改良ESD 联合橡皮圈套扎切除治疗胃固有肌层小肿瘤的临床研究

摘要： 目的 探讨改良内镜黏膜下剥离术 （ESD） 联合橡皮圈套扎切除治疗胃固有肌层小肿瘤的疗效及安全性。方法 选择经超声内镜 （EUS） 明确肿物 （6 mm≤长径≤13 mm） 来源于胃固有肌层的 92 例患者， 在对患者实施静脉麻醉且气管插管状态下， 先采用改良的 ESD 剥离小肿物， 暴露到一定程度后， 采用橡皮圈套扎肿物， 然后进行圈套器套扎切除。观察术中术后出血、 穿孔情况， 观察肿物切除的完整性、 标本大小， 对标本进行病理及免疫组化检查， 术后对患者进行 6 及 12 个月的胃镜及 EUS 随访。结果 92 例胃固有肌层小肿瘤均一次完整切除， 手术平均操作时间（19.2±2.3） min， 术中平均出血量 （2.6±0.5） mL， 切除后穿孔 3 例， 均于内镜下金属止血夹联合尼龙绳结扎闭合创面。术后观察 1 周均无迟发性出血、 穿孔等情况发生； 标本大小 6 mm×5 mm～13 mm×12 mm， 术后病理诊断胃间质瘤 73 例 （均为极低危险度）， 胃平滑肌瘤 18 例， 胃神经纤维瘤 1 例； 术后随访 12 个月， 均未见残留、 复发等情况。结论改良 ESD 联合橡皮圈套扎切除治疗胃固有肌层小肿瘤的疗效确切、 安全， 可完整切除病变， 得到完整的病理学诊断资料， 对评估肿瘤性质、 恶性程度及患者预后有一定的意义。

Clinical study of modified ESD and rubber band ligation assisted endoscopic dissection for treatment of small gastric submucosal tumors originating from the muscularis propria layer

Abstract: Objective To investigate the efficacy and safety of modified endoscopic submucosal dissection (ESD) and rubber band ligation assisted endoscopic dissection for treatment of small gastric submucosal tumors (SMT) originating from the muscularis propria layer. Methods A total of ninety-two patients diagnosed as gastric SMT (6 mm≤diameter≤13 mm) originating from the muscularis propria layer by EUS in our hospital were enrolled in this study. With intravenous anesthesia and tracheal intubation in all patients, modified ESD was performed firstly to stripe the small tumors. After being exposed to a certain extent, the tumors were ligated by rubber band and snared for endoscopic dissection. The situation of bleeding, perforation in both intraoperative and postoperative, the integrity and size of the resected specimens were observed and recorded. The resected specimens were identified with histopathological detection and immunohistochemistry assay. At the 6-month and 12-month after the operation, all patients were reviewed by gastroscopy and EUS in our hospital. Results All the 92 tumors were resected completely and successfully. The mean operating time was (19.2±2.3) min and the mean blood loss in operation was (2.6±0.5) mL. Perforation after resection occurred in 3 cases, which were closed with metal hemostatic clips and nylon ropes. No delayed bleeding and perforation occurred in one week after the operation. The tumor sizes ranged from 6 mm×5 mm to 13 mm×12 mm. Seventy-three gastric stromal tumors (risk classification: all were very low risk), 18 gastric leiomyomas and 1 gastric neurofibroma were identified. There were no residue or recurrence in all cases during the 12-month follow-up period. Conclusion The modified ESD and rubber band ligation assisted endoscopic dissection are effective and safe for treatment of small gastric submucosal tumors originating from the muscularis propria layer. The tumors are resected completely and successfully, showing certain significance to assess the nature, degree of malignancy of the tumor and prognosis of the patients.