Evaluating long-term attachment of two different endoclips in the human gastrointestinal tract

AIM:To evaluate the long-term attachment of two types of endoclips in the human gastrointestinal tract. METHODS:In this prospective observational study,endoclips were placed and followed-up during endoscopies or using fluoroscopic images as part of a pro s pective feasibility study evaluating external beam radiotherapy (EBRT,wk 1-3) followed by high dose rate brachytherapy (HDRBT with an endoluminal app licator once a week for 3 wk,wk 9-11) in medically inoperablerectal cancer patients. Initially,the type and number of endoclips were chosenrandomly and later refined to 1 Resolution clip (Microvasive) proximal and 2 Quickclips (Olympus) distal to the tumor. Nine consecutive patients from between September 2007 and August 2008 were analyzed. Retention rates were evaluated over three different observational periods [period 1:pre-HDRBT (wk-2-8),period 2:during HD RBT (wk 9-11) and period 3:post-HDRBT (wk 1216)]. RESULTS:In this study,a total of 44 clips were placed during endoscopy,either at the beginning or at the end of period 1. The Resolution clip had a higher overall retention rate than the Quickclip (P = 0.01). After a median period of 81 d after placement (in period 1),longterm retention rates for the Resolution clip and Quickclip clip were 67% and 35% respectively. CONCLUSION:The Resolution clip has a high retention rate and is useful in situations where long-term attachment to the human gastrointestinal mucosa is warranted.

Migrated endoclip and stone formation after cholecystectomy:A new danger of acute pancreatitis

Endoclip migration into the common bile duct following laparoscopic cholecystectomy (LC) is an extremely rare complication. Migrated endoclip into the common bile duct can cause obstruction,serve as a nidus for stone formation,and cause cholangitis. We report a case of obstructive jaundice and acute biliary pancreatitis due to choledocholithiasis caused by a migrated endoclip 6 mo after LC. The patient underwent early endoscopic retrog-rade cholangiopancreatography (ERCP) with endoscopic sphincterotomy and stone extraction.

Endoclipping treatment of life-threatening rectal bleeding after prostate biopsy

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound(TRUS)-guided multiple biopsy of the prostate,but is usually mild and stops spontaneously.We report what is believed to be the first case of life-threatening rectal bleeding following this procedure,which was successfully treated by endoscopic intervention through placement of three clips on the sites of bleeding.This case emphasizes endoscopic intervention associated with endoclipping as a safe and effective method to achieve hemostasis in massive rectal bleeding after prostate biopsy.Additionally,current data on the complications of the TRUS-guided multiple biopsy of the prostate and the options for treating fulminant rectal bleeding, a consequence of this procedure,are described.

金属夹联合尼龙套圈在内镜带蒂大息肉摘除中的应用

背景：消化道出血是内镜息肉摘除术最常见的并发症。目的：观察金属夹联合尼龙套圈对内镜带蒂大息肉摘除术的效果和安全性。方法：选取2011年6月一2012年8月上海市第一人民医院分院89例带蒂大息肉患者，分为尼龙套圈组（A组）和金属夹联合尼龙圈套组（B组），回顾性分析息肉形态、部位、大小以及并发症发生率。结果：A组和B组息肉形态均以山田Ⅳ型为主，主要位于乙状结肠，两组患者性别、年龄、息肉顶部、蒂部平均直径相比均无明显差异（P〉0．05）。A组和B组的术中出血发生率（12．8％对10．0％）、术后迟发性出血发生率（10．3％对4．0％）相比均无明显差异（P〉0．05），经治疗后出血均停止。A组2例患者术后3个月息肉复发，B组手术创面愈合良好，无息肉残端残留。结论：金属夹联合尼龙套圈能有效预防内镜下带蒂大息肉切除术中和术后的出血。

