内镜下ESD及射频消融治疗食管及结肠病变

2019-12-02 小早 早诊早治与健康

内镜下ESD及射频消融治疗食管及结肠病变

No.1
 武威肿瘤医院



内镜所见:

退镜至距肛门缘约为16~17cm乙状结肠、13~15cm结肠可见2处宽基息肉样病变,病变表面黏膜充血、粗糙,NBI+ME示病变表面血管Sano分型以II型为主,结晶紫+ME示病变表面腺管Kudo分型以III型及IV型为主。

超声内镜检查示:

乙状结肠及直肠病变处肠壁增厚,以肠壁的黏膜层增厚为主,病变处黏膜下层、固有肌层及浆膜层尚清晰、连续、完整。所见探查范围内未见明确肿大淋巴结。 

内镜诊断

乙状结肠、直肠宽基息肉样变(性质待病理,距肛门缘约为16~17cm、13~15cm),局灶警惕癌变,病变主要位于肠壁的黏膜层,建议内镜下治疗。

心得体会:

该患者结肠宽基息肉样病变,结晶紫+ME示病变表面腺管Kudo分型以III型及IV型为主。色素内镜是指内镜下喷洒化学染色剂使正常组织与病变黏膜对比度增强,使病变表面形态及边界更为清晰,从而使普通内镜难以观察到的病变更易于识别,提高病变的发现率及活检的准确率。

其中,结晶紫染色的的两个应用范围:术后黏膜ESD标本观察腺体和术前肠道ESD观察腺体的分型。一般在怀疑恶性侵袭性病变时进行结晶紫染色。

染色的机制,它是一种吸收型的染料,使上皮细胞的细胞质,而不是细胞核发生着色,而肿瘤的表面上皮以及腺体破坏导致固有层和黏膜下层的间质开始显露,所以肿瘤部分并不显示。染色方法:在病变表面滴数滴进行染色,切勿喷酒,然后用温水或链霉蛋白酶冲洗。



内镜所见: 

距门齿约为26cm6-9点位食管可见一浅表平坦型病变(0-IIb型),病变表面黏膜充血、粗糙、覆以白斑,NBI+放大示局部可见B1型IPCL。

在向患者及家属交代病情后,患者及家属要求行经电子内镜食管黏膜(下)剥离术(ESD),在病变外缘0.5cm进行标记,应用25G注射针于病变基底部行黏膜下注射1∶4透明脂酸钠,病变抬举良好,于标记外0.5cm进行预切开,沿黏膜下层进行剥离,术中可见少量出血,应用热活检钳电凝止血,剥离后创面未见穿孔及出血,剥离顺利结束。

剥离后应用热活检钳处理创面,观察10min后创面无血及活动性出血。余食管黏膜粗糙,碘染色可见散在阳性灶。在向患者家属交代病情并征得其同意后,应用HAL090行内镜下射频消融治疗,治疗方案12J/cm2*3次,治疗顺利,治疗后未见明显出血、穿孔等。治疗后行内镜下管置入,胃管置入顺利。治疗结束后安全送病人返至病房。

内镜诊断

1.食管浅表平坦型病变(性质待病理),行经电子内镜食管黏膜(下)剥离术(ESD),术中合并出血,行内镜下止血处置术。

2.余食管散在碘染色阳性,行内镜下射频消融治疗术(RFA)。

3.内镜下胃管植入。

4.建议禁食水4天,卧床体息5天,密切观察病情,对症治疗,待术后病理回报后门诊随访。

心得体会:

对于早期食管癌的患者,我们首选ESD治疗,但对于碘染色后呈虎皮样改变的患者,由于病变范围较广,不可能把病变黏膜全部剥离,一般我们选择密切随访,必要时再次行ESD治疗。本次看了带教老师RFA的治疗过程后,查阅了RFA的相关资料,对于RFA有了一个基本的了解。

射频消融术 (radiofrequency ablation, RFA) 利用电磁波的热效应发挥治疗作用,使组织脱水、干燥和凝固坏死从而达到治疗目的,在多发、病变较长或累及食管全周的早期食管癌及其癌前病变的治疗中具有明显的优势,作用均匀且其治疗的深度控制在1000μm左右,降低了穿孔和术后狭窄的发生率。

