窄带成像技术联合内镜黏膜下剥离术治疗胃黏膜高级别上皮内瘤变的临床价值

Clinical value of the narrow-band imaging combined with endoscopic submucosal dissection for gastric high grade intraepithelial neoplasia

目的探讨窄带成像技术（NBI）联合内镜黏膜下剥离术（ESD）治疗胃黏膜高级别上皮内瘤变（HGIN）的可行性、安全性和近期疗效。方法回顾性分析2014年1月至2015年12月期间江苏省无锡市第二人民医院及上海复旦大学附属中山医院经胃镜及病理检查诊断为胃黏膜HGIN并行NBI联合ESD治疗的78例患者的临床资料，分析患者的术中、术后及随访情况。结果全组78例患者中，男性47例，女性31例，年龄38～85岁。术前NBI显示，78例（100％）病变分界明显，有91．O％（71／78）病变中央凹陷区域有丰富的血管。除1例发生术中穿孔中转外科手术治疗外，采用ESD技术成功切除胃黏膜HGIN病灶77例（98．7％），ESD病灶整块切除率94．9％（74／78）；另3例（5．5％）术中因黏膜下层粘连，黏膜剥除不完整，予以氩气喷灼创面以防止残留。病变最大直径为（1．2±0．8）cm，手术时间（48±21）min。术后5例（6．4％）出现迟发性出血，予内镜止血治疗及内科保守治疗止血。术后病理显示，病灶完整切除率91．0％（71／78），切缘阳性率3.8％（3／78）；治愈性切除率89．7％（70／78）。32例（41．0％）仍维持HGIN诊断，6例（7．7％）为低级别上皮内瘤变，40例（51.3％）诊断为腺癌；57例获12月随访，21例随访6月，切缘阳性的3例患者未见复发；有2例（2．6％）出现复发，复查病理诊断为腺癌。结论NBI联合ESD对于诊治胃黏膜HGIN安全有效，可以实现病灶的整块完整切除，且并发症少。

Objective To determine the feasibility, safety and short-time efficacy of narrow- band imaging （NBI） combined with endoscopic submueosal dissection （ESD） for treating gastric high grade intraepitbelial neoplasia （HGIN）. Methods Clinical data of 78 patients with gastric HGiN diagnosed by gastroscope and pathology undergoing NBI combined with ESD at Wuxi No.2 People＇s Hospital and Zhongshan Hospital of Fudan University from January 2014 to December 2015 were retrospectively analyzed. Their clinicopathological and follow-up data were analyzed. Results There were 47 males and 31 females aged from 38 to 85 years old. Preoperative NBI showed that lesions of all the 78 （100%）patients bad clear resection margin, and 91%（71/78）lesions had abundant vessels in the central depression area. One case was converted to open abdominal operation due to intra- operational perforation, 77 （98.7%） gastric HGIN lesions were successfully dissected under ESD,including 74 cases （94.9%） of en bloc dissection, and other 3 cases with severe adhesion of submucosa whose lesion wound after ESD was treated with argon plasma coagulation （APC）. The mean maxinmm diameter of the lesion size was （1.2 ±0.8） cm. The average operation time was（48 ± 21） minutes. Delayed hemorrhage occurred in 5 cases（6.4%） who were also treated successfully by endoscopic hemostasis. Postoperational pathology revealed en bloc dissection rate was 91.0%（71/78）, positive rate of resection margin was 3.8% （3/78）, and healing dissection rate was 89.7% （70/78）. Thirty-two lesions （41.0%） remained the diagnosis as HGIN, 6 lesions（7.7%） were diagnosed as low grade intraepithelial neoplasia, and 40 lesions （51.3%） were diagnosed as adenocarcinoma. Fifty-seven cases were followed up for 12 months, 21 cases were followed up for 6 months, and there was no recurrence in those 3 patients with positive margin. Two cases （2.6%） relapsed and were diagnosed as adenocarcinoma by repeat pathology examination. Conclusion NBI combined with ESD for diagnosis and treatment of gastric HGIN is safe and effective, and can achieve en bloc complete resection of the lesions with a low complication rate.