经食管黏膜下隧道内镜治疗大面积食管黏膜病变的价值
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摘要
目的探讨经食管黏膜下隧道内镜治疗大面积食管黏膜病变的应用价值。方法徐州医科大学附属淮安医院2015年1月至2017年7月经胃镜及病理诊断大面积食管高级别上皮内瘤变18例,采用随机数字表法分为传统内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)法及经食管黏膜下隧道法切除病变,对比及随访观察治疗效果。结果隧道组均于术中一次性完整剥离切除,一次性整块切除率均为100%,经典ESD组1例圈套器辅助分片切除,一次性整块切除率均为88.9%,术后病理结果提示所有切除标本的侧切缘和基底切缘无肿瘤累及。病变切除的平均直径隧道组为(7.5±3.2)cm,经典ESD组为(8.3±1.4)cm,2组在病变切除面积差异无统计学意义(P>0.05);平均手术时间隧道组为(50.4±28.0)min,经典ESD组为手术时间(82.5±29.7)min,2组在一次性整块切除率、平均手术时间方面,差异有统计学意义(P<0.05)。隧道技术组术中无1例皮下气肿;剥离过程无环形肌受伤害;经典ESD组术中出现纵隔、皮下气肿2例,其中小穿孔的1例应用钛夹缝合,术后3 d气肿均自行消失,术后24 h内出现发热1例,伴有白细胞升高,抗炎对症处理后第2天完全缓解,差异有统计学意义(P<0.05)。结论内镜经食管黏膜下隧道技术是大面积食管黏膜病变切除安全有效的方法,能有效降低内镜下病变切除的难度,缩短手术时间,减少并发症发生。
Objective To investigate the value of endoscopic submucosal tunnel resection of large area esophageal mucosal lesions.Methods Between January 2015 and June 2017,18 patients with large area esophageal high grade epithelial neoplasia confirmed by pathology were collected.All the patients were divided into two groups using random number table method.The patients in control group were treated with traditional endoscopic submucosal dissection(ESD),and the patients in test group were treated with submucosal tunnel resection.The therapeutic effect of the two groups were observed and compared.Results The total removal rate of the tunnel group was 100%.In the classic ESD group,1 case was fractionally excised by a snare,and the total removal rate was 88.9%.The postoperative pathological results showed that the lateral cutting edge and basal cutting edge of the excised specimen were complete in the two groups of lesions.The maximum diameters in tunnel group and classic ESD group were(7.5±3.2)cm and(8.3±1.4)cm respectively,and the difference of the lesion resection area was not statistically significant between the two groups(P>0.05).The operation times in tunnel group and classic ESD group were(50.4±28.0)min and(82.5±29.7)min.There was significant difference between the two groups in lump-sum slice and average operation time(P<0.05).There was no subcutaneous emphysema in tunnel group,and the stripping process has no ring muscle injury.In classic ESD group,there were 2 cases of mediastinal and subcutaneous emphysema,of which 1 case of small perforation was applied with titanium clip,and the emphysema disappeared by itself 3 days after operation.There was a fever of 1 in 24 h after operation,accompanied by elevated white blood cell,and the symptom was completely relieved in the second day after treatment.The incidence of complications between the two groups has significant statistical significance(P<0.05).Conclusion Using submucosal tunnel technology for the treatment of large area esophageal mucosal lesion is a safe and effective method.It can effectively reduce the difficulty of endoscopic lesion resection,shorten the operation time,and reduce the complications.
