食管表浅隆起型病变的内镜下诊断与治疗
|
摘要
[目的]探讨内镜诊断及治疗技术对食管表浅隆起型病变的诊治价值。
[方法] 2007年4月～2009年12月在我院住院治疗食管表浅隆起型病变的30例患者共37处病灶,其中男性19例,女性11例,男女比为1.7：1。年龄38～66岁,平均51.2±8.6岁。经普通胃镜、色素内镜、超声内镜及术前活检等检查,确定病变性质、边界、大小、浸润层次及淋巴结和脉管转移等情况,对病灶进行综合评估,均符合内镜下黏膜切除术(EMR)或内镜黏膜下剥离术(ESD)治疗适应证,其中32处病灶行EMR治疗,5处病灶行ESD治疗。术中及时用肾上腺素盐水冲洗、热活检钳、APC、剥离刀等止血以保证视野的清晰。病灶切除后,必要时应用APC、钛夹等处理创面及裸露的小血管。术后标本送病检。癌性切除标本进行连续切片全瘤活检,黏膜下切除标本行常规病理及免疫组化检查。术后禁食、补液、止血、抑酸、抗生素治疗3d,创面较大时给予胃肠减压。所有患者术后均进行内镜随访,评估创面愈合、病灶残留及复发情况,及时发现多发癌的异时性发生。
[结果]37处病灶行普通内镜检查,18处考虑早期癌及癌前病变的黏膜层扁平病灶行色素内镜检查,32处病灶行超声内镜检查。25例患者的32处病灶行EMR治疗,其中息肉法EMR13处、EMR-C18处、EPMR1处,5处病灶行ESD治疗。1例患者有4处病灶,先后行4次EMR治疗,4例患者有2处病灶,先后行2次EMR。部位：食管上段4处,中段23处,下段8处,中下段2处。病灶最大直径：EMR为0.8～2.5cm,平均1.74±0.41cm；ESD为2.2-3.6cm,平均2.96±0.59cm。来源：黏膜层22处,黏膜肌层14处,黏膜下层1处。病理结果：早期食管癌7处,重度不典型增生9处,中度不典型增生2处,腺瘤性息肉1处,非腺瘤性息肉2处,白斑1处,平滑肌瘤14处,先天性囊肿1例。操作时间：EMR15～30min,平均20.0±4.8min ESD80～100min,平均90.0±7.9min。住院天数：EMR3～10d,平均4.9±1.6d;ESD3～12d,平均7.0±3.2d。所有病灶均完全切除,全部癌性病灶切除标本基底和边缘均未见病变累及。所有患者术中术后未出现大量出血,EMR8处病灶术中少量出血,ESD2处病灶术中少量出血,经各种内镜治疗措施成功止血。1例ESD患者术中穿孔,及时给予内镜下抽吸腔内气体,钛夹夹闭创面,术后禁食水、胃肠减压、腹腔穿刺排气、抗炎、补液等内科治疗,穿孔成功愈合。术后3月复查胃镜时37处病灶创面均成功愈合。所有病灶严格按照良恶性病变的不同随访制度随访至今,无1例复发。
[结论]普通内镜联合色素内镜、超声内镜可准确判断病变的性质、来源、范围、淋巴结转移等情况,为制定恰当的治疗措施及确定内镜下切除范围提供可靠的依据。采用内镜下黏膜切除术(EMR)及内镜下黏膜剥离术(ESD)治疗早期食管癌、癌前病变、黏膜下肿瘤及广基息肉等病变是一种微创、安全、有效、快速的措施。
Objective To explore the valuation of the endoscopic diagnosis and therapy for esophagus superficial elevated-type lesions.
Methods 37 superficial elevated-type lesions of esophagus from 30 patients were treated by endoscopic therapy from April 2007 to December 2009 in our hospital. Among the 30 patients, there were 19 men and 11 women(male to female ratio was 1.7:1), and the age was from 38 to 66 years old(the average age was 51.2±8.6). After comprehensive assessed by ordinary endoscopy, chromoendoscopy(CE), endoscopic ultrasonography(EUS) and preoperative biopsy examination, the 37 lesions were in the lines with endoscopic muscosal resection (EMR) and endoscopic submucosal dissections(ESD) indications. The 32 lesions were treated by EMR and the other 5 lesions were treated by ESD. To keeping the vision clear, we used epinephrine saline irrigation, hot biopsy forceps, APC and peeling knives to stop bleeding in timely. After excision, we used APC to treat the wound surfaces and the exposed blood vessels if necessary. After EMR and ESD, the specimens were examined by pathology. The cancer specimens were all continuously sliced and all the section were examined by pathology. All the specimens that excised from muscularis mucosa were examined by routine pathological examination and immunohistochemical test. All the patients were trested with fasting, fluid infusion, restraining acid secretion and antibiotics for 3 days. The patients were gave decompression if their wound surfaces were big. The endoscopy was performed to evaluate the status of wound surfaces, lesions residual and recurrence.