无创血管夹在腹腔镜保胆取石术治疗胆囊泥砂样结石中的应用

目的探讨术中应用无创血管夹钳夹胆囊管,联合腹腔镜、胆道镜行微创保胆取石术治疗胆囊泥砂样结石病的可行性。方法回顾分析46例应用无创血管夹钳夹胆囊管,腹腔镜联合胆道镜微创保胆取石术治疗胆囊泥砂样结石病患者的临床资料。结果46例患者全部成功行微创保胆取石术取尽泥沙样结石,手术时间30～60min,平均50min,住院时间3～6d,术后B超检查显示无继发胆管结石并发症。结论术中应用无创血管夹钳夹胆囊管,联合腹腔镜、胆道镜行微创保胆取石术仍然是治疗胆囊泥砂样结石病的一种比较可行、有效、安全的方法之一。

Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.

透明帽吸引内镜夹闭合法在经自然腔道内镜外科手术切口闭合中的实验研究

目的：探索经自然腔道内镜外科手术（NOTES）切口大小的选择以及闭合方法。方法以41例离体猪胃为模型，用针状刀直接切开做入路切口。按切口大小及闭合方法分为4组，A组8例做大切口（长度1．2～2．0cm），直接用内镜夹闭合；B组10例做大切口（长度1．2～2．0cm），用透明帽吸引下内镜夹闭合切口；C组10例做小切口（长度小于或等于1．1cm），直接用内镜夹闭合；D组13例做小切口（长度小于或等于1．1 cm ），用透明帽吸引下内镜夹闭合切口。闭合完成后行注水测漏试验，比较结果。结果 A组1例闭合良好，7例失败；B组2例闭合良好，8例失败；C组2例闭合良好，8例失败，D组11例闭合良好，2例失败。采用χ2 Fisher确切概率法检验分析各组数据。A组与B组、C组比较，差异无统计学意义（ P＞0．05）。A组与D组比较，B组与D组比较，差异有统计学意义（P＜0．05）。结论 NOTES切口以小于1 cm ，内镜刚好通过为佳，透明帽吸引内镜夹闭合法简单、实用、有效。

Unexpected endoscopic full-thickness resection of a duodenal neuroendocrine tumor

A 57-year-old man underwent endoscopy for investigation of a duodenal polyp. Endoscopy revealed a hemispheric submucosal tumor, about 5 mm in diameter, in the anterior wall of the duodenal bulb. Endoscopic biopsy disclosed a neuroendocrine tumor histologically, therefore endoscopic mucosal resection was conducted. The tumor was effectively and evenly elevated after injection of a mixture of 0.2% hyaluronic acid and glycerol at a ratio of 1:1 into the submucosal layer. A small amount of indigo-carmine dye was also added for coloration of injection fluid. The lesion was completely resected en bloc with a snare after submucosal fluid injection. Immediately, muscle-fiber-like tissues were identified in the marginal area of the resected defect above the blue-colored layer, which suggested perforation. The defect was completely closed with a total of 9 endoclips, and no symptoms associated with peritonitis appeared thereafter. Histologically, the horizontal and vertical margins of the resected specimen were free of tumor and muscularis propria was also seen in the resected specimen. Generally, endoscopic mucosal resection is considered to be theoretically successful if the mucosal defect is colored blue. The blue layer in this case, however, had been created by unplanned injection into the subserosal rather than the submucosal layer.

Endotherapy of leaks and fistula

Perforations, leaks and fistula involving gastrointestinal(GI) tract are increasing encountered in clinical practice. There is a changing paradigm for their management with surgical approach being replaced by conservative approach including endoscopic therapy. Clips(through the scope and over the scope) and covered stent are front runners for endotherapy for GI leaks and fistula.Over the scope clips introduced recently, can treat larger defects compared to through the scope clips. Covered stents are suited for larger defects and those associated with luminal narrowing. However cervical esophagus, gastro-esophageal junction, stomach and right colonic lesions may be better for clip therapy rather than stenting. Recent developments in this field include use of endovac therapy which consists of a sponge with suction device, biodegradable stent, use of fibrin glue and some endo-suturing device. Conservative therapy with no surgical or endoscopic intervention, may be suitable for a small subset of patients. An algorithm based on location, size of defect, associated stricture, infection and available expertise needs to be developed to reduce the mortality and morbidity of this difficult clinical problem.