初步研究结果显示,RFA可用于Ⅱb型病变,且治疗前活检证实为食管鳞状上皮细胞中度异型增生和 ( 或 ) 重度异型增生及局限于M2层的中 - 高分化鳞癌。符合条件的早期食管鳞癌及其癌前病变RFA术后12个月完全缓解率可达97%。但RFA对早期平坦食管鳞癌疗效的大样本量研究尚缺乏,长期疗效需进一步验证。

环周型消融系统多应用于多发、延伸较长或环周病变的治疗, 治疗过程包括记录消融位置、测量食管内径、置入消融导管进行消融等步骤, 依据病变及第一次消融情况,可在清除已消融病变黏膜后行第二次消融,局灶型消融系统则多应用于局灶性病变及术后残余灶的处理,无需经过测量步骤。

该患者早期食管癌行内镜下ESD治疗,但检查过程中发现食管碘染后呈虎皮样改变,病变部位较广泛且病变程度较轻(低级别上皮内瘤变),故选择RFA治疗。 

No.2
甘肃省肿瘤医院



内镜所见:

寻腔进镜至回盲部,沿回肠瓣进入回肠远端约15cm,未见明显异常。部分肠腔可见大量宿便,无法清楚检查。距肛缘约为40~50cm结肠全周可见一不规则隆起肿物,肿物基底宽基无活动性,肿物表面黏膜粗糙、糜烂,肿物质脆易出血(活检6块),肿物处肠腔偏心性狭窄,内镜通过困难但尚可通过。

结肠可见多发息肉,最大者约1.5cm×1.2cm(于回盲部活检一块)。距肛缘约7~10cm直肠可见一大小约为3.5X3.0cm大小侧向发育型肿瘤(LST),非颗粒型,表面粘膜凹陷且粘膜充血、糜烂伴糜烂(活检4块),NBI+ME染色示JNET分型为2B+3型。

工藤分型为Vi+Vn型为主。直肠黏膜充血、略粗糙。余所见结肠黏膜光滑、完整且血管网清晰。肛管可见一宽基息肉样病变,表面光滑且完整,活动性尚可(家属要求暂不取活检)。

肠镜诊断:

1.结肠癌(性质待病理,距肛缘约40~50cm)。

2.直肠侧向发育型肿瘤(性质待病理,距肛缘约7~10cm,LST-NG-PD),考虑为腺瘤癌变,建议超声内镜检查。

3.肛管宽基息肉样病变,建议超声内镜及内镜下治疗。

4.结肠多发息肉(性质待病理),建议择期内镜下治疗。

5.部分肠腔内大量粪便,建议充分准备后再次肠镜检查。

超声肠镜:

距肛缘约7~10cm直肠可见一大小约为3.5cm×3.0cm大小侧向发育型肿瘤(LST),非颗粒型,表面黏膜凹陷、充血伴糜烂。NBI+ME染色示JNET分型为2B+3型。

工藤分型为Vi+Vn型为主。病变处(7~10cm)肠壁增厚,主要以肠壁的黏膜层及黏膜下层为主,最厚处约为0.43cm,部分层次与固有肌层关系密切,病变处肠壁的外膜清晰、完整、连续。病变周围未见肿大淋巴结。

肛管可见一宽基息肉样病变,表面光滑且完整,活动性尚可。超声示病变处肠壁内可见一中等偏高回声占位,病变主要来源于肠壁的黏膜层,病变处肠壁的黏膜下层、固有肌层及外膜清晰、连续、完整。病变处肠壁周围未见明显肿大的淋巴结。

超声内镜诊断:

1.直肠侧向发育型肿瘤,病变主要位于黏膜层及黏膜下层,警惕侵及黏膜下层,建议外科会诊。

2.肛管宽基息肉样病变,考虑为早期癌或癌前病变,病变主要位于肠壁的黏膜层,建议内镜下治疗。

心得体会:

这是一个结肠癌(距肛缘40~50cm)+直肠侧向发育型肿瘤(LST)(距肛缘7~10cm)+肛管癌前病变+结肠多发息肉的患者,病变较为复杂,多余不同部位的病变需要区别对待。直肠病变及肛管病变都主要局限于管壁的黏膜层,是内镜下黏膜剥离术的适应证。