Results All of the 37 lesions were examined by ordinary endoscopy, and 32 of them were examined by EUS,18 of them were examined by CE. There were 32 lesions from 25 patients treated by EMR, and among these lesions,13 were treated by strip biopsy,18 lesions by cap EMR (EMR-C) and 1 lesion by endoscopic piecemeal mucosal resection(EPMR). The other 5 lesions from 5 patients were treated by ESD. One patient had 4 lesions, and was operated through EMR by 4. Four patients had 2 lesions, and were operated through EMR by 2. The location of these lesions:four lesions located at upper esophagus,23 lesions located at middle esophagus,8 lesions located at lower esophagus and 2 lesions spanned middle and lower esophagus. The mean lesion size of EMR was 1.74±0.41cm(0.8-2.5cm) and mean lesion size of ESD was 2.96±0.59cm(2.2-3.6cm).The source level:there were 22 lesions located at mucosa,14 lesions located at muscularis mucosa and 1lesions located at submucosa. The pathologic type:early esophageal cancer 7 lesions, severe dysplasia 9 lesions, moderate dysplasia 2 lesions, adenomatous polyp 1 lesions, noadenomatous polyp 2 lesions, leukoplakia 1 lesions, leiomyoma 14 lesions and congenital cyst 1 lesion. The mean operation time of EMR was 20.0±4.8min(15-30min) and the mean operation time of ESD was 90.0±7.9min(80-100min). All the lesions were completely excised, and there was no residual. Non of the 30 patients occurred massive bleeding during and after operation. There were 8 lesions those operated by EMR and 2 operated by ESD occurred a little of bleeding. And all of them were successfully stopped by endoscopic treatments. One patient occurred perforation during ESD, then we aspirated the air in esophagus in timely and used endoclips to close the wound. After operation,the patient were given active medical treatment for 3 days, such as fasting, fluid infusion, peritoneocentesis, gastrointestinal decompression, antibiotics treatment, absorption of oxygen and so on. The mean hospitalization time of EMR was 4.9±1.6d (3～10d) and the mean hospitalization time of ESD was 7.0±3.2d (3-12d). All the wound surfaces healed completely at 3 months post-operation. In accordance with the different follow-up system of benign and malignant lesions, no lesion recurs.
Conclusion Ordinary endoscopy combines chromoendoscopy and endoscopic ultrasonography can accurately determine the nature, source as well as lymph node metastasis of the diseases. These can provide a reliable basis for the development of appropriate therapeutic measures and to determine the scope of endoscopic resection. EMR and ESD are minimally invasive, safe, effective, fast and economy for treating of early esophageal cancer, precancerous lesions, submucosal tumors, sessile polyps and other lesions.
[方法] 2007年4月～2009年12月在我院住院治疗食管表浅隆起型病变的30例患者共37处病灶,其中男性19例,女性11例,男女比为1.7：1。年龄38～66岁,平均51.2±8.6岁。经普通胃镜、色素内镜、超声内镜及术前活检等检查,确定病变性质、边界、大小、浸润层次及淋巴结和脉管转移等情况,对病灶进行综合评估,均符合内镜下黏膜切除术(EMR)或内镜黏膜下剥离术(ESD)治疗适应证,其中32处病灶行EMR治疗,5处病灶行ESD治疗。术中及时用肾上腺素盐水冲洗、热活检钳、APC、剥离刀等止血以保证视野的清晰。病灶切除后,必要时应用APC、钛夹等处理创面及裸露的小血管。术后标本送病检。癌性切除标本进行连续切片全瘤活检,黏膜下切除标本行常规病理及免疫组化检查。术后禁食、补液、止血、抑酸、抗生素治疗3d,创面较大时给予胃肠减压。所有患者术后均进行内镜随访,评估创面愈合、病灶残留及复发情况,及时发现多发癌的异时性发生。
[结果]37处病灶行普通内镜检查,18处考虑早期癌及癌前病变的黏膜层扁平病灶行色素内镜检查,32处病灶行超声内镜检查。25例患者的32处病灶行EMR治疗,其中息肉法EMR13处、EMR-C18处、EPMR1处,5处病灶行ESD治疗。1例患者有4处病灶,先后行4次EMR治疗,4例患者有2处病灶,先后行2次EMR。部位：食管上段4处,中段23处,下段8处,中下段2处。病灶最大直径：EMR为0.8～2.5cm,平均1.74±0.41cm；ESD为2.2-3.6cm,平均2.96±0.59cm。来源：黏膜层22处,黏膜肌层14处,黏膜下层1处。病理结果：早期食管癌7处,重度不典型增生9处,中度不典型增生2处,腺瘤性息肉1处,非腺瘤性息肉2处,白斑1处,平滑肌瘤14处,先天性囊肿1例。操作时间：EMR15～30min,平均20.0±4.8min ESD80～100min,平均90.0±7.9min。住院天数：EMR3～10d,平均4.9±1.6d;ESD3～12d,平均7.0±3.2d。所有病灶均完全切除,全部癌性病灶切除标本基底和边缘均未见病变累及。所有患者术中术后未出现大量出血,EMR8处病灶术中少量出血,ESD2处病灶术中少量出血,经各种内镜治疗措施成功止血。1例ESD患者术中穿孔,及时给予内镜下抽吸腔内气体,钛夹夹闭创面,术后禁食水、胃肠减压、腹腔穿刺排气、抗炎、补液等内科治疗,穿孔成功愈合。术后3月复查胃镜时37处病灶创面均成功愈合。所有病灶严格按照良恶性病变的不同随访制度随访至今,无1例复发。
[结论]普通内镜联合色素内镜、超声内镜可准确判断病变的性质、来源、范围、淋巴结转移等情况,为制定恰当的治疗措施及确定内镜下切除范围提供可靠的依据。采用内镜下黏膜切除术(EMR)及内镜下黏膜剥离术(ESD)治疗早期食管癌、癌前病变、黏膜下肿瘤及广基息肉等病变是一种微创、安全、有效、快速的措施。
Objective To explore the valuation of the endoscopic diagnosis and therapy for esophagus superficial elevated-type lesions.
