Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma and precancerous lesions

AIM To evaluate the clinical outcomes of patients who underwent endoscopic submucosal tunnel dissection(ESTD) for esophageal squamous cell carcinoma(ESCC) and precancerous lesions.METHODS ESTD was performed in 289 patients. The clinical outcomes of the patients and pathological features of the lesions were retrospectively reviewed.RESULTS A total of 311 lesions were included in the analysis. The en bloc rate, complete resection rate, and curative resection rate were 99.04%, 81.28%, and 78.46%, respectively. The ESTD procedure time was 102.4 ± 35.1 min, the mean hospitalization time was 10.3 ± 2.8 d, and the average expenditure was 3766.5 ± 846.5 dollars. The intraoperative bleeding rate was 6.43%, the postoperative bleeding rate was 1.61%, the perforation rate was 1.93%, and the postoperative infection rate was 9.65%. Esophageal stricture and positive margin were severe adverse events, with an incidence rate of 14.79% and 15.76%, respectively. No tumor recurrence occurred during the follow-up period. CONCLUSION ESTD for ESCC and precancerous lesions is feasible and relatively safe, but for large mucosal lesions, the rate of esophageal stricture and positive margin is high.

Modified endoscopic submucosal tunnel dissection for large esophageal submucosal gland duct adenoma: A case report

BACKGROUND With the recent improvement of endoscopic techniques,endoscopic ultrasoundguided fine needle aspiration and endoscopic submucosal tunnel dissection(ESTD)have been widely used for accurate diagnosis and dissection acceleration of esophageal tumors.CASE SUMMARY We used a modified submucosal tunnel technique during endoscopic en bloc resection in a 58-year-old man with large esophageal submucosal gland duct adenoma(ESGDA).During modified ESTD,the oral end of the involved mucosa was cut transversely,followed by a submucosal tunnel created from the proximal to the distal end,and the anal end of the involved mucosa blocked by the tumor was incised.As a result of retaining submucosal injection solutions using the submucosal tunnel technique,it was possible to reduce the amount of injection required and increase the efficiency and safety of dissection.CONCLUSION Modified ESTD is an effective treatment strategy for large ESGDAs.Single-tunnel ESTD appears to be a time-saving procedure compared with conventional endoscopic submucosal dissection.

Endoscopic submucosal tunnel dissection for largesuperficial esophageal squamous cell neoplasms

Endoscopic submucosal dissection(ESD)is a wellestablished treatment for superficial esophageal squamous cell neoplasms(SESCNs)with no risk of lymphatic metastasis.However,for large SESCNs,especially when exceeding two-thirds of the esophageal circumference,conventional ESD is time-consuming and has an increased risk of adverse events.Based on the submucosal tunnel conception,endoscopic submucosal tunnel dissection(ESTD)was first introduced by us to remove large SESCNs,with excellent results.Studies from different centers also reported favorable results.Compared with conventional ESD,ESTD has a more rapid dissection speed and R0 resection rate.Currently in China,ESTD for large SESCNs is an important part of the digestive endoscopic tunnel technique,as is peroral endoscopic myotomy for achalasia and submucosal tunnel endoscopic resection for submucosal tumors of the muscularis propria.However,not all patients with SESCNs are candidates for ESTD,and postoperative esophageal strictures should also be taken into consideration,especially for lesions with a circumference greater than three-quarters.In this article,we describe our experience,review the literature of ESTD,and provide detailed information on indications,standard procedures,outcomes,and complications of ESTD.

Endoscopic submucosal dissection for esophageal granular cell tumor using the clutch cutter

Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure associated with a high complication rate.The shortcomings of this method are the deficiencies of fixing the knife to the target lesion,and of compressing it.These shortcomings can lead to major complications such as perforation and bleeding.To reduce the risk of complications related to ESD,we developed a new grasping type scissors forceps (Clutch Cutter,Fujifilm,Japan) which can grasp and incise the targeted tissue using an electrosurgical current.Esophagogastroduodenoscopy on a 59-year-old Japanese man revealed a 16mm esophageal submucosal nodule with central depression.Endoscopic ultrasonography demonstrated a hypoechoic solid tumor limited to the submucosa without lymph node involvement.The histologic diagnosis of the specimen obtained by biopsy was granular cell tumor.It was safely and accurately resected without unexpected incision by ESD using the CC.No delayed hemorrhage or perforation occurred.Histological examination confirmed that the granular cell tumor was completely excised with negative resection margin.We report herein a case of esophageal granular cell tumor successfully treated by an ESD technique using the CC.

