早期胃癌的内镜诊断与内镜下粘膜切除术(4)
注射生理盐水可以使粘膜下层与固有肌层间距离增加、电阻增大，电凝的作用局限于粘膜下层，对穿孔等并发症的发生也有预防作用。
⑵双圈套器息肉切除法
应用双孔道内镜，用电凝器标记病变范围后，沿两个孔道分别置入两个圈套器，用其中一个提起病变，用另一个圈套器套取后电凝切除[18、19]。
⑶高张盐水加肾上腺素注射后分步切除法
应用双孔道内镜，用电凝器标记病变范围后，向病变周边粘膜下注射15～20ml含肾上腺素的高张生理盐水使标记线隆起。沿一个孔道置入高频电切刀，沿标记线外缘切开粘膜至粘膜下层，使拟切除粘膜周边翘起，换用抓取活检钳提起病变，从另一孔道用圈套器套取后电凝切除[20、21]。
⑷应用带帽内镜吸引后切除法
, 百拇医药
应用特制帽附于内镜前端，活检孔预置圈套器。将内镜前端对准病变，用力吸引使病变进入帽内，用圈套器套取后电凝切除[22-24]。
⑸套扎后切除法
用套扎环套扎病变后，在其下方置入圈套器电凝切除[25、26]。
⑹其它改进措施
四点固定法：用小夹子标记病变范围，使电切更容易。
倾斜帽法：带帽内镜帽的边缘较锋利，吸引后直接切除。
3、内镜下粘膜切除术的效果
据Tada-M等对599个病灶的统计结果，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标本每隔2mm连续切片，每张切片水平方向上标本边缘均有至少一个正常腺体、垂直方向上边缘无肿瘤、肿瘤局限于粘膜层内者。在病灶完全切除的421例中，无1例局部复发(0%)，而病灶不完全切除的178例中，有63例局部复发(35.6%)，总局部复发率为10.5%。5年生存率为84.9%，10年生存率为83.5%，与同期外科手术的效果相当(5年生存率和10年生存率分别为90.9%，87.4%)[27]。
, 百拇医药
4、局部复发的预防和处理
局部复发的原因是不完全切除，常见于较大病变、凹陷型病变、病变位于胃底胃体胃角等。对于较难一次切除的病变，可采取分次切除的办法。若已证实为完全切除，可给予局部激光治疗等方法预防局部复发。但非完全切除者不可给予局部激光治疗等，建议再次行粘膜切除术以确定局部病理情况。
若已经发生了局部复发，首选治疗方法仍推荐粘膜切除。多数复发仍局限于粘膜内。不应简单地采取外科手术治疗。有斑痕影响再次内镜下粘膜切除术时，也可考虑激光、射频、光动力等治疗方法。
5、内镜下粘膜切除术的并发症
⑴出血
多发生于术后数天内，也有发生于手术当时者。处理上除制酸、保护粘膜等常规措施外，可内镜下注射1:10000肾上腺素、电凝止血等，与一般溃疡治疗相似。
, 百拇医药
⑵穿孔
穿孔是严重的并发症，重在预防。电凝切除粘膜前，应向粘膜下注入足够的盐水使粘膜层提起。“非提起征”是内镜下粘膜切除术的禁忌症。若行电凝切除时患者感到剧痛，应立即停止以防穿孔。
术中发现穿孔，可立即用夹子夹住穿孔处，辅以禁食、胃肠减压、补液等措施。效果不佳可考虑手术治疗。出血和穿孔为两个最主要的并发症，发生率约为5%。
6、内镜下粘膜切除术术后处理
除制酸、保护粘膜等常规措施外，术后应进行联合活检的术后随访。局部发现癌细胞(由于电凝烧灼可能有部分病例为不完全切除但术后病理切片边缘找不到癌细胞)者可再次行内镜下粘膜切除术。对于年轻患者，可考虑外科手术。
参考文献：
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.
, 百拇医药
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.
, 百拇医药
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.
, 百拇医药 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)
, 百拇医药
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)
, 百拇医药
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.