Methods 37 superficial elevated-type lesions of esophagus from 30 patients were treated by endoscopic therapy from April 2007 to December 2009 in our hospital. Among the 30 patients, there were 19 men and 11 women(male to female ratio was 1.7:1), and the age was from 38 to 66 years old(the average age was 51.2±8.6). After comprehensive assessed by ordinary endoscopy, chromoendoscopy(CE), endoscopic ultrasonography(EUS) and preoperative biopsy examination, the 37 lesions were in the lines with endoscopic muscosal resection (EMR) and endoscopic submucosal dissections(ESD) indications. The 32 lesions were treated by EMR and the other 5 lesions were treated by ESD. To keeping the vision clear, we used epinephrine saline irrigation, hot biopsy forceps, APC and peeling knives to stop bleeding in timely. After excision, we used APC to treat the wound surfaces and the exposed blood vessels if necessary. After EMR and ESD, the specimens were examined by pathology. The cancer specimens were all continuously sliced and all the section were examined by pathology. All the specimens that excised from muscularis mucosa were examined by routine pathological examination and immunohistochemical test. All the patients were trested with fasting, fluid infusion, restraining acid secretion and antibiotics for 3 days. The patients were gave decompression if their wound surfaces were big. The endoscopy was performed to evaluate the status of wound surfaces, lesions residual and recurrence.
Results All of the 37 lesions were examined by ordinary endoscopy, and 32 of them were examined by EUS,18 of them were examined by CE. There were 32 lesions from 25 patients treated by EMR, and among these lesions,13 were treated by strip biopsy,18 lesions by cap EMR (EMR-C) and 1 lesion by endoscopic piecemeal mucosal resection(EPMR). The other 5 lesions from 5 patients were treated by ESD. One patient had 4 lesions, and was operated through EMR by 4. Four patients had 2 lesions, and were operated through EMR by 2. The location of these lesions:four lesions located at upper esophagus,23 lesions located at middle esophagus,8 lesions located at lower esophagus and 2 lesions spanned middle and lower esophagus. The mean lesion size of EMR was 1.74±0.41cm(0.8-2.5cm) and mean lesion size of ESD was 2.96±0.59cm(2.2-3.6cm).The source level:there were 22 lesions located at mucosa,14 lesions located at muscularis mucosa and 1lesions located at submucosa. The pathologic type:early esophageal cancer 7 lesions, severe dysplasia 9 lesions, moderate dysplasia 2 lesions, adenomatous polyp 1 lesions, noadenomatous polyp 2 lesions, leukoplakia 1 lesions, leiomyoma 14 lesions and congenital cyst 1 lesion. The mean operation time of EMR was 20.0±4.8min(15-30min) and the mean operation time of ESD was 90.0±7.9min(80-100min). All the lesions were completely excised, and there was no residual. Non of the 30 patients occurred massive bleeding during and after operation. There were 8 lesions those operated by EMR and 2 operated by ESD occurred a little of bleeding. And all of them were successfully stopped by endoscopic treatments. One patient occurred perforation during ESD, then we aspirated the air in esophagus in timely and used endoclips to close the wound. After operation,the patient were given active medical treatment for 3 days, such as fasting, fluid infusion, peritoneocentesis, gastrointestinal decompression, antibiotics treatment, absorption of oxygen and so on. The mean hospitalization time of EMR was 4.9±1.6d (3～10d) and the mean hospitalization time of ESD was 7.0±3.2d (3-12d). All the wound surfaces healed completely at 3 months post-operation. In accordance with the different follow-up system of benign and malignant lesions, no lesion recurs.
Conclusion Ordinary endoscopy combines chromoendoscopy and endoscopic ultrasonography can accurately determine the nature, source as well as lymph node metastasis of the diseases. These can provide a reliable basis for the development of appropriate therapeutic measures and to determine the scope of endoscopic resection. EMR and ESD are minimally invasive, safe, effective, fast and economy for treating of early esophageal cancer, precancerous lesions, submucosal tumors, sessile polyps and other lesions.
引文
[1]王国清.食管癌癌前病变的发展趋势及对策[J].中华肿瘤杂志,2002,24(2)：206-207.
[2]朱雄增.胃肠道癌前病变和癌的WHO诊断新标准[J].中华病理学杂志,2003,32(2)：168-169.
[3]姚汉青,王贵齐.Barrett食管和食管腺癌：东西方的差异[J].胃肠病学,2006,11(9)：513-515.
[4]张月明,贺舜,郝长青,等.窄带成像技术诊断早期食管癌及其癌前病变的临床应用价值[J].中华消化内镜杂志,2007,24(6)410-414.
[5]郝晓雯,黄晓俊.甘肃省近30年间食管癌流行病学分析[J].现代预防医学,2009,36(2)：215-219.
[6]Wang LD, Zhou Q, Gou RY, et al. Reproducibility of an esophageal biopsy sampling procedure in a high-incidence area for esophageal cancer in northern China[J].Cancer Epidemiol Biomarkers Prev,1996,5(5):405-406.
[7]王国清,郝长青,赖少情,等.碘染色在食管癌高发区直接内镜普查中的应用和效果[J].中华消化内镜杂志,2003,20(6)：377-379.
[8]Mori M, Adachi Y, Matsushima T, et al. Lugol staining pattern and histology of esophageal lesions[J]. Am J Gastroenterology,1993,88(5):701-705.
[9]邵颖,冀明,吴咏东,等.2.5%卢戈氏液诊断早期食管癌及癌前病变的临床研究[J].临床内科杂志,2006,23(8)：534-536.
[10]施开窘,时兰珍.内镜下食管粘膜碘染色的临床价值[J].安徽医学,2007,28(5)：470-471.
[11]Aibe T,Fuji T,Okita K, et al. A fundamental study of normal layer structure of the Gastrointestinal wall visualized by endoscopic ultrasonography[J]. Scand J Gastroenterol Suppl,1986,123:6-15.
[12]陈灏珠.实用内科学[M].人民卫生出版社,2005,1817.
[13]Hunerbein M, Ulmer C, Handke T, et al. Endosonography of upper gastrointestinal tract cancer on demand using mliniprobes or endoscopic ultrasound[J]. Surg Endosc,2003,17(4):615-619.