应用尼龙圈联合钛夹预防结肠息肉切除后出血

目的:评价尼龙圈联合钛夹方法在预防结肠大息肉切除后出血的价值.方法:回顾性研究经肠镜下切除直径≥2 cm有蒂息肉患者的临床资料.对照组采用混合电流切除并采用钛夹预防出血,实验组采用尼龙圈套扎后混合电流切除,然后再行钛夹预防出血.对早期出血率、迟发性出血率、严重出血发生率及住院天数进行比较.结果:本研究共有66例患者72枚息肉进行肠镜下混合电流切除.其中对照组42枚息肉,实验组30枚息肉.总出血发生率为6.94%(5/72),对照组有4例出现出血,出血发生率为9.52%,3例早期出血,1例迟发性出血.实验组1例发生迟发性出血,发生率为3.13%,无早期出血发生.两组出血发生率比较差异无统计学意义.对照组中出现1例大量出血并需输血治疗.实验组肠镜操作过程较对照组时间延长(P=0.027),但住院天数明显下降(P=0.047).结论:尼龙圈联合钛夹是预防结肠息肉切除术后出血发生的一种有效措施.

内镜下钛夹治疗儿童结直肠大息肉的效果观察

目的研究内镜下钛夹治疗儿童结直肠大息肉(≥2.0 cm)的临床疗效及安全性。方法选择2014年12月至2020年6月郑州大学第三附属医院收治的86例结直肠大息肉患儿为研究组,另选同期随机22例未使用钛夹患儿为对照组。回顾性分析每组息肉大小、位置、术后出血率、感染及腹痛等并发症发生率。结果所有息肉切除均获得成功,两组年龄(P=0.831)、性别(P=0.339)、息肉大小(P=0.699)、息肉位置(P=0.654)比较差异均无统计学意义;研究组迟发性出血发生率明显低于对照组(3.5%、22.7%,P=0.009),总体并发症发生率也低于对照组(8.1%、27.3%,P=0.036),均未发生肠穿孔等严重并发症。结论在≥2.0 cm儿童结直肠息肉中,内镜下联合钛夹治疗可以预防术后延迟出血,降低术后并发症,疗效确切、安全可行。

胃肠镜钛夹在肌层浸润性膀胱癌保留膀胱综合治疗放疗定位中的应用

目的研究胃肠镜钛夹(以下简称钛夹)在肌层浸润性膀胱癌保留膀胱综合治疗放疗定位中的有效性、可靠性和安全性。方法选取自2015年1月至2016年2月于本院就诊要求行综合治疗保留膀胱的9例(8男1女)肌层浸润性膀胱癌患者,给予经尿道根治性膀胱肿瘤电切术,并在电切后病灶边缘放置3~5枚钛夹作为标记物,随访至2017年2月。记录放疗计划完成前标记物的可见率、丢失率、患者的不适及不良反应发生率以及术后1年肿瘤复发情况。结果 9例患者置入的共32枚钛夹在腹部平片清晰可见,放疗结束后均在膀胱镜下完整取出,未见与钛夹放置相关的不适及不良反应。9例患者术后随访2年无进展生存率为89%(8/9)。结论钛夹用于肌层浸润性膀胱癌保留膀胱综合治疗的放疗定位可清晰显示电切后病灶边缘,安全、可靠。

新型内镜连续止血闭合器械的设计与分析

目的设计一种新型内镜连续止血闭合器械,并进行有限元分析,验证其是否满足实现组织闭合功能的设计要求。方法在器械抓钳聚拢目标组织后推送金属夹,使其部分穿透组织,通过金属夹与抓钳内壁的相互挤压强迫金属夹细臂弯曲闭合,完成施夹后金属夹留在组织上,并对金属夹施加2 mm反向位移。设定金属夹材料弹性极限为239.0 MPa,抗拉强度为901.0 MPa。结果在穿刺组织过程中金属夹没有发生变形,最大应力为212.6 MPa;在闭合过程中变形符合设计预期,最大应力为727.7 MPa;在反向2 mm位移下金属夹最大应力为75.8 MPa。金属夹在施夹过程和2 mm位移作用下材料均未失效,最大总应力为741.0 MPa。结论设计的新型内镜连续止血闭合器械能够一次性施放4个金属夹,具备用于聚拢组织的独立抓钳,能够减少更换金属夹的时间并提高施夹准确性,同时有限元方法验证了器械在使用过程中是安全可靠的。

