内镜下黏膜切除、夹子缝合和特殊检查在大肠肿瘤处理中的应用

Application of endoscopic mucosal resection,clip suture and adjuvant diagnostic techniques in the management of colonic neoplasms

目的 探讨内镜下黏膜切除术 (EMR)或内镜下分次黏膜切除术 (EPMR)、夹子缝合和特殊检查对大肠肿瘤诊断和治疗的价值。方法 采用染色、放大和超声探头进行特殊检查判断大肠肿瘤起源、性质、形态和浸润深度 ,根据病变大小分别行一次切除 (≤ 2cm的病变 )和多次切除 (>2cm的病变 )共 5 4个病变 ,切除创面行夹子缝合。结果 组织病理学检查为腺瘤 13例 ,腺瘤伴异型增生 38例(10例轻度异型增生、2 3例中度异型增生、5例重度异型增生 ) ,黏膜层癌 3例。 4 0例随访中 ,一次切除2 9例 ,半年复查 ,未见局部再发 ;分次切除 11例 ,分别在术后 1个月有 2例 ,3个月和 6个月各有 1例局部再发 ,追加治疗后未见再发。 3例黏膜层癌中 ,2例内镜治疗后转外科治疗 ,组织病理学均未发现癌残留 ;另 1例长期内镜随访 ,未见局部再发。结论 染色、放大和超声探头综合检查能提高早期大肠癌浸润深度的诊断率 ,对正确选择治疗方法具有重要的临床意义 ,规范的操作能减少肿瘤组织残留 ,强调首次完全切除肿瘤组织、仔细观察有否残留肿瘤和定期随访复查的必要性。

Objective To eveluate the application of endoscopic mucosal resection (EMR) or endoscopic piecemeal mucosal resection (EPMR),clip suture and adjuvant techniques in diagnosis and treatment of large bowel neoplasms. Methods Fifty-four patients were enrolled into study. The morphological characteristic, nature,origination and infiltration depth of colonic neoplasms were diagnosed by routine colonoscopy and adjuvant techniques including spray staining,magnifying colonoscopy (Olympus 240ZL) and endoscopic ultrasonography (EUS) with intraluminal miniature-probe (Olympus EU-M30,UM-2R-3R). Fifty-four colonic lesions were treated by EMR (≤2 cm) or EPMR (>2 cm) according to the size of lesions. Large wound sections were sutured with metal clips. Results Histopathologic investigation showed that among 54 lesions,there were 13 cases of adenoma,38 cases of adenoma with atypical hyperplasia (10 cases with mild dysplasia,23 with moderate dysplasia and 5 with severe dysplasia )and 3 cases of mucosal cancer. We followed forty cases,local recurrence was found in none of 29 cases after 6 months of EMR. However,the recurrence was found in 2 of 11 cases after 1 month of EPMR and 1 each after 3 and 6 month of EPMR. There was no recurrence after further endoscopic re-treatment. Among 3 cancer patients,2 patients shifted to surgery due to patient's preference and 1 patient was followed up for 6 months. All of them were found without local recurrence by endoscopic biopsies or surgical results. Conclusions Chromoscopy,magnifying colonoscopy and EUS have benefits in diagnosis of early large bowel tumors,and it is also helpful in selecting the proper treatment so as to reduce the complication and recurrence.