[14]黄留业,周福润,刘运祥.微型超声探头在食管、胃疾病的临床应用[J].中国内镜 杂志,2002,8(12)：58-59.
[15]Akahoshi K, Chijiiwa Y, HamadaS, et al.Pretreatment staging of endoscopically early gastric cancer with a 15 MHz ultrasound catheter probe[J]. Gastrointest Endosc,1998, 48(5):470-476.
[16]严超,朱正纲,诸琦,等.内镜超声检查在早期胃癌术前分期的应用[J].中华肿瘤杂志,2003,25(4)：390-393.
[17]张月明,程贵余,贺舜,等.联合应用超声内镜与超声小探头在早期食管癌术前分期中的作用[J].中华消化内镜杂志,2008,25(3)：138-141.
[18]Rosch T, Kapfer B, Will U, et al. Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions:a prospective multicenter study [J].Scand J Gastroenterol,2002,37 (7):856-862.
[19]金震东,李兆申.消化超声内镜学[M].北京：科学出版社,2006：261-264.
[20]张蔚,倪金良.食管平滑肌瘤内镜下诊治分析[J].现代诊断与治疗,2007,18(6)：333-334.
[21]王永华,刘庆森,王志强,等.食管低回声病灶内镜诊治分析[J].胃肠病学和肝病学杂志,2009,18(10)：952-954.
[22]Saito Y, Fujii T, Kondo H, et al. Endoscopic treatment for laterally spreading tumors in the colon [J].Endoscopy,2001,33(8):682-686.
[23]Waxman I, Saitoh Y, Raju GS, et al. High-frequency probe EUS-assisted endoscopic mucosal resection:a therapeutic strategy for submucosal tumors of the GI tract[J]. Gastrointeat Endosc,2002,55(1):44-49.
[24]Theisen J, Feith M, Stein HJ, et al. Management of early esophageal cancer[J].Adv Surg.2007,41:229-239.
[25]Waxman I, Saitoh Y, Raju GS, et al.High-frequency probe EUS-assisted endoscopic mucosal resection:a therapeutic strategy for submucosal tumors of the GItract[J]. Gastrointest Endoscc,2002,55(1):44-49.
[26]Watanabe K, Ogata S, Kawazoe S, et al.Clinical outcomes of EMR for gastric tumors: historical pilot evaluation between endoscopic submucosal dissection and conventional mucosalre section[J].Gastrointest Endosc,2006,63(6):776-782.
[27]Lee SH, Cho WY, Kim HJ, et al. A new method of EMR:submucosal injection of a fibrinogen mixture.Gastrointest[J]. Endosc,2004,59(2):220-224.
[28]Oyama T, Tomori A, Hotta K, et al. Endoscopic submucosal dissection of early esophageal cancer[J]. Clin Gastroenterol Hepatol,2005,3 (7 Suppl 1):s67-s70.
[29]Takekoshi T, Baba Y,Ota H, et al.Endoscopic resection of early gastric carcinoma: results of a retrospective analysis of 308 cases[J].Endoscopy,1994,26(4):352-358.
[30]Kato M. Endoscopic submucosal dissection (ESD) is being accepted as a new procedure of endoscopic treatment of early gastric cancer[J].Internal Med,2005, 44(2):85-86.
[31]Oda I, Saito D, Tada M, et al. A multicenter retrospective study of endoscopic resection for early gastric cancer[J]. Gastric Cancer,2006,9(4):262-270.
[32]Oka S, Tanaka S, Kaneko I, et al. Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer[J]. Gastrointest Endosc,2006, 64(6):877-83.
[33]Gotoda T. Endoscopic resection of early gastric cancer [J].Gastric Cancer,2007,10(1): 1-11.
[34]Isomoto H, Yamaguchi N. Endoscopic submucosal dissection in the era of proton pump inhibitors[J]. J Clin Biochem Nutr,2009,44(3):205-211.
[35]刘娜,魏子白,孙旭芳,等.内镜下粘膜切除术治疗食管癌前病变的疗效与护理[J].中华腹部疾病杂志,2003,3(3)：167-170.
[36]Fujishiro M, Yahagi N, Kakushima N, et al. Endoscopic submucosal dissection of esophageal squamous cell neoplasms[J]. Clin Gastroenterol Hepatol,2006, 4(6):688-694.
[37]刘思德,姜泊,周殿元.国内早期大肠癌及大肠平坦型病变的内镜诊治进展[J].国消化内镜,2008,2(4)：1-10.
[1]Soetikno RM, lnoue H, Chang KJ. Endoscopic mucosal resection[J]. Gastrointest Endosc Clin N Am,2000,10(4):595-617.
[2]毛永平,刘庆森,卢忠生,等.胃镜下钬激光气化切除术治疗早期食管癌[J].中华消化内镜,2007,1(1)7-9.
[3]Webber J, Herman M, Kessel D, et al. Photodynamic treatment of neoplastic lesions of the gastrointestinal tract. Recent advances in techniques and results [J]. Langenbecks Arch Surg,2000,385 (4):299-304.
[4]Karanov SI. Long-term results after photodynamic therapy (PDT) of T1N0M0 gastrointestinal (GI) tumors[J]. Hepatogastroenterology,2002,49 (48):1579-1581.
[5]Pereira-Lima JC, Busnello JV, Saul C, et al. High power selling argon plasma coagulation for the eradication of Barretts esophagus.[J]. Am J Gastroenterol, 2000,95(7):1661-1668.
[6]王国清.从食管癌早诊早治看肿瘤治疗模式的改变[J].中国肿瘤,1998,7(3)：6-8.
[7]Jonathan P, Watson PhD, Mark K, et al. The tissue effect of argon plasma coagulation on esophageal and gastric mucosa[J]. Gastrointestinal Endoscopy, 2000,52 (3):342-345.