医源性消化道穿孔内镜处理研究进展

医源性消化道穿孔是内镜治疗的严重并发症之一。对于急性医源性穿孔,简单而快速的内镜治疗能避免传统开放性手术治疗带来的创伤,使手术最大限度地微创化。医源性消化道穿孔的内镜下闭合方法主要有金属夹闭合术、专用缝合器械缝合、覆膜支架封堵、可降解生物材料联合组织胶封堵以及内镜联合治疗如圈套联合金属夹等。本文就医源性消化道急性穿孔内镜处理的现状和研究进展作一综述。

内镜缝合器械的临床应用和技术评估

目的:内镜缝合器械现已成为消化内镜治疗的重要组成部分,主要用于治疗消化道急性出血,医源性、非医源性穿孔,修复缺损组织或作为其他治疗手段的辅助工具。本文介绍了内镜缝合器械的临床应用与技术,并对现有产品进行对比,总结各类产品的优势及缺陷,为临床医师及研发人员提供参考。方法:内镜缝合器械分为内镜金属夹和内镜专用缝合器,内镜金属夹还可分为经内镜钳道金属夹和内镜外金属夹。结果:金属夹的体积小、操作简便、效果可靠,多用于快速止血及小穿孔闭合,其中内镜外金属夹的夹闭效果优于经内镜钳道金属夹;缝合器能实现全层固定,用作组织固定的效果优于金属夹,但器械本身体积较大、成本高、操作复杂,现多用于GERD的内镜治疗和大面积组织的修复和固定。结论:内镜缝合器与内镜金属夹在其应用范围内都具有良好的治疗效果,但也分别存在一些问题。金属夹的改进要着重于实现全层夹闭和连发,缝合器需要加强其柔顺性能并降低使用成本。相信随着科技的发展,未来的内镜缝合器械会越来越完善。

Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips

Perforation is one of the most serious complications of endoscopic sphincterotomy (ES) necessitating immediate surgical intervention. We present a case of successful management of such a complication with endoclipping. A85-year-old woman developed duodenal perforation after ES. The perforation was identified early and its closure was achieved using three metallic clips in a single session.There was no procedure-related morbidity or complications and our patient was discharged from hospital 10 d later.Endoclipping of duodenal perforation induced by ES is a safe, effective and alternative to surgery treatment.

内镜夹闭乳头成形术在内镜逆行胰胆管造影术中的应用

目的探讨内镜夹闭乳头成形术在内镜逆行胰胆管造影术(ERCP)中的临床应用价值。方法选取2021年11月-2022年11月该院行ERCP的患者62例。随机行内镜乳头夹闭成形术32例,成功30例。分为两组,内镜夹闭乳头成形术成功组(A组,n=30)和十二指肠乳头未夹闭组(B组,n=30)。比较两组患者的近期并发症和远期并发症发生率。结果内镜夹闭乳头成形术的成功率为93.8%(30/32)。两组患者术后胰腺炎、术后出血和术后胆管炎的发生率比较,差异均无统计学意义(P>0.05);两组患者均无十二指肠穿孔病例。两组患者1年内胆管炎发病率和胆总管结石复发率比较,差异均无统计学意义(P>0.05),但A组胆管炎发生率+结石复发率明显低于B组,差异有统计学意义(P<0.05)。结论内镜夹闭乳头成形术对内镜下乳头括约肌大球囊扩张术(EPLBD)后乳头的夹闭成形成功率高,手术安全,可减少远期胆管炎的发生,降低结石复发率。

