注水黏膜切开刀推进式内镜黏膜下剥离术切除早癌及癌前病变的应用研究

Clinical application of pushing-endoscopic submucosal dissection for large early cancer and precancerous lesions in cardia

摘要:

目的 探讨应用注水型电刀行推进式内镜黏膜下剥离术（PESD）切除大面积贲门早癌及癌前病变的价值，并分析总结相关技术要点。方法 选取2017年1月－2020年12月在保定市第一中心医院内镜诊疗中心通过胃镜活检及放大染色内镜检查考虑贲门早癌或高级别上皮内瘤变且病变最大径 > 2.0 cm的病例，术中用注水型电刀行PESD治疗，并选取该中心同期该医生以普通黏膜切开刀行贲门常规内镜黏膜下剥离术（ESD）治疗的病例，对比分析两组病例的单位面积剥离速度、病变完整切除率、并发症发生率（术后迟发性出血和穿孔）等。结果 PESD组（n = 32）病变直径2.0～8.0 cm，平均（5.1±2.9）cm；其中1处病变位于前壁，16处位于后壁，3处位于大弯侧，12处位于小弯侧；30处病变为一次性切除，2处病变（贲门大弯侧）为分块切除；剥离时间19～112 min，平均（65.5±48.3）min；术中出血8例（25.0%），无迟发性出血及穿孔发生，术后住院3～5 d；ESD组（n = 17）病变直径2.0～6.5 cm，平均（4.2±2.2）cm；2处病变位于前壁，10处位于后壁，5处位于小弯侧；所有病变均为一次性切除；剥离时间26～157 min，平均（91.5±26.5）min；术中出血8例（47.1%），术中穿孔2例（11.8%），均给予金属夹夹闭并内科保守治疗取得成功，无迟发性出血和迟发性穿孔发生，术后住院3～6 d。结论 应用注水型电刀行PESD是一种基于贲门解剖结构的创新术式，与常规ESD相比，可有效提高剥离速度，降低并发症发生率，使内镜手术更安全和快捷。

Abstract:

Objective To explore the application value of water-injected mucosal incision (Golden Knife) pushing endoscopic submucosal dissection for large area of early cardiac cancer and precancerous lesions.Methods Patients with early cardiac carcinoma or high-grade intraepithelial neoplasia with the maximum diameter of > 2.0 cm were selected through endoscopic biopsy and magnification staining endoscopy from January 2017 to December 2020, pushing endoscopic submucosal dissection (PESD) was performed with Golden Knife, and patients treated with conventional endoscopic submucosal dissection (ESD) of cardia by the same doctor under ordinary mucosal resection were selected, the peel-away speed of unit area, the rate of complete resection of lesions, and the incidence of complications (postoperative delayed bleeding and perforation) were compared and analyzed between the two groups.Results The diameter of the lesions in the PESD group (n = 32) was 2.0 ~ 8.0 cm, average (5.1 ± 2.9) cm; Of which 1 case was located in the anterior wall, 16 cases were located in the posterior wall, 3 cases were located in the greater curvature, and 12 cases were located in the lesser curvature; 30 cases had a one-time resection, 2 cases (the greater curvature of the cardia) was segmented; The stripping time was 19~112 min, average (65.5 ± 48.3) min. 8 cases had intraoperative bleeding (25.0%), without delay bleeding and perforation, postoperative hospital stay was 3~5 d. ESD group (n = 17) with a diameter of 2.0 ~ 6.5 cm, mean (4.2 ± 2.2) cm; 2 cases were located in the anterior wall, 10 cases were located in the posterior wall, and 5 cases were located in the lesser curvature; All lesions were removed at one time, and the stripping time was 26 ~ 157 min, average (91.5 ± 26.5) min; Eight patients had intraoperative bleeding (47.1%), 2 patients had perforation during surgery (11.8%), all patients were treated with metal clamps and conservative medical treatment was successful. There was no delayed bleeding and delayed perforation, and the postoperative hospital stay was 3 ~ 6 d.Conclusion The application of the Golden Knife to advance endoscopic submucosal dissection is an innovative operation based on the anatomy of the cardia. Compared with conventional ESD, it can effectively improve the rate of stripping and reduce concurrency, the incidence of symptoms makes endoscopic surgery safer and faster.