[8]张文全,史连和.内镜下微波凝固治疗上校消化道息肉353例临床分析[J].内蒙古民族大学学报(自然科学版),2009,24(4)：442-444.
[9]王贵齐,张月明,贺舜.中国早期食管癌和癌前病变的治疗现状与展望[J].中国肿瘤,2009,18(9)：690-694.
[10]Tada M, Shimada M, Murakami F, et al. Development of strip-off biopsy[J]. Gastroenterol Endodc,1984,26:833-839.
[11]Eguchi T, Nakanishi Y, Shimoda T, et al. Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer:analysis of 464 surgically resected cases[J]. Mod Pathol,2006,19(3):475-480.
[12]Soetikno R, Kaltenbach T, Yeh R, et al. Endoscopic mucosal resection for early cancers of the upper gastrointestinal tact [J]. J Clin Oncol,2005,23 (20): 4490-4498.
[13]刘斌,郭强.从内镜下粘膜切除术到内镜粘膜下层剥离术[J].云南医药,2007,28(5)：500-504.
[14]Inoue H, Takeshita K, Hori H, et al. Endoscopic mucosal resection with cap-fitted panendoscope for esophagus, stomach and colon mucosal lesions[J]. Gastrointest Endosc,1993,39(1):58-62.
[15]Fbrams JA, Fedi P, Vakiani E, et al. Depth of resection using two different endoscopic mucosal resection techniques [J]. Endoscopy,2008,40(5):395-399.
[16]Smith LA, Baraza W, Tiffin N, et al. Endoscopic resection of adenoma-like mass In chronic ulcerative colitis using a combined endoscopic mucosal resection and Cap assisted submucosal dissection technique[J]. Inflamm Bowel Dis,2008,14 (10):1380-1386.
[17]Akiyama M, Ota M, Nakajima H, et al.Endoscopic mucosal resection of gastric neoplasms using a ligating device[J]. Gastrointest Endosc.1997,45(2):182-186.
[18]Pech O, Andrea May A, Rabenstein T, et al. Endoscopic resection in neoplastic lesions of the esophagus[J].Langenbecks Arch Surg,2003,388(6):421-424.
[19]Zhong YS, Zhou PH, Xu MD, et al. Endoscopic submucosal resection with ligation of rectal carcinoids:3 years experience[J]. Zhonghua YiXue Za Zhi,2007, 87(21):1452-1456.
[20]Ahmadi A, Draganov P. Endoscopic mucosal resection in the upper gastrointestinal tract[J]. World J Gastroenterol,2008,14(13):1984-1989.
[21]Kojima T, Parra B A, Takahashi H, et al. Outcome of endoscpic mucosal resection for early gastric cancer:review of the Japanese literature[J]. Gastrointest Endosc, 1998,48(5):550-554.
[22]陈坚,林庚金.胃、食管早期癌的内镜下切除[J].中华消化内镜杂志,2001,18(6)：378-379.
[23]Ohta J, Kodama I, Yamasaki K, et al. Efficacy of transgastrostomal endoscopic surgery(TGES) for early gastric cancer[J]. Int Surg,1997,82(4):382-385.
[24]Takekoshi T, Baba Y, Ota H, et al. Endoscopic resection of early gastric carcinoma: results of retrospective analysis of 308 cases[J]. Endoscopy,1994,26(4):352-358.
[25]Gotoda T, Kondo H, One H, et al. A new endoscopic mucosal resection(EMR) procedure using an insulation-tipped electrosurgical Knife for rectal flat lesions: report of two cases[J]. Gastrointest Endosc,1999,50(4):560-563.
[26]Kato M. Endoscopic submucosal dissection (ESD) is being accepted as a new procedure of endoscopic treatment of early gastric cancer[J]. Internal Med,2005, 44(2):85-86.
[27]Fujishiro M, Yahagi N,Nakamura M, et al. Successful outcomes of a novel endoscopic treatment for GI tumors:endoscopic submucosal dissection with a mixture of high molecular-weight hyaluronic acid, glycerin and sugar[J]. Gastrointest Endosc,2006,63(2):243-249.
[28]Yokoi C, Gotoda T, Hamanaka H, et al. Enoscopic submocosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection[J]. Gastrointest Endosc,2006,64(2):212-218.
[29]Fujishiro M, Goto O, Kakushima N, et al. Endoscopic submucosal dissection of stomach neoplasms after unsuccessful endoscopic resection[J]. Dig Liver Dis, 2007,39(6):566-571.
[30]Shoji Hirasaki, Hiromitsu Kanzaki,et al. Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife[J]. World J Gastroenterol,2008,14(16):2550-2555.
[31]Zoepf T, Jakobs R, Arllold JC, et al. Palliation of nonresectable bile duct cancer: improved survival after photodynamic therapy[J]. Am J Gastroenterol,2005, 100(11):2426-2430.
[32]Cao Y, Liao C, Tan A, et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract[J]. Endoscopy,2009,41(9):751-757.
[33]Manner H, Rabenstein T, May A, et al. Long-term results of endoscopic resection in early gastric cancer:the Western experience [J]. Am J Gastroensterol,2009, 104(3):566-573.
[34]Takizawa K, Oda I, Gotoda T, et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection—an analysis of risk factors[J]. Endoscopy,2008,40(3):179-183.
[35]Ono H, kondo H, Gotoda T, et al. Endoscopic mucosal resection for treatment of early gastric cancer[J]. Gut,2001,48(2):225-229.
[36]Isomoto H, Yamaguchi N. Endoscopic submucosal dissection in the era of proton pump inhibitors[J]. J Clin Biochem Nutr,2009,44(3):205-211.
[37]Watanabe K, Ogata S,Kawazoe S, et al. Clinical outcomes of EMR for gastric tumors:historical pilot evaluation between endoscopic submucosal dissection and conventional mucosal resection[J]. Gastrointest Endosc,2006,63(6):776-782.
