早期胃癌的內(nèi)鏡診斷與內(nèi)鏡下粘膜切除術(shù)(4)
注射生理鹽水可以使粘膜下層與固有肌層間距離增加、電阻增大，電凝的作用局限于粘膜下層，對穿孔等并發(fā)癥的發(fā)生也有預(yù)防作用。
⑵雙圈套器息肉切除法
應(yīng)用雙孔道內(nèi)鏡，用電凝器標(biāo)記病變范圍后，沿兩個孔道分別置入兩個圈套器，用其中一個提起病變，用另一個圈套器套取后電凝切除[18、19]。
⑶高張鹽水加腎上腺素注射后分步切除法
應(yīng)用雙孔道內(nèi)鏡，用電凝器標(biāo)記病變范圍后，向病變周邊粘膜下注射15～20ml含腎上腺素的高張生理鹽水使標(biāo)記線隆起。沿一個孔道置入高頻電切刀，沿標(biāo)記線外緣切開粘膜至粘膜下層，使擬切除粘膜周邊翹起，換用抓取活檢鉗提起病變，從另一孔道用圈套器套取后電凝切除[20、21]。
⑷應(yīng)用帶帽內(nèi)鏡吸引后切除法
, 百拇醫(yī)藥
應(yīng)用特制帽附于內(nèi)鏡前端，活檢孔預(yù)置圈套器。將內(nèi)鏡前端對準(zhǔn)病變，用力吸引使病變進入帽內(nèi)，用圈套器套取后電凝切除[22-24]。
⑸套扎后切除法
用套扎環(huán)套扎病變后，在其下方置入圈套器電凝切除[25、26]。
⑹其它改進措施
四點固定法：用小夾子標(biāo)記病變范圍，使電切更容易。
傾斜帽法：帶帽內(nèi)鏡帽的邊緣較鋒利，吸引后直接切除。
3、內(nèi)鏡下粘膜切除術(shù)的效果
據(jù)Tada-M等對599個病灶的統(tǒng)計結(jié)果，421例病灶完全切除(70.3%)，178例病灶不完全切除(29.7%)。完全切除是指切下的標(biāo)本每隔2mm連續(xù)切片，每張切片水平方向上標(biāo)本邊緣均有至少一個正常腺體、垂直方向上邊緣無腫瘤、腫瘤局限于粘膜層內(nèi)者。在病灶完全切除的421例中，無1例局部復(fù)發(fā)(0%)，而病灶不完全切除的178例中，有63例局部復(fù)發(fā)(35.6%)，總局部復(fù)發(fā)率為10.5%。5年生存率為84.9%，10年生存率為83.5%，與同期外科手術(shù)的效果相當(dāng)(5年生存率和10年生存率分別為90.9%，87.4%)[27]。
, 百拇醫(yī)藥
4、局部復(fù)發(fā)的預(yù)防和處理
局部復(fù)發(fā)的原因是不完全切除，常見于較大病變、凹陷型病變、病變位于胃底胃體胃角等。對于較難一次切除的病變，可采取分次切除的辦法。若已證實為完全切除，可給予局部激光治療等方法預(yù)防局部復(fù)發(fā)。但非完全切除者不可給予局部激光治療等，建議再次行粘膜切除術(shù)以確定局部病理情況。
若已經(jīng)發(fā)生了局部復(fù)發(fā)，首選治療方法仍推薦粘膜切除。多數(shù)復(fù)發(fā)仍局限于粘膜內(nèi)。不應(yīng)簡單地采取外科手術(shù)治療。有斑痕影響再次內(nèi)鏡下粘膜切除術(shù)時，也可考慮激光、射頻、光動力等治療方法。
5、內(nèi)鏡下粘膜切除術(shù)的并發(fā)癥
⑴出血
多發(fā)生于術(shù)后數(shù)天內(nèi)，也有發(fā)生于手術(shù)當(dāng)時者。處理上除制酸、保護粘膜等常規(guī)措施外，可內(nèi)鏡下注射1:10000腎上腺素、電凝止血等，與一般潰瘍治療相似。
, 百拇醫(yī)藥
⑵穿孔
穿孔是嚴(yán)重的并發(fā)癥，重在預(yù)防。電凝切除粘膜前，應(yīng)向粘膜下注入足夠的鹽水使粘膜層提起。“非提起征”是內(nèi)鏡下粘膜切除術(shù)的禁忌癥。若行電凝切除時患者感到劇痛，應(yīng)立即停止以防穿孔。
術(shù)中發(fā)現(xiàn)穿孔，可立即用夾子夾住穿孔處，輔以禁食、胃腸減壓、補液等措施。效果不佳可考慮手術(shù)治療。出血和穿孔為兩個最主要的并發(fā)癥，發(fā)生率約為5%。
6、內(nèi)鏡下粘膜切除術(shù)術(shù)后處理
除制酸、保護粘膜等常規(guī)措施外，術(shù)后應(yīng)進行聯(lián)合活檢的術(shù)后隨訪。局部發(fā)現(xiàn)癌細(xì)胞(由于電凝燒灼可能有部分病例為不完全切除但術(shù)后病理切片邊緣找不到癌細(xì)胞)者可再次行內(nèi)鏡下粘膜切除術(shù)。對于年輕患者，可考慮外科手術(shù)。
參考文獻：
1 Mayinger B, Horner P, Jordan M, Gerlach C, Horbach T, Hohenberger W, Hahn EG . Light-induced auto fluorescence spectroscopy for tissue diagnosis of GI lesions. Gastrointest Endosc 2000; 52: 395-400.