, 百拇医药
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.100md.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)
, 百拇医药
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)
, 百拇医药
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), 百拇医药(程留芳 李长政 李 闻 范开春)
⑵双圈套器息肉切除法
应用双孔道内镜，用电凝器标记病变范围后，沿两个孔道分别置入两个圈套器，用其中一个提起病变，用另一个圈套器套取后电凝切除[18、19]。
⑶高张盐水加肾上腺素注射后分步切除法
应用双孔道内镜，用电凝器标记病变范围后，向病变周边粘膜下注射15～20ml含肾上腺素的高张生理盐水使标记线隆起。沿一个孔道置入高频电切刀，沿标记线外缘切开粘膜至粘膜下层，使拟切除粘膜周边翘起，换用抓取活检钳提起病变，从另一孔道用圈套器套取后电凝切除[20、21]。
⑷应用带帽内镜吸引后切除法
, 百拇医药
应用特制帽附于内镜前端，活检孔预置圈套器。将内镜前端对准病变，用力吸引使病变进入帽内，用圈套器套取后电凝切除[22-24]。
⑸套扎后切除法
用套扎环套扎病变后，在其下方置入圈套器电凝切除[25、26]。
⑹其它改进措施
四点固定法：用小夹子标记病变范围，使电切更容易。
倾斜帽法：带帽内镜帽的边缘较锋利，吸引后直接切除。
3、内镜下粘膜切除术的效果
据Tada-M等对599个病灶的统计结果，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标本每隔2mm连续切片，每张切片水平方向上标本边缘均有至少一个正常腺体、垂直方向上边缘无肿瘤、肿瘤局限于粘膜层内者。在病灶完全切除的421例中，无1例局部复发(0%)，而病灶不完全切除的178例中，有63例局部复发(35.6%)，总局部复发率为10.5%。5年生存率为84.9%，10年生存率为83.5%，与同期外科手术的效果相当(5年生存率和10年生存率分别为90.9%，87.4%)[27]。
, 百拇医药
4、局部复发的预防和处理
局部复发的原因是不完全切除，常见于较大病变、凹陷型病变、病变位于胃底胃体胃角等。对于较难一次切除的病变，可采取分次切除的办法。若已证实为完全切除，可给予局部激光治疗等方法预防局部复发。但非完全切除者不可给予局部激光治疗等，建议再次行粘膜切除术以确定局部病理情况。
若已经发生了局部复发，首选治疗方法仍推荐粘膜切除。多数复发仍局限于粘膜内。不应简单地采取外科手术治疗。有斑痕影响再次内镜下粘膜切除术时，也可考虑激光、射频、光动力等治疗方法。
5、内镜下粘膜切除术的并发症
⑴出血
多发生于术后数天内，也有发生于手术当时者。处理上除制酸、保护粘膜等常规措施外，可内镜下注射1:10000肾上腺素、电凝止血等，与一般溃疡治疗相似。
, 百拇医药
⑵穿孔
穿孔是严重的并发症，重在预防。电凝切除粘膜前，应向粘膜下注入足够的盐水使粘膜层提起。“非提起征”是内镜下粘膜切除术的禁忌症。若行电凝切除时患者感到剧痛，应立即停止以防穿孔。
术中发现穿孔，可立即用夹子夹住穿孔处，辅以禁食、胃肠减压、补液等措施。效果不佳可考虑手术治疗。出血和穿孔为两个最主要的并发症，发生率约为5%。
6、内镜下粘膜切除术术后处理
除制酸、保护粘膜等常规措施外，术后应进行联合活检的术后随访。局部发现癌细胞(由于电凝烧灼可能有部分病例为不完全切除但术后病理切片边缘找不到癌细胞)者可再次行内镜下粘膜切除术。对于年轻患者，可考虑外科手术。
参考文献：
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.
, 百拇医药
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.
, 百拇医药
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.
, 百拇医药 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)
, 百拇医药
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)
, 百拇医药
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.
, 百拇医药
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.100md.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)
, 百拇医药
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)
, 百拇医药
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), 百拇医药(程留芳 李长政 李 闻 范开春)