Endoscopic submucosal tunnel dissection of upper gastrointestinal submucosal tumors: A comparative study of hook knife vs hybrid knife

AIM to compare the efficacy and safety of a hook knife(HO) with a hybrid knife(HK) during endoscopic submucosal tunnel dissection(EStD) procedure.METHODS Between August 2012 and December 2015, the ESt D procedure was performed for 83 upper GI submucosal lesions, which originated from the muscularis propria layer identified by upper endoscopy and endoscopic ultrasonography. Of these, 34 lesions were treated by a HO, whereas 49 lesions were treated by a HK. Data regarding age, gender, presenting symptoms, tumor location and size, procedure time, complications, en bloc resection rate and others were analyzed and compared between the two groups.RESULTS there were no significant differences in the age, gender, presenting symptoms and tumor location between the two groups. EStD was successfully completed in all the patients, and no case was converted to laparoscopy. the mean procedure time was significantly shorter in the HK group than in the HO group(41.3 ± 20.3 min vs 57.2 ± 28.0 min, p = 0.004). the mean frequency of device exchange was 1.4 ± 0.6 in the HK group and significantly less than 3.3 ± 0.6 in the HO group(p < 0.001). the differences in tumor size and histopathological diagnoses were not significant between the two groups(p = 0.813, p = 0.363, respectively). Both groups had an equal en bloc resection rate and complete resection rate. Additionally, the complication rate was similar between the two groups(p = 0.901). During the follow-up, no recurrence occurred in either group.CONCLUSION We demonstrate for the first time that HO and HK do not differ in efficacy or safety, but HK reduces the frequency of device exchange and procedure time.

Esophageal bronchogenic cyst excised by endoscopic submucosal tunnel dissection: A case report

BACKGROUND Esophageal bronchogenic cyst(EBC) is a rare congenital disease that is difficult to diagnose preoperatively, and treatment remains controversial.CASE SUMMARY We report a 53-year-old Chinese woman hospitalized in our hospital following the discovery of a submucosal protruding mass of the esophagus by upper endoscopy. A preliminary diagnosis of EBC was made by endoscopic ultrasonography(EUS), and treatment was accomplished by endoscopic submucosal tunnel dissection(ESTD). The pathological results verified the diagnosis. No scar changes or cystic lesion within the original lesion were found under EUS after a 3-mo follow-up.CONCLUSION EUS is valuable for the preliminary diagnosis of EBC and surveillance. ESTD is a safe and effective treatment for EBC. Further evaluation of complications and long-term follow-ups are required.

Endoscopic submucosal tunnel dissection for early esophageal squamous cell carcinoma in patients with cirrhosis:A propensity score analysis

BACKGROUND Although early esophageal squamous cell carcinoma(EESCC)with cirrhosis is a relatively rare clinical phenomenon,the management of EESCC in cirrhotic patients continues to be a challenge.AIM To evaluate the feasibility,safety,efficacy and long-term survival outcomes of endoscopic submucosal tunnel dissection(ESTD)for treating EESCC in patients with cirrhosis.METHODS This was a single-center retrospective cohort study.We examined 590 EESCC patients who underwent ESTD between July 14,2014,and May 26,2021,from a large-scale tertiary hospital.After excluding 25 patients with unclear lesion areas or pathological results,the remaining 565 patients were matched at a ratio of 1:3 by using propensity score matching.A total of 25 EESCC patients with comorbid liver cirrhosis and 75 matched EESCC patients were ultimately included in the analysis.Parametric and nonparametric statistical methods were used to compare the differences between the two groups.The Kaplan–Meier method was used to create survival curves,and differences in survival curves were compared by the log-rank test.RESULTS Among 25 patients with liver cirrhosis and 75 matched noncirrhotic patients,there were no significant differences in intraoperative bleeding(P=0.234),30-d post-ESTD bleeding(P=0.099),disease-specific survival(P=0.075),or recurrence-free survival(P=0.8196).The mean hospitalization time and costs were significantly longer(P=0.007)and higher(P=0.023)in the cirrhosis group than in the noncirrhosis group.The overall survival rate was significantly lower in the cirrhosis group(P=0.001).CONCLUSION ESTD is technically feasible,safe,and effective for patients with EESCC and liver cirrhosis.EESCC patients with Child-Pugh A disease seem to be good candidates for ESTD.