, 百拇醫(yī)藥
2 Yao K, Yao T, Matsui T, Iwashita A, Oishi T . Hemoglobin content in intramucosal gastric carcinoma as a marker of histologic differentiation: a clinical application of quantitative electronic endoscopy. Gastrointest Endosc 2000; 52: 241-5.
3.Yoshida S . Endoscopic diagnosis and treatment of early cancer in the alimentary tract. Digestion 1998; 59: 502-8.
4 Tseng LJ, Mo LR, Tio TL, Fresner YT, Jao N, Lin RC, Kuo JY, Chang KK, Wang CH, Wey KC . Video-endoscopic ultrasonography in staging gastric carcinoma. Hepatogastroenterology 2000; 47: 897-900.
, 百拇醫(yī)藥
5 Akahoshi K, Chijiwa Y, Hamada S, Sasaki I, Nawata H, Kabemura T, Yasuda D, Okabe H . Pretreatment staging of endoscopically early gastric cancer with a 15 MHz ultrasound catheter probe. Gastrointest Endosc 1998; 48: 470-6.
6 Giovannini M, Bernardini D, Moutardier V, Monges G, Houvenaeghel G, Seitz JF, Derlpero JR . Endoscopic mucosal resection (EMR): results and prognostic factors in 21 patients. Endoscopy 1999; 31: 698-701.
, 百拇醫(yī)藥 7 Akahoshi K, Chijiiwa Y, Hamada S, Sasaki I, Maruoka A, Kabemura T, Nawata H . Endoscopic ultrasonography: a promising method for assessing the prospects of endoscopic mucosal resection in early gastric cancer. Endoscopy 1997; 29: 614-9.
8 Tada m, Shimada M, Yanai H, et al. New technique of gastric biopsy (in Japanese with English abstract). Stomach Intest 1984; 19: 1107-16.
9 Takekoshi T, Fujii A, Takagi K, et al: (radical endoscopic treatment of early gastric cancer – indication and evaluation of endosopic resection). Gan to Kagaku Ryoho – Jpn J Cancer Chemother 1988; 15(4 ty 2-3); 1449-1459. (Jpn)
, 百拇醫(yī)藥
10 Tajiri H, Mukai T, Yoshida S. et al: (Indications and problems of endoscopic treatment for gastrointestinal tract cancers, with special reference to early gastric cancer). Gan to Kagaku Ryoho – Jpn J Cancer Chemother 1988; 15(4 Pt 2-3): 1429-1434. (Jpn)
11 Ohshiba S, Ashida K, Tanaka M, et al: (Curative endoscopic resection of early gastric cancer: the possibility of extending its indications), Stomach Intestine 1993; 28: 1421-1142.(Jpn)
, 百拇醫(yī)藥
12 Amano Y, Ishihara S, Amano K, Hirakawa K, Adachi K, Fukuda R, Watanabe M, Fukumoto S, Fujishiro H, Imaoka T . An assessment of local curability of endoscopic surgery in early gastric cancer without satisfaction of current therapeutic indications. Endoscopy 1998; 30: 548-52.
13 Yamazaki H, Oshima A, Murakami t, Endoh S, et al. A long term follow – up study of patients with gastric cancer detected by mass screening. Cancer 1989; 63:613-7.
, 百拇醫(yī)藥
14 Kaneko E. Nakamura T, Umeda N, Fujino M, et al. Outcome of gastric carcinoma detected by gastric mass survey in Japan. Gut 1977; 18:626-30.
