内镜黏膜下剥离术治疗消化道黏膜下肿瘤

Endoscopic Submucosal Dissection for Submucosal Tumor of the Gastrointestinal Tract

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗消化道黏膜下肿瘤(submucosal tumor,SMT)的疗效和安全性。方法对内镜发现的19例消化道SMT(食管6例,胃6例,十二指肠1例,乙状结肠1例,直肠5例)进行超声内镜检查(18例病变位于黏膜下层,1例位于固有肌层),应用头端弯曲的针形切开刀进行ESD治疗。黏膜下注射生理盐水抬高病变,使病变与肌层相分离,预切开病变周围黏膜,剥离病变下方黏膜下层结缔组织,完整切除病变。结果病变最大直径0.5～3.0cm(平均1.6cm)。18例成功完成ESD治疗,手术时间15～105min(平均45min)。2例ESD术中出现内镜难以控制的大出血,1例成功保守治疗(三腔管食管囊压迫),1例转开腹手术。无术后出血。ESD穿孔3例:2例术中消化道穿孔(十二指肠球部和胃底),应用金属夹缝合成功,未转开腹手术;1例直肠类癌剥离深至肌层,术后出现皮下气肿,保守治疗气肿减退。所有ESD剥离病变包膜完整,基底和切缘未见病变累及。结论ESD治疗消化道SMT安全、有效,可以完整切除消化道黏膜下层病变,提供完整的病理诊断资料。对于来源于固有肌层的SMT,应慎行ESD。

Objective To assess the clinical efficacy and safety of endoscopic submucosal dissection （ESD） for submucosal tumor （SMT） of the gastrointestinal （GI） tract. Methods A total of 19 patients with SMT of the GI tract diagnosed by endoscopy （6 in the esophagus, 6 the stomach, 1 the duodenum, 1 the sigmoid, and 5 the rectum）, were examined using endoscopic ultrasonography （EUS）. Among the cases, 18 lesions were within the submucosa and 1 in the muscularis propria. The SMTs were managed by ESD with a needle knife. After injection of physiological saline solution into the submucosal layer to separate the lesion from the muscle layer, the mucosa surrounding the lesion was pre-cut, and the connective tissues of the submucosa beneath the lesion were dissected. Then, the lesion was resected completely. Results The resected lesions sized 0.5 - 3.0 cm in diameter （mean, 1.6 cm）. Among the 19 lesions, 18 were successfully resected with ESD. The mean ESD procedure time was 45 min （ranged from 15 to 105 min）. Two patients had massive hemorrhage during ESD, which could not be controlled under a gastroscope. One of them was treated with balloon compression, and the other was managed surgically. None of the patients had delayed bleeding after ESD. Perforation of the GI tract occurred in 2 cases （ the duodenal ball in one, and the gastric fundus in another） during the procedure, and was closed with endoclips without surgical treatment. One patient with rectal carcinoid developed subcutaneous emphysema after the operation owning to deep tearing of the muscle layer, and recovered after several days＇ conservative treatment. Histological evaluation showed that the tunica of the tumors was intact, and both the lateral and basal margins of the specimens were free of tumor cells. Conclusions ESD is an efficacious and safe procedure for the treatment of SMT of the GI tract. It is possible to completely resect submucosal lesions and provide sufficient pathological information. For the SMT originated from the muscularis propria, ESD should be performed cautiously.