Endoscopic submucosal dissection in a patient with esophageal adenoid cystic carcinoma

We report the first use of endoscopic submucosal dissection(ESD) for the treatment of a patient with adenoid cystic carcinoma of the esophagus(EACC). An 82-year-old woman visited our hospital for evaluation of an esophageal submucosal tumor. Endoscopic examination showed a submucosal tumor in the middle third of the esophagus. The lesion partially stained with Lugol's solution,and narrow band imaging with magnification showed intrapapillary capillary loops with mild dilatation and a divergence of caliber in the center of the lesion. Endoscopic ultrasound imaging revealed a solid 8 mm × 4.2 mm tumor,primarily involving the second and third layers of the esophagus. A preoperative biopsy was non-diagnostic. ESD was performed to resect the lesion,an 8 mm submucosal tumor. Immunohistologically,tumor cells differentiating into ductal epithelium and myoepithelium were observed,and the tissue type was adenoid cystic carcinoma. There was no evidence of esophageal wall,vertical stump or horizontal margin invasion with p T1 b-SM2 staining(1800 μm from the muscularis mucosa). Further studies are needed to assess the use of ESD for the treatment of patients with EACC.

Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most impor-tant predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559),P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients were submitted to surgery (log-odds, ADC: -2.1206 ± 0.6249 vs SCC: 4.1356 ± 0.4038, P < 0.05). The odds for re-classification of tumor stage after endoscopic resection were 53% and 39% for ADC and SCC, respectively. Local tumor recurrence was best predicted by grade 3 differentiation and piecemeal resection, metachronous cancer development by the carcinoma in situ component, and lymph node positivity by lymphovascular invasion. With regard to surgically resected patients: Significant differences in patients with positive lymph nodes were observed between ADC and SCC [coefficient: 1.889569, 95%CI: (0.3945146, 3.384624), P<0.01). In contrast, lymphovascular and microvascular invasion and grade 3 patients between histologic types were comparable, the respective rank order of the predictors of lymph node positivity was: Grade 3, lymphovascular invasion (L+), microvascular invasion (V+), submucosal (Sm) 3 invasion, Sm2 invasion and Sm1 invasion. Histologic type (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were Sm3 invasion and (V+). For ADC, the most important predictor was (L+). CONCLUSION: Local tumor recurrence is predicted by grade 3, metachronous cancer by the carcinoma insitu component, and lymph node positivity by L+. T1b cancer should be treated with surgical resection.

Curative ESD for intraepithelial esophageal carcinoma with leiomyoma mimicking submucosal invasive carcinoma

This case report presents a 65-year-old man who developed early esophageal cancer with leiomyoma treated by endoscopic submucosal dissection(ESD).There have been several reports of co-existing superficial esophageal cancer and leiomyoma treated by endoscopic mucosal resection.However,there is no previous report describing the co-existing lesion treated by ESD.In order to determine treatment strategies for esophageal cancer,accurate endoscopic evaluation of the cancerous depth is essential.In the present case,the combination of endoscopic ultrasonography and narrow-band imaging system with magnifying endoscopy was extremely useful to evaluate the superficial esophageal cancer with leiomyoma,which lead to the appropriate treatment,ESD.

Endoscopic resection of benign esophageal schwannoma:Three case reports and review of literature

BACKGROUND Esophageal schwannomas are uncommon esophageal submucosal benign tumors and are usually treated with surgery.CASE SUMMARY Here,we report three cases of middle/lower thoracic esophageal schwannoma treated successfully with endoscopic resection.These lesions were misdiagnosed as leiomyoma on preoperative imaging.During the endoscopic resection of such tumors,there is a risk of esophageal perforation due to their deep location.If possible,submucosal tunneling endoscopic resection should be used.CONCLUSION For larger schwannomas,endoscopy combined with thoracoscopy can be considered for en bloc resection.We performed a mini literature review in order to present the current status of diagnosis and treatment for esophageal schwannoma.

Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction

BACKGROUND Endoscopic resection approaches,including endoscopic submucosal dissection(ESD),submucosal tunneling endoscopic resection(STER)and endoscopic fullthickness resection(EFTR),have been widely used for the treatment of submucosal tumors(SMTs)located in the upper gastrointestinal tract.However,compared to SMTs located in the esophagus or stomach,endoscopic resection of SMTs from the esophagogastric junction(EGJ)is much more difficult because of the sharp angle and narrow lumen of the EGJ.SMTs originating from the muscularis propria(MP)in the EGJ,especially those that grow extraluminally and adhere closely to the serosa,make endoscopic resection even more difficult.AIM To investigate the predictors of difficult endoscopic resection for SMTs from the MP layer at the EGJ.METHODS A total of 90 patients with SMTs from the MP layer at the EGJ were included in the present study.The difficulty of endoscopic resection was defined as a long procedure time,failure of en bloc resection and intraoperative bleeding.Clinicopathological,endoscopic and follow-up data were collected and analyzed.Statistical analysis of independent risks for piecemeal resection,long operative time,and intraoperative bleeding were assessed using univariate and multivariate analyses.RESULTS According to the location and growth pattern of the tumor,44 patients underwent STER,14 patients underwent EFTR,and the remaining 32 patients received a standard ESD procedure.The tumor size was 20.0 mm(range 5.0–100.0 mm).Fourty-seven out of 90 lesions(52.2%)were regularly shaped.The overall en bloc resection rate was 84.4%.The operation time was 43 min(range 16–126 min).The intraoperative bleeding rate was 18.9%.There were no adverse events that required therapeutic intervention during or after the procedures.The surgical approach had no significant correlation with en bloc resection,long operative time or intraoperative bleeding.Large tumor size(≥30 mm)and irregular tumor shape were independent predictors for piecemeal resection(OR:7.346,P=0.032 and OR:18.004,P=0.029,respectively),long operative time(≥60 min)(OR:47.330,P=0.000 and OR:6.863,P=0.034,respectively)and intraoperative bleeding(OR:20.631,P=0.002 and OR:19.020,P=0.021,respectively).CONCLUSION Endoscopic resection is an effective treatment for SMTs in the MP layer at the EGJ.Tumors with large size and irregular shape were independent predictors for difficult endoscopic resection.

Resection of early esophageal neoplasms: The pendulum swings from surgical to endoscopic management

Esophageal cancer is a highly lethal disease and is the sixth leading cause of cancer related mortality in the world.The standard treatment is esophagectomy which is associated with significant morbidity and mortality.This led to development of minimally invasive,organ sparing endoscopic therapies which have comparable outcomes to esophagectomy in early cancer.These include endoscopic mucosal resection and endoscopic submucosal dissection.In early squamous cell cancer,endoscopic submucosal dissection is preferred as it is associated with cause specific 5-year survival rates of 100%for M1 and M2 tumors and 85%for M3 and SM1 tumors and low recurrence rates.In early adenocarcinoma,endoscopic resection of visible abnormalities is followed by ablation of the remaining flat Barrett’s mucosa to prevent recurrences.Radiofrequency ablation is the most widely used ablation modality with others being cryotherapy and argon plasma coagulation.Focal endoscopic mucosal resection followed by radiofrequency ablation leads to eradication of neoplasia in 93.4%of patients and eradication of intestinal metaplasia in 73.1%of patients.Innovative techniques such as submucosal tunneling with endoscopic resection are developed for management of submucosal tumors of the esophagus.This review includes a discussion of various endoscopic techniques and their clinical outcomes in early squamous cell cancer,adenocarcinoma and submucosal tumors.An overview of comparison between esophagectomy and endoscopic therapy are also presented.