15 Tada M. Yanai H. Arima K. et al. (New technique of gastric biopsy). Stomach Intestine 1984: 19: 1107-1116. (Jpn)
16 Tada M, Murata M, Murakami F, et al. (Development of the strip-off biopsy). Gastoenterol Endosc 1984; 26:833-839). (Jpn)
17 Tada M, Strip biopsy method. In NakamuraK (ed): (Endoscopic treatment of gastric and esophageal cancer.) (Practical Gastroenterology 15). Tokyo: Bunkodo: 1998. P. 57.(Jpn)
, http://www.www.srpcoatings.com
18 Takekoshi T, Takagi K, Fujii A, et al. (The treatment of early gastric cancer by endoscopic double snare polypectomy (EDSP)). Gan no Rinsho – Jpn J Cancer Clin 1`986; 32: 1185-1190. (Jpn)
19 Sakai T, Takekoshi T, Kaku S. et al. (Endoscopic treatment of gastric and esophageal cancer). (Practical Gastroenteroloty 15). TOKYO: Bunkodo; 1998. P. 62-68. (Jpn)
20 Hirao M, Kobayashi T, Hase Y, et al: Endoscopic resection of early gastric carcinomas and other gastric lesions with malignant potential). Gastroenterol Endosc 1983; 25: 1942-1953. (Jpn)
, 百拇醫(yī)藥
21 Hirao M, et al: (ERHSE method). In Makuuchi H (ed): “Endoscopic mucosal resection for esophageal and gastric cancer: a challenge to its limitations.” Tokyo: Japan Medical Center; 1997; p. 147. (Jpn)
22 Inoue H, Endo M, Takeshita K, et al: (Endoscopic esophageal mucosal resection using a cap – fitted panendoscope (EMRC)). Gastroenterol Endosc 1992; 34: 2387-2391. (Jpn)
23 Inoue H, Noguchi O, Saito N, et al. (Endoscopic mucosectomy for early cancer using a pre- looped plastic cap). Gastrointest Endosc 1994; 40: 263-264. (Jpn)
, 百拇醫(yī)藥
24 Takeshita K: (EMRC method). In Nakamura K (ed): “Endoscopic treatment of gastric and esophageal cancer.”(Practical Gastroenterology 15). Tokyo: Bunkodo; 1998. P. 175. (Jpn)
25 Inatsuchi S, Tanaka M: (Clinical evaluation of an improved technique in strip biopsy for gastric lesion). Gastroenterol Endosc 1994; 36: 939-948. (Jpn)
26 Inatsuchi S, Tanaka M: (Safer and more reliable endoscopic mucosal resection by the four-points fixation method in the treatment of early gastric cancer). Endoscopia Digestiva 1996; 8: 499-507. (Jpn)
27 Tada M: “Endoscopic treatment in the stomach: the practice of strip biopsy”. Tokyo: Igaku-Shoin; 1998. P. 61-87. (Jpn), 百拇醫(yī)藥(程留芳 李長政 李 聞 范開春)
⑵雙圈套器息肉切除法
應(yīng)用雙孔道內(nèi)鏡，用電凝器標(biāo)記病變范圍后，沿兩個孔道分別置入兩個圈套器，用其中一個提起病變，用另一個圈套器套取后電凝切除[18、19]。
⑶高張鹽水加腎上腺素注射后分步切除法