金属夹与黏膜下注射辅助插管技术在内镜逆行胰胆管造影术困难插管中的应用(含视频)

目的探讨金属夹辅助与黏膜下注射辅助插管技术在内镜逆行性胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)困难插管中的临床价值。方法回顾性分析2015年6月—2020年9月在海军军医大学第一附属医院初次行ERCP的12458例患者资料,其中采用金属夹或黏膜下注射辅助插管的困难插管患者28例(0.22%),分析两种技术在困难插管患者的插管成功率、插管时间及并发症发生率。结果28例采用金属夹或黏膜下注射辅助插管患者,男18例(64.3%)、女10例(35.7%),年龄(69.6±14.1)岁。乳头分型:Ⅱ型5例(17.9%),Ⅲ型5例(17.9%),Ⅴ型18例(64.3%)。采用金属夹辅助插管16例(57.1%),黏膜下注射辅助插管12例(42.9%),其中25例(89.3%)顺利完成选择性插管,插管时间(9.9±4.3)min。出现轻度ERCP术后胰腺炎1例(3.6%),术后高淀粉酶血症3例(10.7%),未出现术后出血或穿孔者,所有患者经保守治疗治愈出院。结论对于乳头暴露不佳、位置偏斜等原因而选择性插管困难时,继续用金属夹或黏膜下注射辅助插管,可有效提高ERCP选择性插管成功率,且并发症发生率较低,值得临床推广。

内镜下钛夹、尼龙圈套辅助高频电切术治疗胃肠道巨大有蒂息肉的临床研究

目的 评价内镜下钛夹、尼龙圈套辅助高频电切术治疗胃肠道巨大息肉的效果及安全性.方法 对50例患者共85处消化道巨大有蒂息肉样病变分别采用钛夹、尼龙圈套辅助高频电凝切除术的治疗方法进行回顾性分析.结果 85枚巨大息肉中,上消化道15枚,结肠66枚,直肠4枚.其中62枚息肉采用尼龙圈套＋高频电凝切除术治疗,23枚息肉采用高频电凝切除术＋肽夹钳夹术治疗,术中无一例发生出血;术后迟发性出血2例（2.4%）,急诊内镜下钛夹止血成功,无其它并发症发生.结论 消化道息肉高频电切术后最常见且最棘手的并发症是出血,巨大息肉发生在术中或术后迟发性出血的机率更大,采用尼龙圈套及金属肽夹辅助高频电凝切除术,能有效预防粗蒂大息肉样病变切除术中和术后出血,是消化道巨大息肉内镜下治疗安全有效的联合治疗技术.

圈套器和止血夹肿瘤牵拉技术在胃黏膜下肿瘤内镜切除中的应用:倾向评分匹配分析

背景:包括内镜黏膜下剥离术(ESD)和内镜全层切除术(EFR)在内的内镜技术可用以切除较小的胃黏膜下肿瘤(SMT)。我们团队开发了一种圈套器和止血夹肿瘤牵拉方法,用以辅助SMT的内镜切除。本研究旨在评估这一技术的安全性和有效性。方法:本研究采用倾向评分匹配(PSM)分析,比较圈套器和止血夹辅助的ESD/EFR(圈套器牵拉组)与传统ESD/EFR(传统技术组)用于切除胃SMT的手术时间、整块切除率、围手术期并发症发生率及内镜治疗相关的费用。结果:2012年1月至2019年3月间收治的253例胃SMT患者纳入研究。PSM获得51对病例,两组围手术期并发症发生率和内镜耗材费用的差异均无统计学意义,但圈套器牵拉组中位手术时间缩短(39 vs 60 min,P=0.005),整块切除率提高(100%vs 88.2%,P=0.027)。结论:圈套器牵拉辅助的ESD/EFR用于胃SMT具有更高的手术效率和整块切除率,而且不会增加围手术期并发症发生风险和手术耗材费用。因此,该方法似乎是胃SMT内镜切除的良好选择。