ESD与STER治疗食管平滑肌瘤的临床应用及效果分析

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)和经内镜黏膜下隧道肿瘤切除术(submucosal tunneling endoscopic resection,STER)在食管平滑肌瘤治疗中的价值。方法回顾性分析2016年1月至2022年6月于武汉大学人民医院消化内科进行ESD与STER治疗、术后病理及免疫组化确诊为食管平滑肌瘤的181例患者的临床资料。结果181例患者的食管平滑肌瘤在内镜下被成功切除,病灶多呈表面光滑隆起形态(175/181,96.7%),色泽多正常,多位于食管下段处(84/181,46.4%)。ESD组135例,其中125例(92.6%)行EUS检查,结果显示,91例(72.8%)病灶起源于黏膜肌层,15例(12.0%)起源于黏膜下层,15例(12.0%)起源于固有肌层,4例(3.2%)起源于黏膜多层,大部分为均匀低回声灶,有5例内部回声欠均匀。STER组46例,其中45例(97.8%)行EUS检查,10例(22.2%)病灶起源于黏膜肌层,1例(2.2%)起源于黏膜下层,31例(68.9%)起源于固有肌层,3例(6.7%)起源于黏膜多层,大部分呈均匀低回声灶,仅有2例内部回声欠均匀。在病灶位置上,ESD组中食管上段45例,食管中段40例,食管下段50例,STER组中食管上段4例,食管中段8例,食管下段34例。在病灶大小上,ESD组中病灶<2 cm有127例、≥2 cm有8例,STER组中34例<2 cm、12例≥2 cm;两组在病灶起源、位置、大小方面比较,差异有显著统计学意义(P<0.001)。行内镜下治疗时,STER组手术时间较ESD组时间长,且其在住院天数、治疗费用、术后发生并发症方面也比ESD手术组多,差异均有统计学意义(P<0.05)。随访出院后门诊行胃镜检查发现,181例患者中有64例(35.4%)完成术后1~24个月内随访,其中有8例(12.5%)发现食管肿物残留或复发。结论食管平滑肌瘤多位于食管下段且病灶常<2 cm,以黏膜肌层来源常见。ESD治疗黏膜肌层来源、STER治疗固有肌层来源的食管平滑肌瘤均较为安全有效,STER治疗技术仍需进一步优化从而减少并发症的发生。

胃肠激素变化评估STER与ESD治疗上消化道黏膜下肿瘤的价值

目的基于胃肠激素变化,探究评估STER与ESD治疗上消化道黏膜下肿瘤的价值。方法 回顾性分析安庆市第一人民医院消化内科2020年1月至2023年1月收治的70例SMT患者临床资料,根据手术方式分为STER组(n=34,STER切除肿瘤)和ESD组(n=36,ESD剥离肿瘤),比较两组临床疗效、围术期指标、创面恢复情况、胃肠功能恢复情况、胃肠激素水平、并发症。结果 两组临床疗效比较无统计学意义(P>0.05);STER组术中出血量、术后住院天数均少于ESD组,而住院费高于ESD组,差异均有统计学意义(P<0.05);STER组创面长径、创面愈合时间、首次肛门排气时间、首次排便时间均少于ESD组,差异均有统计学意义(P<0.05);STER组胃泌素-17水平低于ESD组,胃蛋白酶原Ⅰ、胃蛋白酶原Ⅱ水平高于ESD组,差异有统计学意义(P<0.05);两组手术并发症构成比比较差异无统计学意义(P>0.05)。结论 ESD与STER治疗SMT均有较好的临床疗效。与ESD相比,STER更有助于改善围术期指标与术后胃激素水平,缩短康复进程,且术后并发症少,但住院费用相对较高,建议医生与患者应根据实际情况选择术式。

内镜下隧道式与常规黏膜剥离术治疗食管大面积浅表性肿瘤的对比研究

目的比较隧道式黏膜剥离术（ESTD）与常规黏膜剥离术（ESD）治疗食管大面积浅表陛肿瘤手术效率和安全性。方法回顾性分析2010年10月～2013年6月于我院消化内镜中心行食管肿瘤内镜下切除治疗235例患者的临床资料。按照纳入和排除标准，筛选接受ESTD或ESD治疗的食管大面积浅表性肿瘤患者，分析其临床资料。结果共29例患者纳人研究，平均年龄62岁（49～78岁），男16例，女13例，手术平均时间81.3min（34-239min）。其中ESTD组11例，ESD组18例。两组比较，ESTD组剥离速度明显快于ESD组（22．4±5．2mm2／min vs 12．2±4．0mm2／min，P〈0．05）。虽然两组整块切除率差异不明显[100％（11／11）郴83．3％（15／18），P〉0．05]，但在根治性切除率方面，ESTD明显高于ESD组[81．8％（9／11）vs 66．7％（12／18），P〈0．05]。ESD组有1例出现术中出血，而ESTD组均无出血、穿孔及纵膈气肿发生。术后8例发生食管狭窄，其发生率同病变环周程度和长度有关（P〈0．05）。结论ESTD不仅能安全有效地完成食管大面积的表浅性肿瘤的切除，而且同ESD相比，手术时间短，剥离速度快，肿瘤根治性切除率高。但是，对于食管环周超过3／4或长度超过50mm的病变，应注意防治术后食管狭窄的发生。