應(yīng)用雙孔道內(nèi)鏡，用電凝器標(biāo)記病變范圍后，向病變周邊粘膜下注射15～20ml含腎上腺素的高張生理鹽水使標(biāo)記線隆起。沿一個孔道置入高頻電切刀，沿標(biāo)記線外緣切開粘膜至粘膜下層，使擬切除粘膜周邊翹起，換用抓取活檢鉗提起病變，從另一孔道用圈套器套取后電凝切除[20、21]。
⑷應(yīng)用帶帽內(nèi)鏡吸引后切除法
, 百拇醫(yī)藥
應(yīng)用特制帽附于內(nèi)鏡前端，活檢孔預(yù)置圈套器。將內(nèi)鏡前端對準(zhǔn)病變，用力吸引使病變進入帽內(nèi)，用圈套器套取后電凝切除[22-24]。
⑸套扎后切除法
用套扎環(huán)套扎病變后，在其下方置入圈套器電凝切除[25、26]。
⑹其它改進措施
四點固定法：用小夾子標(biāo)記病變范圍，使電切更容易。
傾斜帽法：帶帽內(nèi)鏡帽的邊緣較鋒利，吸引后直接切除。
3、內(nèi)鏡下粘膜切除術(shù)的效果
據(jù)Tada-M等對599個病灶的統(tǒng)計結(jié)果，421例病灶完全切除(70.3%)，178例病灶不完全切除(29.7%)。完全切除是指切下的標(biāo)本每隔2mm連續(xù)切片，每張切片水平方向上標(biāo)本邊緣均有至少一個正常腺體、垂直方向上邊緣無腫瘤、腫瘤局限于粘膜層內(nèi)者。在病灶完全切除的421例中，無1例局部復(fù)發(fā)(0%)，而病灶不完全切除的178例中，有63例局部復(fù)發(fā)(35.6%)，總局部復(fù)發(fā)率為10.5%。5年生存率為84.9%，10年生存率為83.5%，與同期外科手術(shù)的效果相當(dāng)(5年生存率和10年生存率分別為90.9%，87.4%)[27]。
, 百拇醫(yī)藥
4、局部復(fù)發(fā)的預(yù)防和處理
局部復(fù)發(fā)的原因是不完全切除，常見于較大病變、凹陷型病變、病變位于胃底胃體胃角等。對于較難一次切除的病變，可采取分次切除的辦法。若已證實為完全切除，可給予局部激光治療等方法預(yù)防局部復(fù)發(fā)。但非完全切除者不可給予局部激光治療等，建議再次行粘膜切除術(shù)以確定局部病理情況。
若已經(jīng)發(fā)生了局部復(fù)發(fā)，首選治療方法仍推薦粘膜切除。多數(shù)復(fù)發(fā)仍局限于粘膜內(nèi)。不應(yīng)簡單地采取外科手術(shù)治療。有斑痕影響再次內(nèi)鏡下粘膜切除術(shù)時，也可考慮激光、射頻、光動力等治療方法。
5、內(nèi)鏡下粘膜切除術(shù)的并發(fā)癥
⑴出血
多發(fā)生于術(shù)后數(shù)天內(nèi)，也有發(fā)生于手術(shù)當(dāng)時者。處理上除制酸、保護粘膜等常規(guī)措施外，可內(nèi)鏡下注射1:10000腎上腺素、電凝止血等，與一般潰瘍治療相似。
, 百拇醫(yī)藥
⑵穿孔
穿孔是嚴(yán)重的并發(fā)癥，重在預(yù)防。電凝切除粘膜前，應(yīng)向粘膜下注入足夠的鹽水使粘膜層提起。“非提起征”是內(nèi)鏡下粘膜切除術(shù)的禁忌癥。若行電凝切除時患者感到劇痛，應(yīng)立即停止以防穿孔。
術(shù)中發(fā)現(xiàn)穿孔，可立即用夾子夾住穿孔處，輔以禁食、胃腸減壓、補液等措施。效果不佳可考慮手術(shù)治療。出血和穿孔為兩個最主要的并發(fā)癥，發(fā)生率約為5%。
6、內(nèi)鏡下粘膜切除術(shù)術(shù)后處理
除制酸、保護粘膜等常規(guī)措施外，術(shù)后應(yīng)進行聯(lián)合活檢的術(shù)后隨訪。局部發(fā)現(xiàn)癌細(xì)胞(由于電凝燒灼可能有部分病例為不完全切除但術(shù)后病理切片邊緣找不到癌細(xì)胞)者可再次行內(nèi)鏡下粘膜切除術(shù)。對于年輕患者，可考慮外科手術(shù)。
參考文獻：
1 Mayinger B, Horner P, Jordan M, Gerlach C, Horbach T, Hohenberger W, Hahn EG . Light-induced auto fluorescence spectroscopy for tissue diagnosis of GI lesions. Gastrointest Endosc 2000; 52: 395-400.
, 百拇醫(yī)藥
2 Yao K, Yao T, Matsui T, Iwashita A, Oishi T . Hemoglobin content in intramucosal gastric carcinoma as a marker of histologic differentiation: a clinical application of quantitative electronic endoscopy. Gastrointest Endosc 2000; 52: 241-5.
3.Yoshida S . Endoscopic diagnosis and treatment of early cancer in the alimentary tract. Digestion 1998; 59: 502-8.
4 Tseng LJ, Mo LR, Tio TL, Fresner YT, Jao N, Lin RC, Kuo JY, Chang KK, Wang CH, Wey KC . Video-endoscopic ultrasonography in staging gastric carcinoma. Hepatogastroenterology 2000; 47: 897-900.