Objective To investigate the value of endoscopic submucosal tunnel resection of large area esophageal mucosal lesions.Methods Between January 2015 and June 2017,18 patients with large area esophageal high grade epithelial neoplasia confirmed by pathology were collected.All the patients were divided into two groups using random number table method.The patients in control group were treated with traditional endoscopic submucosal dissection(ESD),and the patients in test group were treated with submucosal tunnel resection.The therapeutic effect of the two groups were observed and compared.Results The total removal rate of the tunnel group was 100%.In the classic ESD group,1 case was fractionally excised by a snare,and the total removal rate was 88.9%.The postoperative pathological results showed that the lateral cutting edge and basal cutting edge of the excised specimen were complete in the two groups of lesions.The maximum diameters in tunnel group and classic ESD group were(7.5±3.2)cm and(8.3±1.4)cm respectively,and the difference of the lesion resection area was not statistically significant between the two groups(P>0.05).The operation times in tunnel group and classic ESD group were(50.4±28.0)min and(82.5±29.7)min.There was significant difference between the two groups in lump-sum slice and average operation time(P<0.05).There was no subcutaneous emphysema in tunnel group,and the stripping process has no ring muscle injury.In classic ESD group,there were 2 cases of mediastinal and subcutaneous emphysema,of which 1 case of small perforation was applied with titanium clip,and the emphysema disappeared by itself 3 days after operation.There was a fever of 1 in 24 h after operation,accompanied by elevated white blood cell,and the symptom was completely relieved in the second day after treatment.The incidence of complications between the two groups has significant statistical significance(P<0.05).Conclusion Using submucosal tunnel technology for the treatment of large area esophageal mucosal lesion is a safe and effective method.It can effectively reduce the difficulty of endoscopic lesion resection,shorten the operation time,and reduce the complications.
引文
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2 Othman MO,Wallace MB.Endoscopic mucosal resection(EMR)and endoscopic submucosa1 dissection(ESD)in 2011,a Westem perspective[J].Clin Res Hepatol Gastroenterol,201l,35(4):288-294.
3 Inoue H,Minami H,Kaga M,et al.Endoscopic mucosal resection and endoscopic submucosal dissection for esophageal dysplasia and carcinoma[J].Gastointest Endosc Clin N Am,2010,16(3):392-394.
4 周平红,姚礼庆,蔡明琰.隧道内镜技术的发展与临床应用[J].中华消化内镜杂志,2013,28(11):601-603.
5 徐美东,张晨.隧道内镜技术在消化道疾病中的应用价值[J/CD].中华临床医师杂志(电子版),2016,10(20):9027-9030.
6 彭芊芊,戴文华,王伟飞.经黏膜下隧道内镜肿瘤切除术在食管肿瘤治疗中的进展[ J].中华消化内镜杂志,2013,30(8):478-480.
7 赵国策,赵晓晏,于劲.内镜下食管环行肌切开术治疗贲门失弛缓症15例疗效分析[J].第三军医大学学报,2012,34(12):1141.
8 令狐恩强,李惠凯.横开口法经口内镜下肌切开术治疗贲门失弛缓症疗效及安全性评价[J].中华消化内镜杂志,2012,29(9):483-486.
9 姚礼庆,周平红.内镜黏膜下剥离术[M].上海:复旦大学出版社,2009:144-145.
10 仲恒高,缪林,季国忠.内镜黏膜下剥离术治疗早期胃癌及癌前病变36例临床分析[J].中国内镜杂志,2016,22(1),90-92.
11 高雪峰,丁岩冰,邓彬.透明质酸钠、甘油果糖混合液黏膜下注射行内镜黏膜下剥离术:26例临床分析[J].胃肠病学,2010,15(5):299-301.
12 内镜黏膜下剥离术专家协作组.消化道黏膜病变内镜黏膜下剥离术治疗专家共识[J].中华胃肠外科杂志,2012,15(10):1083-1086.
13 张轶群,姚礼庆,周平红.内镜下黏膜剥离术后迟发性出血的治疗及危险因素分析[J].中华消化内镜杂志,2010,27(12):647-649.
14 钟超,杨建宇,李启睿.内镜黏膜下剥离术与外科手术治疗早期胃癌的有效性及安全性的Meta分析[J].中国内镜杂志,2017,23(5):57-63.
15 姚礼庆,陈巍峰.提高我国消化道早期癌的内镜诊治水平[J].中华胃肠外科杂志,2012,15(7):649-653.
16 陈伟,黄慧峰,夏态军.消化道内镜诊治早期癌前病变62例回顾性分析[J].中华全科医学.2017(11).
17 田慧,孙畅,王策.消化道早癌内镜黏膜下剥离术的配合及护理[J].临床荟萃,2017(11):29-31.
18 钟芸诗,姚礼庆,周平红.内镜黏膜下剥离术治疗胃食管交界部早期癌的价值[J].中华消化外科杂志,2011,10(3):185-187.
19 王伟,郝璐,施新岗.内镜黏膜下剥离术在早期胃癌及癌前病变治疗中的价值[J].第二军医大学学报,2017,38(7):923-927.
