内镜下全层切除术后创面闭合的临床评价

Evaluation of a new closure technique of large defects after endoscopic full-thickness resection

目的研究一种新的内镜下缝合创面缺损的方法——经单钳道镜联合应用钛夹以及尼龙套圈行双荷包缝合技术的安全性和有效性。方法回顾性分析2015年6月至2016年7月在国家癌症中心、中国医学科学院北京协和医学院肿瘤医院内镜科行内镜下治疗的胃部或者食管黏膜下肿瘤患者的临床资料。对于胃部和食管黏膜下肿瘤或内镜经黏膜下隧道肿瘤剥离术中损伤黏膜者，在肿瘤行内镜下全层切除后，创面缺损行单钳道内镜下双荷包缝合。具体处理方法：安装尼龙套圈至推送器并随内镜一起进入胃腔到达创面缺损处。释放尼龙套圈使之平行于创面缺损处；调整钛夹角度，钛夹之间的间隔约为5mm，使其携持尼龙套圈固定于创面缺损的边缘并尽量夹住胃壁全层；助手收手柄使尼龙套圈收紧将创面缺损闭合，应用活检钳调整创面边缘已固定的钛夹方向使之保持与创面垂直：在原荷包的外缘5～10mm处再次释放1个尼龙套圈，按照上述方法再次行荷包缝合，收紧尼龙套圈直至各个钛夹之间无缝隙为止，双荷包缝合完成。共有23例患者纳入研究，其中18例位于胃部，5例位于食管；男性15例、女性8例：平均年龄56（19-76）岁。结果18例胃部黏膜下肿瘤患者均成功行内镜下全层切除及双荷包缝合；5例食管黏膜下肿瘤患者，其中位于颈段食管（距门齿15-20cm）3例，食管平滑肌瘤合并鳞状上皮原位癌1例，内镜经黏膜下隧道肿瘤剥离术中黏膜损伤1例，均成功应用荷包缝合修复食管黏膜。肿瘤平均最大直径为2．3cm，平均缝合时间为22．8rain。术后病理显示，13例为胃肠间质瘤，7例平滑肌瘤，2例神经鞘瘤，1例平滑肌瘤合并黏膜层早期食管癌。所有患者术中及术后均未出现严重并发症。结论经单钳道镜联合应用钛夹以及尼龙套圈行双荷包缝合技术是封闭胃壁黏膜下肿瘤全层切除术后创面缺损相对安全、简单而有效的缝合方法；对于颈段食管黏膜下肿瘤、或合并表面黏膜层病变、或内镜经黏膜下隧道肿瘤剥离术过程中黏膜层损伤时，可借助荷包缝合技术进行黏膜层有效的封闭。

Objective To investigate the security and efficacy of a new endoscopic closure method of large defects after endoscopic full-thickness resection （EFFR） double purse-string suture using two endoloops and metallic clips via single-channel endoscopy. Methods Clinical data of 23 cases with submucosal tumors （SMT） who received endoscopic resection from June 2015 to July 2016 in our National Cancer Center were collected. For gastric and esophageal SMTs or the mucosa layer injured during submucosal tunneling endoscopic resection （STER）, double purse-string suture was conducted after EFTR. The key steps of closure were as follows： the endoloop was installed onto the delivery system and inserted into the gastric cavity to the defect location with endoscopy and then opened; the clips were transported into the gastric cavity from the biopsy channel; the endoloop was fixed onto the full thickness of gastric wall along the edge of the defect by clips one by one between the interval of about 5 ram; the endoloop was tightened slowly till the entire circumference of the defect was sutured, thus, one purse-string suture was done ; in accordance with the operation above, another endoloop was released, and the second endoloop was fixed at 5-10 mm to the outer edge of the original one, and tied the endoloop gently; this sequence was continued till there was no gap, thus, the double-purse string suture was finished. A total of 23 patients were enrolled in the study, including 18 with gastric tumor and 5 with esophageal tumor, 15 males and 8 females, with the average age of 56 （19 to 76） years. Results Eighteen cases of gastric SMT were successfully treated by endoscopic EFTR and double purse-string suture. The esophageal mucosa layer of all the 5 cases of esophageal SMT, including tumors of 3 cases located in cervical esophagus at 15-20 cm from the fore-tooth, 1 esophageal leiomyoma case complicated with squamous cell carcinoma in situ, and 1 case of mucosal layer injury during submucosal tunneling endoscopic resection （STER）, was successfully repaired by using double purse-string suture. The mean maximum diameter of tumor was 2.3 cm, and the average suture time was 22.8 min. Postoperative pathology showed that 13 cases were gastrointestinal stromal tumors （GIST）, 7 cases were leiomyoma, 2 cases were neurilemmoma, and 1 case was leiomyoma complicated with early squamous cell carcinoma in situ, No severe complications occurred during or after the operation. Conclusions The double purse-string suture by using metallic clips and endoloops with single channel endoscope is a relatively safe, easy, and reliable technique for repairing large gastric defect after EFTR. For cervical esophageal SMT, or the SMT combined with superficial mucosal lesions, and for the mucosa layer injury during submucosal tunneling endoscopic resection （STER）, double purse-string suture is helpful to perform the closure.