[38]刘思德,智发朝,姜泊,等.早期胃癌内镜下黏膜切除术—设备与技术进展[J],现代消化及介入诊疗,2007,12(2)：124-126.
[39]Neuhaus H, Wirths K, Schenk M, et al. Randomized controlled study of EMR versus endoscopic submucosal dissection with a water-jet hybrid-knife of esophageal lesions in a porcine model[J]. Gastrointest Endosc,2009, 70(1):112-120.
[40]Isshi K, Tajiri H, Fujisaki J, et al. The effectiveness of a new multibending scope for endoscopic mucosal resection[J].Endoscopy,2004,36(4):294-297.
[41]Kobayashi T, Gotohda T, Tamakawa K, et al.Magnetic anchor for more effective endoscopic mucosal resection[J]. Jpn J Clin Oncol,2004,34(3):118-123.
[42]Akahoshi K, Okamoto R, Akahane H, et al. Endoscopic submucosal dissection of early colorectal tumors using a grasping-type scissors forceps:a preliminary clinical study[J]. Endoscopy.2010 Mar 25, [Epub ahead of print.].
[43]Hiki N, Yamamoto Y, Fukunaga T, et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection[J].2008,22(7):1729-1735.
[44]Tsujimotori H, Ihikura T, Nagao S, et al. Minimally invasive surgery for resection of duodenal carcinoid tumors:endoscopic full-thickness resection under laparoscopic observation[J]. Surg Endosc,2010,24(2):471-475.
[45]Abe N, Mori T, Takeuchi H, et al. Successful treatment of early stage gastric cancer by laparoscopy-assisted endoscopic full-thinkness-resection with lymphadenectomy[J]. Gastronintest Endosc,2008,68(6):1220-1224.
[2]朱雄增.胃肠道癌前病变和癌的WHO诊断新标准[J].中华病理学杂志,2003,32(2)：168-169.
[3]姚汉青,王贵齐.Barrett食管和食管腺癌：东西方的差异[J].胃肠病学,2006,11(9)：513-515.
[4]张月明,贺舜,郝长青,等.窄带成像技术诊断早期食管癌及其癌前病变的临床应用价值[J].中华消化内镜杂志,2007,24(6)410-414.
[5]郝晓雯,黄晓俊.甘肃省近30年间食管癌流行病学分析[J].现代预防医学,2009,36(2)：215-219.
[6]Wang LD, Zhou Q, Gou RY, et al. Reproducibility of an esophageal biopsy sampling procedure in a high-incidence area for esophageal cancer in northern China[J].Cancer Epidemiol Biomarkers Prev,1996,5(5):405-406.
[7]王国清,郝长青,赖少情,等.碘染色在食管癌高发区直接内镜普查中的应用和效果[J].中华消化内镜杂志,2003,20(6)：377-379.
[8]Mori M, Adachi Y, Matsushima T, et al. Lugol staining pattern and histology of esophageal lesions[J]. Am J Gastroenterology,1993,88(5):701-705.
[9]邵颖,冀明,吴咏东,等.2.5%卢戈氏液诊断早期食管癌及癌前病变的临床研究[J].临床内科杂志,2006,23(8)：534-536.
[10]施开窘,时兰珍.内镜下食管粘膜碘染色的临床价值[J].安徽医学,2007,28(5)：470-471.
[11]Aibe T,Fuji T,Okita K, et al. A fundamental study of normal layer structure of the Gastrointestinal wall visualized by endoscopic ultrasonography[J]. Scand J Gastroenterol Suppl,1986,123:6-15.
[12]陈灏珠.实用内科学[M].人民卫生出版社,2005,1817.
[13]Hunerbein M, Ulmer C, Handke T, et al. Endosonography of upper gastrointestinal tract cancer on demand using mliniprobes or endoscopic ultrasound[J]. Surg Endosc,2003,17(4):615-619.
[14]黄留业,周福润,刘运祥.微型超声探头在食管、胃疾病的临床应用[J].中国内镜 杂志,2002,8(12)：58-59.
[15]Akahoshi K, Chijiiwa Y, HamadaS, et al.Pretreatment staging of endoscopically early gastric cancer with a 15 MHz ultrasound catheter probe[J]. Gastrointest Endosc,1998, 48(5):470-476.
[16]严超,朱正纲,诸琦,等.内镜超声检查在早期胃癌术前分期的应用[J].中华肿瘤杂志,2003,25(4)：390-393.
[17]张月明,程贵余,贺舜,等.联合应用超声内镜与超声小探头在早期食管癌术前分期中的作用[J].中华消化内镜杂志,2008,25(3)：138-141.
[18]Rosch T, Kapfer B, Will U, et al. Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions:a prospective multicenter study [J].Scand J Gastroenterol,2002,37 (7):856-862.
[19]金震东,李兆申.消化超声内镜学[M].北京：科学出版社,2006：261-264.
[20]张蔚,倪金良.食管平滑肌瘤内镜下诊治分析[J].现代诊断与治疗,2007,18(6)：333-334.
[21]王永华,刘庆森,王志强,等.食管低回声病灶内镜诊治分析[J].胃肠病学和肝病学杂志,2009,18(10)：952-954.
[22]Saito Y, Fujii T, Kondo H, et al. Endoscopic treatment for laterally spreading tumors in the colon [J].Endoscopy,2001,33(8):682-686.
[23]Waxman I, Saitoh Y, Raju GS, et al. High-frequency probe EUS-assisted endoscopic mucosal resection:a therapeutic strategy for submucosal tumors of the GI tract[J]. Gastrointeat Endosc,2002,55(1):44-49.
[24]Theisen J, Feith M, Stein HJ, et al. Management of early esophageal cancer[J].Adv Surg.2007,41:229-239.