, 百拇醫(yī)藥
5 Akahoshi K, Chijiwa Y, Hamada S, Sasaki I, Nawata H, Kabemura T, Yasuda D, Okabe H . Pretreatment staging of endoscopically early gastric cancer with a 15 MHz ultrasound catheter probe. Gastrointest Endosc 1998; 48: 470-6.
6 Giovannini M, Bernardini D, Moutardier V, Monges G, Houvenaeghel G, Seitz JF, Derlpero JR . Endoscopic mucosal resection (EMR): results and prognostic factors in 21 patients. Endoscopy 1999; 31: 698-701.
, 百拇醫(yī)藥 7 Akahoshi K, Chijiiwa Y, Hamada S, Sasaki I, Maruoka A, Kabemura T, Nawata H . Endoscopic ultrasonography: a promising method for assessing the prospects of endoscopic mucosal resection in early gastric cancer. Endoscopy 1997; 29: 614-9.
8 Tada m, Shimada M, Yanai H, et al. New technique of gastric biopsy (in Japanese with English abstract). Stomach Intest 1984; 19: 1107-16.
9 Takekoshi T, Fujii A, Takagi K, et al: (radical endoscopic treatment of early gastric cancer – indication and evaluation of endosopic resection). Gan to Kagaku Ryoho – Jpn J Cancer Chemother 1988; 15(4 ty 2-3); 1449-1459. (Jpn)
, 百拇醫(yī)藥
10 Tajiri H, Mukai T, Yoshida S. et al: (Indications and problems of endoscopic treatment for gastrointestinal tract cancers, with special reference to early gastric cancer). Gan to Kagaku Ryoho – Jpn J Cancer Chemother 1988; 15(4 Pt 2-3): 1429-1434. (Jpn)
11 Ohshiba S, Ashida K, Tanaka M, et al: (Curative endoscopic resection of early gastric cancer: the possibility of extending its indications), Stomach Intestine 1993; 28: 1421-1142.(Jpn)
, 百拇醫(yī)藥
12 Amano Y, Ishihara S, Amano K, Hirakawa K, Adachi K, Fukuda R, Watanabe M, Fukumoto S, Fujishiro H, Imaoka T . An assessment of local curability of endoscopic surgery in early gastric cancer without satisfaction of current therapeutic indications. Endoscopy 1998; 30: 548-52.
13 Yamazaki H, Oshima A, Murakami t, Endoh S, et al. A long term follow – up study of patients with gastric cancer detected by mass screening. Cancer 1989; 63:613-7.
, 百拇醫(yī)藥
14 Kaneko E. Nakamura T, Umeda N, Fujino M, et al. Outcome of gastric carcinoma detected by gastric mass survey in Japan. Gut 1977; 18:626-30.
15 Tada M. Yanai H. Arima K. et al. (New technique of gastric biopsy). Stomach Intestine 1984: 19: 1107-1116. (Jpn)
16 Tada M, Murata M, Murakami F, et al. (Development of the strip-off biopsy). Gastoenterol Endosc 1984; 26:833-839). (Jpn)
17 Tada M, Strip biopsy method. In NakamuraK (ed): (Endoscopic treatment of gastric and esophageal cancer.) (Practical Gastroenterology 15). Tokyo: Bunkodo: 1998. P. 57.(Jpn)
, http://www.www.srpcoatings.com
18 Takekoshi T, Takagi K, Fujii A, et al. (The treatment of early gastric cancer by endoscopic double snare polypectomy (EDSP)). Gan no Rinsho – Jpn J Cancer Clin 1`986; 32: 1185-1190. (Jpn)
19 Sakai T, Takekoshi T, Kaku S. et al. (Endoscopic treatment of gastric and esophageal cancer). (Practical Gastroenteroloty 15). TOKYO: Bunkodo; 1998. P. 62-68. (Jpn)
20 Hirao M, Kobayashi T, Hase Y, et al: Endoscopic resection of early gastric carcinomas and other gastric lesions with malignant potential). Gastroenterol Endosc 1983; 25: 1942-1953. (Jpn)
, 百拇醫(yī)藥
21 Hirao M, et al: (ERHSE method). In Makuuchi H (ed): “Endoscopic mucosal resection for esophageal and gastric cancer: a challenge to its limitations.” Tokyo: Japan Medical Center; 1997; p. 147. (Jpn)
22 Inoue H, Endo M, Takeshita K, et al: (Endoscopic esophageal mucosal resection using a cap – fitted panendoscope (EMRC)). Gastroenterol Endosc 1992; 34: 2387-2391. (Jpn)
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