20 周平红,彭贵勇,杨仕明.内镜黏膜下剥离术治疗早期胃癌及癌前病变的临床疗效分析[J].第三军医大学学报,2014,36(14):1507-1511.
21 姚礼庆,时强,蔡世伦.内镜黏膜下剥离术治疗残胃早期癌或癌前病变的疗效分析[C].昆明:肿瘤多学科综合诊治新进展学术研讨会,2015.
2 Othman MO,Wallace MB.Endoscopic mucosal resection(EMR)and endoscopic submucosa1 dissection(ESD)in 2011,a Westem perspective[J].Clin Res Hepatol Gastroenterol,201l,35(4):288-294.
3 Inoue H,Minami H,Kaga M,et al.Endoscopic mucosal resection and endoscopic submucosal dissection for esophageal dysplasia and carcinoma[J].Gastointest Endosc Clin N Am,2010,16(3):392-394.
4 周平红,姚礼庆,蔡明琰.隧道内镜技术的发展与临床应用[J].中华消化内镜杂志,2013,28(11):601-603.
5 徐美东,张晨.隧道内镜技术在消化道疾病中的应用价值[J/CD].中华临床医师杂志(电子版),2016,10(20):9027-9030.
6 彭芊芊,戴文华,王伟飞.经黏膜下隧道内镜肿瘤切除术在食管肿瘤治疗中的进展[ J].中华消化内镜杂志,2013,30(8):478-480.
7 赵国策,赵晓晏,于劲.内镜下食管环行肌切开术治疗贲门失弛缓症15例疗效分析[J].第三军医大学学报,2012,34(12):1141.
8 令狐恩强,李惠凯.横开口法经口内镜下肌切开术治疗贲门失弛缓症疗效及安全性评价[J].中华消化内镜杂志,2012,29(9):483-486.
9 姚礼庆,周平红.内镜黏膜下剥离术[M].上海:复旦大学出版社,2009:144-145.
10 仲恒高,缪林,季国忠.内镜黏膜下剥离术治疗早期胃癌及癌前病变36例临床分析[J].中国内镜杂志,2016,22(1),90-92.
11 高雪峰,丁岩冰,邓彬.透明质酸钠、甘油果糖混合液黏膜下注射行内镜黏膜下剥离术:26例临床分析[J].胃肠病学,2010,15(5):299-301.
12 内镜黏膜下剥离术专家协作组.消化道黏膜病变内镜黏膜下剥离术治疗专家共识[J].中华胃肠外科杂志,2012,15(10):1083-1086.
13 张轶群,姚礼庆,周平红.内镜下黏膜剥离术后迟发性出血的治疗及危险因素分析[J].中华消化内镜杂志,2010,27(12):647-649.
14 钟超,杨建宇,李启睿.内镜黏膜下剥离术与外科手术治疗早期胃癌的有效性及安全性的Meta分析[J].中国内镜杂志,2017,23(5):57-63.
15 姚礼庆,陈巍峰.提高我国消化道早期癌的内镜诊治水平[J].中华胃肠外科杂志,2012,15(7):649-653.
16 陈伟,黄慧峰,夏态军.消化道内镜诊治早期癌前病变62例回顾性分析[J].中华全科医学.2017(11).
17 田慧,孙畅,王策.消化道早癌内镜黏膜下剥离术的配合及护理[J].临床荟萃,2017(11):29-31.
18 钟芸诗,姚礼庆,周平红.内镜黏膜下剥离术治疗胃食管交界部早期癌的价值[J].中华消化外科杂志,2011,10(3):185-187.
19 王伟,郝璐,施新岗.内镜黏膜下剥离术在早期胃癌及癌前病变治疗中的价值[J].第二军医大学学报,2017,38(7):923-927.
20 周平红,彭贵勇,杨仕明.内镜黏膜下剥离术治疗早期胃癌及癌前病变的临床疗效分析[J].第三军医大学学报,2014,36(14):1507-1511.
21 姚礼庆,时强,蔡世伦.内镜黏膜下剥离术治疗残胃早期癌或癌前病变的疗效分析[C].昆明:肿瘤多学科综合诊治新进展学术研讨会,2015.