[25]Waxman I, Saitoh Y, Raju GS, et al.High-frequency probe EUS-assisted endoscopic mucosal resection:a therapeutic strategy for submucosal tumors of the GItract[J]. Gastrointest Endoscc,2002,55(1):44-49.
[26]Watanabe K, Ogata S, Kawazoe S, et al.Clinical outcomes of EMR for gastric tumors: historical pilot evaluation between endoscopic submucosal dissection and conventional mucosalre section[J].Gastrointest Endosc,2006,63(6):776-782.
[27]Lee SH, Cho WY, Kim HJ, et al. A new method of EMR:submucosal injection of a fibrinogen mixture.Gastrointest[J]. Endosc,2004,59(2):220-224.
[28]Oyama T, Tomori A, Hotta K, et al. Endoscopic submucosal dissection of early esophageal cancer[J]. Clin Gastroenterol Hepatol,2005,3 (7 Suppl 1):s67-s70.
[29]Takekoshi T, Baba Y,Ota H, et al.Endoscopic resection of early gastric carcinoma: results of a retrospective analysis of 308 cases[J].Endoscopy,1994,26(4):352-358.
[30]Kato M. Endoscopic submucosal dissection (ESD) is being accepted as a new procedure of endoscopic treatment of early gastric cancer[J].Internal Med,2005, 44(2):85-86.
[31]Oda I, Saito D, Tada M, et al. A multicenter retrospective study of endoscopic resection for early gastric cancer[J]. Gastric Cancer,2006,9(4):262-270.
[32]Oka S, Tanaka S, Kaneko I, et al. Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer[J]. Gastrointest Endosc,2006, 64(6):877-83.
[33]Gotoda T. Endoscopic resection of early gastric cancer [J].Gastric Cancer,2007,10(1): 1-11.
[34]Isomoto H, Yamaguchi N. Endoscopic submucosal dissection in the era of proton pump inhibitors[J]. J Clin Biochem Nutr,2009,44(3):205-211.
[35]刘娜,魏子白,孙旭芳,等.内镜下粘膜切除术治疗食管癌前病变的疗效与护理[J].中华腹部疾病杂志,2003,3(3)：167-170.
[36]Fujishiro M, Yahagi N, Kakushima N, et al. Endoscopic submucosal dissection of esophageal squamous cell neoplasms[J]. Clin Gastroenterol Hepatol,2006, 4(6):688-694.
[37]刘思德,姜泊,周殿元.国内早期大肠癌及大肠平坦型病变的内镜诊治进展[J].国消化内镜,2008,2(4)：1-10.
[1]Soetikno RM, lnoue H, Chang KJ. Endoscopic mucosal resection[J]. Gastrointest Endosc Clin N Am,2000,10(4):595-617.
[2]毛永平,刘庆森,卢忠生,等.胃镜下钬激光气化切除术治疗早期食管癌[J].中华消化内镜,2007,1(1)7-9.
[3]Webber J, Herman M, Kessel D, et al. Photodynamic treatment of neoplastic lesions of the gastrointestinal tract. Recent advances in techniques and results [J]. Langenbecks Arch Surg,2000,385 (4):299-304.
[4]Karanov SI. Long-term results after photodynamic therapy (PDT) of T1N0M0 gastrointestinal (GI) tumors[J]. Hepatogastroenterology,2002,49 (48):1579-1581.
[5]Pereira-Lima JC, Busnello JV, Saul C, et al. High power selling argon plasma coagulation for the eradication of Barretts esophagus.[J]. Am J Gastroenterol, 2000,95(7):1661-1668.
[6]王国清.从食管癌早诊早治看肿瘤治疗模式的改变[J].中国肿瘤,1998,7(3)：6-8.
[7]Jonathan P, Watson PhD, Mark K, et al. The tissue effect of argon plasma coagulation on esophageal and gastric mucosa[J]. Gastrointestinal Endoscopy, 2000,52 (3):342-345.
[8]张文全,史连和.内镜下微波凝固治疗上校消化道息肉353例临床分析[J].内蒙古民族大学学报(自然科学版),2009,24(4)：442-444.
[9]王贵齐,张月明,贺舜.中国早期食管癌和癌前病变的治疗现状与展望[J].中国肿瘤,2009,18(9)：690-694.
[10]Tada M, Shimada M, Murakami F, et al. Development of strip-off biopsy[J]. Gastroenterol Endodc,1984,26:833-839.
[11]Eguchi T, Nakanishi Y, Shimoda T, et al. Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer:analysis of 464 surgically resected cases[J]. Mod Pathol,2006,19(3):475-480.
[12]Soetikno R, Kaltenbach T, Yeh R, et al. Endoscopic mucosal resection for early cancers of the upper gastrointestinal tact [J]. J Clin Oncol,2005,23 (20): 4490-4498.
[13]刘斌,郭强.从内镜下粘膜切除术到内镜粘膜下层剥离术[J].云南医药,2007,28(5)：500-504.
[14]Inoue H, Takeshita K, Hori H, et al. Endoscopic mucosal resection with cap-fitted panendoscope for esophagus, stomach and colon mucosal lesions[J]. Gastrointest Endosc,1993,39(1):58-62.
[15]Fbrams JA, Fedi P, Vakiani E, et al. Depth of resection using two different endoscopic mucosal resection techniques [J]. Endoscopy,2008,40(5):395-399.
[16]Smith LA, Baraza W, Tiffin N, et al. Endoscopic resection of adenoma-like mass In chronic ulcerative colitis using a combined endoscopic mucosal resection and Cap assisted submucosal dissection technique[J]. Inflamm Bowel Dis,2008,14 (10):1380-1386.
[17]Akiyama M, Ota M, Nakajima H, et al.Endoscopic mucosal resection of gastric neoplasms using a ligating device[J]. Gastrointest Endosc.1997,45(2):182-186.