食管间质瘤的临床特点及内镜下治疗效果评价

目的探讨食管间质瘤的临床特点,评价内镜下治疗的效果和安全性。方法回顾性分析24例内镜下治疗后病理学确诊的食管间质瘤患者的临床资料,其中18例行内镜黏膜下剥离术(ESD),6例行内镜黏膜下隧道肿瘤切除术(STER),分析患者的基本情况、病变部位、超声内镜表现、组织学特征、治疗情况以及术后随访结果。结果 24例患者中,年龄>50岁者占70.83%,男性占70.83%;病变多位于食管下段,多起源于固有肌层;食管间质瘤伴平滑肌分化率高。18例行ESD患者中,肿瘤起源于黏膜肌层和固有肌层各9例,均一次性完整剥离,但1例固有肌层肿瘤剥离后发生0.3 cm穿孔。6例行STER患者的肿瘤起源于固有肌层,均一次性完整剥离。术后随访3～42个月未发现肿瘤残留和复发。结论内镜下治疗食管间质瘤安全、有效,对起源于固有肌层的食管间质瘤STER治疗优于ESD。

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

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。

内镜黏膜下隧道剥离术治疗食管固有肌层肿瘤的效果评价

目的评价经内镜黏膜下隧道剥离术（endoscopic submucosal tunnel dissection,ESTD）治疗食管固有肌层肿瘤的有效性和安全性。方法 2011年8月至2014年6月期间,经我院电子胃镜及超声胃镜诊断来源于食管固有肌层肿瘤患者,所有符合手术条件患者签署知情同意书并在麻醉下行ESTD切除病变,并进行病理及免疫组化检查,记录病变信息及术中情况,术后定期随访观察治疗效果。结果 54例食管固有肌层肿瘤经ESTD完整切。4例患者因肿瘤横径大于3.5 cm无法完整经食管取出而转外科切除。切除标本按长径及横径测量,切除病变长0.8-8.5 cm,平均2.55 cm;横径0.5-3.0 cm,平均1.65 cm;手术时间20-280 min,平均68 min。11例术中发生单纯皮下气肿,发生率20%,3例出现术中可见穿孔,发生率（5.6%）,1例术后发现膈下少量游离气体,发生率1.8%,均保守治疗后恢复。术后54例病变经病理及免疫组化检查诊断均为平滑肌瘤,切缘均为阴性。所有病例均未发生气胸,无术后隧道内出血。术后采用胃镜及超声胃镜随访时间1-24个月,中位随访时间12个月,随访期内未见肿瘤残留或复发病例。结论内镜黏膜下隧道剥离术（ESTD）是近年来新发展的一种微创和高难度的手术治疗方式,因其保留了正常黏膜可以覆盖创面,大大减少了穿孔风险,具有损伤小,切除精度高的特点,是一种治疗食管固有肌层来源的黏膜下肿瘤的安全可行的方法。

食管粘膜下肿瘤的内镜下切除术

目的探讨消化内镜下切除食管粘膜下肿瘤的方法,并依据临床病理及免疫组织化学表型确定其诊断。方法自2003～2007年我们对38例食管粘膜下肿瘤进行了内镜下切除,对位于粘膜肌层的肿瘤进行圈套电切或电铲除的方法切除,对超声胃镜确定位于固有肌层的肿瘤做内镜下粘膜下层剥离术(ESD)切除,并对切下的标本进行临床病理学检查和免疫组织化学分析,通过连续切片进行CD34、CD117、Vimentin、Desmin染色方法观察免疫组织化学表型,术后3个月随访胃镜检查。结果位于粘膜肌层的26例肿瘤,平均直径为15mm(10～35mm),均一次性完整切除,平均手术时间7min(3～31min);位于固有肌层的12例肿瘤,平均直径为20mm(12～32mm),均一次性完整切除,平均手术时间110min(96～145min),其中1例术后3个月复发,进行第二次ESD手术。免疫组化结果:本组38例CD34为100%阴性,CD117为100%阴性,Vimentin为81.6%阴性;Desmin为100%阳性(++～+++),均确定为平滑肌瘤。结论消化内镜下可安全有效地进行食管粘膜下肿瘤切除术,包括源于固有肌层的平滑肌瘤。