resection in 12 patients, including lateral resection margin residues in 3 patients, vertical resection margin residues in one patient, signet ring cell carcinoma or undifferentiated adenocarcinoma in 4 patients, lymphatic or vessel invasion in one patient, vertical residual margin residues combined signet ring cell carcinoma in one patient, and undifferentiated adenocarcinoma with lymphatic or vessel invasion in two patients. Among non-curative resection group, one lost to follow-up, seven patients were underwent additional surgery, the remaining 4 patients were periodically followed up and none had local recurrence or distant metastases. The only complication was delayed bleeding which successfully controlled by conservative treatment or endoscopic therapy for hemostasis in three patients.Conclusions: ESD is safe and effective for intraepithelial neoplasia of the EGJ. R0 en bloc resection is mostly possible and can avoid the risk of local recurrence.