以双弯曲双孔道内镜行隧道法黏膜下剥离术切除胃黏膜下肿瘤

Preliminary experience with endoscopic gastric submucosal tumor resection through the submucosal tunnel using double tunnel and double flex endoscope

目的尽管胃黏膜下肿瘤大多数是良性的,但是一些仍然有潜在的恶变可能,切除肿瘤不但可以通过病理诊断确诊,而且可以完全治愈病变。本研究是通过双孔道双弯曲内镜经胃黏膜下隧道,切除黏膜下肿瘤后完全封闭切口,从而观察该方法是否为一种新颖的安全、有效及实用的技术,并分析术中双孔道双弯曲内镜的优缺点。方法 2012年1月~2013年8月在本内镜中心通过内镜及超声内镜检查考虑为胃黏膜下肿瘤共50例。术中应用CO2气体,在病变一侧行弧形切开黏膜1/3~2/3周,内镜分离黏膜下层建立隧道,暴露病变后完整切除,利用内镜双孔道边钳拉胃黏膜边夹闭对位的弧形切口,直至创面完整闭合。观察术中、术后穿孔、出血的发生率,临床转归以及手术时间,住院时间等指标。结果切除的黏膜下肿瘤标本直径1.1±0.6 cm（范围0.5~2.5 cm）,28例位于胃底,17例位于胃窦,5例位于胃体。所有病例均成功完整切除。手术时间35.3±16.2 min（范围23~76 min）。5例出现穿孔（10%）,在切除病变完毕以钛夹完全夹闭弧形切口后成功封闭穿孔,经内科保守治疗后出院。16例出现术中出血,均内镜下成功止血,无内镜无法控制的大出血。无术后迟发性出血及穿孔病例。48例术后1年随访均无复发,2例失访。结论本研究显示该技术是一种比较安全、有效的切除胃黏膜下肿物的内镜治疗方法。

Objective To examine the feasibility and safety of gastric submucosal tunnel dissection of gastric submucosal tumors（SMTs） by double tunnel and double flex endoscope. Methods Fifty patients with gastric SMTs detected by gastric endoscopy and endoscopic ultrasonography between January, 2012 and August, 2013 were enrolled in this study. Using carbon dioxide throughout the procedure, the mucous in the arc was incised along the margins of the lesion to separate the submucosa and create a tunnel. The exposed SMTs were resected completely and the mucosa was covered by endoscopic forceps followed by clipping of the incision. The complication, clinical outcomes, hospital stays and operation time were evaluated. Results Of the50 lesions, 50 were located in the gastric fundus, 17 in the gastric antrum and 5 in the gastric body. The lesions were completely resected in all the patients. The diameter of the resected lesions ranged from 0.5 to 2.5 cm（mean 1.1±0.6 cm）, and the operation lasted for 35.3 ± 16.2 min（range 23- 76 min）. In 5 cases（10%）, perforation occurred during the operation and was closed by clipping the incision with endoclips after the lesion resection; these patients were discharged after conservative management.Intraoperative bleeding occurred in 16 cases and was successfully managed through endoscopic methods. No delayed postoperative bleeding or perforation occurred in these patients. None of the 48 patients followed up showed tumor recurrence at one year after the operation, and 2 patients were lost for follow up. Conclusion Endoscopic submucosal dissection of gastric SMTs is effective and safe using double tunnel and double flex endoscope.