内镜黏膜下隧道剥离术治疗食管固有肌层肿瘤的效果评价

Efficacy evaluation of endoscopic submucosal tunneling dissection for esophageal tumor originating from muscularis propria

目的评价经内镜黏膜下隧道剥离术（endoscopic submucosal tunnel dissection,ESTD）治疗食管固有肌层肿瘤的有效性和安全性。方法 2011年8月至2014年6月期间,经我院电子胃镜及超声胃镜诊断来源于食管固有肌层肿瘤患者,所有符合手术条件患者签署知情同意书并在麻醉下行ESTD切除病变,并进行病理及免疫组化检查,记录病变信息及术中情况,术后定期随访观察治疗效果。结果 54例食管固有肌层肿瘤经ESTD完整切。4例患者因肿瘤横径大于3.5 cm无法完整经食管取出而转外科切除。切除标本按长径及横径测量,切除病变长0.8-8.5 cm,平均2.55 cm;横径0.5-3.0 cm,平均1.65 cm;手术时间20-280 min,平均68 min。11例术中发生单纯皮下气肿,发生率20%,3例出现术中可见穿孔,发生率（5.6%）,1例术后发现膈下少量游离气体,发生率1.8%,均保守治疗后恢复。术后54例病变经病理及免疫组化检查诊断均为平滑肌瘤,切缘均为阴性。所有病例均未发生气胸,无术后隧道内出血。术后采用胃镜及超声胃镜随访时间1-24个月,中位随访时间12个月,随访期内未见肿瘤残留或复发病例。结论内镜黏膜下隧道剥离术（ESTD）是近年来新发展的一种微创和高难度的手术治疗方式,因其保留了正常黏膜可以覆盖创面,大大减少了穿孔风险,具有损伤小,切除精度高的特点,是一种治疗食管固有肌层来源的黏膜下肿瘤的安全可行的方法。

Objective To evaluate the efficacy of endoscopic submucosal tunneling dissection（ESTD）in the treatment of esophageal submucosal tumor（SMT） originating from the muscularis propria.Methods The patients with esophageal SMT originating from the muscularis propria received ESTD in Xinqiao Hospital of Third Military Medical University from August 2011 to Jun 2014,and the data of the tumors and procedures were recorded carefully.All the patients were followed-up.Results Fifty-four cases of tumors were removed completely with ESTD,and 4 cases of tumors underwent surgical resection because the tumor had the transverse diameter greater than 3.5 cm and could not be taken out completely.The dissected specimens had the length of0.8-8.5 cm（mean 2.55 cm）,and the transverse diameter of 0.5-3.0 cm（mean 1.65 cm）.The operation time of ESTD was 20 to 280 min,and the mean time was 68 min.There were 11 cases（20%） with subcutaneous emphysema,3 cases（5.6%） with perforation,and 1 case（1.8%） with a little of free gas under the diaphragm by X-ray examination,and all of them were recovered uneventfully after conservative treatment.Histological examination confirmed the diagnosis of leiomyoma.Both the lateral and basal margins of the specimens were free of tumor cells.No pneumothorax or submucosal hematoma happened.No tumor residual or recurrence was found during follow-up by endoscopy and endoscopic ultrasonography,and the follow-up median period was 12 months（ranging in 1-24 months）.Conclusion ESTD retains the normal mucosa to cover the wound and then reduces the risk of perforation.ESTD has little injury and high precision and is a safe and effective procedure for treating esophageal SMT originating from the muscularis propria.