[18]Pech O, Andrea May A, Rabenstein T, et al. Endoscopic resection in neoplastic lesions of the esophagus[J].Langenbecks Arch Surg,2003,388(6):421-424.
[19]Zhong YS, Zhou PH, Xu MD, et al. Endoscopic submucosal resection with ligation of rectal carcinoids:3 years experience[J]. Zhonghua YiXue Za Zhi,2007, 87(21):1452-1456.
[20]Ahmadi A, Draganov P. Endoscopic mucosal resection in the upper gastrointestinal tract[J]. World J Gastroenterol,2008,14(13):1984-1989.
[21]Kojima T, Parra B A, Takahashi H, et al. Outcome of endoscpic mucosal resection for early gastric cancer:review of the Japanese literature[J]. Gastrointest Endosc, 1998,48(5):550-554.
[22]陈坚,林庚金.胃、食管早期癌的内镜下切除[J].中华消化内镜杂志,2001,18(6)：378-379.
[23]Ohta J, Kodama I, Yamasaki K, et al. Efficacy of transgastrostomal endoscopic surgery(TGES) for early gastric cancer[J]. Int Surg,1997,82(4):382-385.
[24]Takekoshi T, Baba Y, Ota H, et al. Endoscopic resection of early gastric carcinoma: results of retrospective analysis of 308 cases[J]. Endoscopy,1994,26(4):352-358.
[25]Gotoda T, Kondo H, One H, et al. A new endoscopic mucosal resection(EMR) procedure using an insulation-tipped electrosurgical Knife for rectal flat lesions: report of two cases[J]. Gastrointest Endosc,1999,50(4):560-563.
[26]Kato M. Endoscopic submucosal dissection (ESD) is being accepted as a new procedure of endoscopic treatment of early gastric cancer[J]. Internal Med,2005, 44(2):85-86.
[27]Fujishiro M, Yahagi N,Nakamura M, et al. Successful outcomes of a novel endoscopic treatment for GI tumors:endoscopic submucosal dissection with a mixture of high molecular-weight hyaluronic acid, glycerin and sugar[J]. Gastrointest Endosc,2006,63(2):243-249.
[28]Yokoi C, Gotoda T, Hamanaka H, et al. Enoscopic submocosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection[J]. Gastrointest Endosc,2006,64(2):212-218.
[29]Fujishiro M, Goto O, Kakushima N, et al. Endoscopic submucosal dissection of stomach neoplasms after unsuccessful endoscopic resection[J]. Dig Liver Dis, 2007,39(6):566-571.
[30]Shoji Hirasaki, Hiromitsu Kanzaki,et al. Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife[J]. World J Gastroenterol,2008,14(16):2550-2555.
[31]Zoepf T, Jakobs R, Arllold JC, et al. Palliation of nonresectable bile duct cancer: improved survival after photodynamic therapy[J]. Am J Gastroenterol,2005, 100(11):2426-2430.
[32]Cao Y, Liao C, Tan A, et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract[J]. Endoscopy,2009,41(9):751-757.
[33]Manner H, Rabenstein T, May A, et al. Long-term results of endoscopic resection in early gastric cancer:the Western experience [J]. Am J Gastroensterol,2009, 104(3):566-573.
[34]Takizawa K, Oda I, Gotoda T, et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection—an analysis of risk factors[J]. Endoscopy,2008,40(3):179-183.
[35]Ono H, kondo H, Gotoda T, et al. Endoscopic mucosal resection for treatment of early gastric cancer[J]. Gut,2001,48(2):225-229.
[36]Isomoto H, Yamaguchi N. Endoscopic submucosal dissection in the era of proton pump inhibitors[J]. J Clin Biochem Nutr,2009,44(3):205-211.
[37]Watanabe K, Ogata S,Kawazoe S, et al. Clinical outcomes of EMR for gastric tumors:historical pilot evaluation between endoscopic submucosal dissection and conventional mucosal resection[J]. Gastrointest Endosc,2006,63(6):776-782.
[38]刘思德,智发朝,姜泊,等.早期胃癌内镜下黏膜切除术—设备与技术进展[J],现代消化及介入诊疗,2007,12(2)：124-126.
[39]Neuhaus H, Wirths K, Schenk M, et al. Randomized controlled study of EMR versus endoscopic submucosal dissection with a water-jet hybrid-knife of esophageal lesions in a porcine model[J]. Gastrointest Endosc,2009, 70(1):112-120.
[40]Isshi K, Tajiri H, Fujisaki J, et al. The effectiveness of a new multibending scope for endoscopic mucosal resection[J].Endoscopy,2004,36(4):294-297.
[41]Kobayashi T, Gotohda T, Tamakawa K, et al.Magnetic anchor for more effective endoscopic mucosal resection[J]. Jpn J Clin Oncol,2004,34(3):118-123.
[42]Akahoshi K, Okamoto R, Akahane H, et al. Endoscopic submucosal dissection of early colorectal tumors using a grasping-type scissors forceps:a preliminary clinical study[J]. Endoscopy.2010 Mar 25, [Epub ahead of print.].
[43]Hiki N, Yamamoto Y, Fukunaga T, et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection[J].2008,22(7):1729-1735.
[44]Tsujimotori H, Ihikura T, Nagao S, et al. Minimally invasive surgery for resection of duodenal carcinoid tumors:endoscopic full-thickness resection under laparoscopic observation[J]. Surg Endosc,2010,24(2):471-475.
[45]Abe N, Mori T, Takeuchi H, et al. Successful treatment of early stage gastric cancer by laparoscopy-assisted endoscopic full-thinkness-resection with lymphadenectomy[J]. Gastronintest Endosc,2008,68(6):1220-1224.