【作者】 杨江华；

【导师】 黄晓俊；

【作者基本信息】 兰州大学 ， 内科学， 2010， 硕士

【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。更多还原

【Abstract】 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.更多还原