结肠侧向发育型肿瘤(LST)是指起源于结直肠黏膜的一类隆起型病变,这类病变极少向肠壁垂直侵犯,主要位于黏膜表面呈侧向浅表扩散,故称侧向发育型肿瘤。

按其形态特征区分为两大类:颗粒型(LST-G)和非颗粒型(LST-NG)。颗粒型根据有无大的结节又分为颗粒均一型(LST-G-H)和结节混合型(LST-G-M)。非颗粒型又根据病变表面有无凹陷,分为扁平隆起型(LST-NG-F)及假凹陷型(LST-NG-PD)。

与颗粒型侧向发育型肿瘤(LST-G)相比非颗粒型侧向发育型肿瘤(LST-NG)有更高的黏膜下浸润的概率。在大约30%的病灶中,由于多中心生长,很难鉴别病灶的侵犯深度。

对于肠道肿物,熟练掌握分型可较好地把握病变,对病变性质及浸润深度做出初步判断。





内镜报告:

距门齿约为30~32cm5-7点位食管可见一表浅平坦型病变(0-IIb型),病变表面黏膜充血、粗糙、发红,NBI+ME示IPCL分型为B1型,局部区域呈B2型,病变处碘染色呈阳性(活检两块)。

余食管黏膜粗糙,碘染未见明显异常。食管胃交界线距门齿约为40cm,贲门、胃底及胃体未见明显异常。胃窦部黏膜充血,幽门水肿。所见十二指肠球部及降部未见明显异常。

内镜诊断:

食管浅表平坦型病变(性质待病理,距门齿约30~32cm),考虑为早期食管癌或癌前病变,建议我院超声内镜检查并行内镜下治疗。

超声内镜:

距门齿约为30~32cm5-7点位食管可见一表浅平坦型病变(0-IIb型),病变表面黏膜充血、粗糙、发红。病变处食管壁增厚,主要以食管壁的黏膜层增厚为主,最厚处约为0.18cm,病变处食管壁的黏膜下层、固有肌层及外膜清晰、连续、完整。

超声内镜诊断:

早期食管癌或癌前病变(距门齿约30~32cm),病变处主要位于黏膜层,可考虑内镜下治疗。

心得体会:

该患者病变主要位于食管中部,术前NBI+放大可见B1型血管及少量B2型血管。超声内镜示病变主要位于黏膜层,余层次结构清晰,是内镜下黏膜剥离术的绝对适应证。

但食管管壁较薄,操作时容易发生穿孔的风险,需要充分的预切开及黏膜下注射,使得术中暴露较好的视野,黏膜下剥离时遇到血管需要提前判断血管的走形进行电凝处理,以免出血后影响视野增加手术时长。

术前需对手术的操作有大致的规划,先切低位侧、容易积水的一侧,由口侧向肛侧推进式的预切开,处理出血后再进行1-2次的深度预切开,使得黏膜下层被充分的切开。

再雷同切开相对较高位后,由口侧补充注射“水垫”,打开“天使之窗”后由口侧向肛侧进行V字型剥离,术中注意穿支血管,遇到较粗的血管在剥离清晰较粗血管周围的黏膜下组织后,应用热活检钳凝断血管后再行剥离。

No.3
山丹县人民医院



内镜所见:

距约门齿38cm4-5点位食管可见一大小约l.0cm×l.0cm局限性隆起,隆起宽基无活动性,隆起处表面黏膜光滑、完整,质软。食管胃交界线距门齿约为40cm。贲门、胃底及胃体未见明显异常,胃窦部黏膜充血、水肿、略粗糙,幽门充血、水肿。所见十二指肠球部及降部未见明显异常。

内镜诊断:

1.食管局限性隆起(距门齿约为38cm),考虑为食管壁内占位,囊肿?

2.慢性非萎缩性胃炎,以胃窦为著,建议追踪随访。

超声内镜:

距约门齿38cm4-5点位食管可见一大小约1.0cm×1.0cm局限性隆起,隆起宽基无活动性,隆起处表面黏膜光滑、完整,质软。

超声内镜检査示:

隆起处食管壁内可见一横截面枳大小均6.9mm×3.5mm的无回声区域,回声均匀,边界清楚,主要起源于食管壁的黏膜层,隆起处食管壁的黏膜下层、固有肌层及外膜层清晰、连续、完整。隆起处食管壁周围未见明显肿大的淋巴结。

超声诊断:

食管壁局限性隆起(距门齿约38cm),隆起处食管壁内无回声区域,考虑食管壁内囊肿,主要来源于食管壁内的黏膜层,建议追踪随访。

心得体会:

本例患者内镜检查后发现食管下段见一宽基无活动性及质软的局限性隆起,行超声内镜后为无回声区域,回声均匀,边界清楚,诊断为食管囊肿。食管囊肿患者无明显症状,经上消化道内镜检查偶然发现。

食管囊肿(前肠囊肿)起源于胚胎期前肠的残存组织,是食管良性肿瘤之一,发生率仅次于食管平滑肌瘤与食管息肉。可分为3类:重复畸形囊肿、包涵囊肿、潴留囊肿。

前2种是先天性的,与胚胎期脱落的前肠细胞于食管壁内生长而形成,第三种是后天形成,与慢性食管炎有关,可为食管壁内腺体腺管阻塞致分泌液排出不畅,聚集而成,多位于食管上段,起源于食管黏膜下层,形成上覆正常食管黏膜的凸向管腔内的囊肿。食管囊肿可发生于任何年龄,以儿童和青少年多见。

临床表现取决于囊肿的大小及部位;小的食管囊肿没有任何症状,较大的食管囊肿在成人中多表现为食管受压、梗阻或呼吸道受压的表现。食管囊肿需与食管平滑肌瘤、食管外压性病变相鉴别。胃镜根据肉眼观察及活检钳触之的感觉可大致分辨出病变的质地、活动度。

应用超出内镜检查对消化道内壁的层次结构及隆起型病变的起源有很大的优势。超声内镜(EUS)可判断该病变是来源于黏膜下、肌层,还是食管外,并根据回声不同进行鉴别。

要注意的是食管囊肿和食管静脉瘤在超声内镜下的表现一样,再通过彩色多普勒超声进行分析,可显示出静脉瘤内的血流信号,且后者在内镜中多表现为表面紫蓝色改变,若是食管静脉瘤则不适宜行射频治疗、穿刺引流术等。

对于食管囊肿的治疗,内镜下治疗及外科手术是较为常用的方法,且预后良好。内镜下食管囊肿剥离术、射频消融术是治疗较小的食管囊肿(<2.5cm)的可行方法。

射频消融治疗来源于黏膜下的食管囊肿,治疗后食管囊肿囊壁均完全破坏,极少出现出血、穿孔等严重并发症;内镜下食管囊肿剥离术(ESD)可完整切除病变。

对于较大的食管囊肿(>2.5cm),或其临近重要的脏器、血管、气管,行剥离术风险较大时,亦可在囊肿的表面做一大小适中的切口,使囊液引流通畅,缓解患者症状,虽安全但较易复发。

本例患者结合胃镜及超声检查明确诊断为食管囊肿。结合患者的囊肿部位及大小,可建议患者行内镜下囊肿剥离术或射频消融治疗。





内镜所见:

距门齿约为25cm5-6点位食管可见一大小约 0.8cm×0.6cm的表浅平坦型病变(O-IIb型),病变表面黏膜粗糙、发白,NBI+放大示IPCL呈TypeR型血管,病变处碘染色过染(患者家属要求不取活检)。

余食管黏膜粗糙, 碘染色后距门齿约为21cm6点位及30cm12点位可见碘染色阳性灶(各活检1块)。食管胃交界线距门齿约为40cm,距门 齿42cm贲门局部黏膜充血、粗糙(活检1块)。

胃底未见明显异常。胃窦、骨角至胃体小弯侧黏膜平薄、粗糙,略充血水肿,幽门水肿。所见十二指肠降部十二指肠乳头远端见一直径大小约0.5cm局限性隆起,表面黏膜光滑、完整,质软。余所见十二指肠球部及乳头未见异常。

内镜诊断:

1.食管浅表平坦型病变(距门齿约为25cm),考虑为早期食管癌,建议行内镜下治疗。

2.食管黏膜碘染色阳性灶(性质待病理,距门齿约21cm、30cm),建议内镜下射频治疗。

3.贲门局部黏膜充血、粗糙(性质待病理)。

4.慢性萎缩性胃炎(C-2)。

5.十二指肠降部局限性隆起,考虑为囊肿,建议追踪随访。

超声内镜:

距门齿约为25cm5-6点位食管可见一大小约0. 8cm×0. 6cm的表浅平坦型病变(0-IIb型),病变表面黏膜粗糙、发白,NBI+放大示IPCL呈TypeR型血管,病变处碘染色过染。

超声内镜检査示:

病变处食管壁增厚,主要以食管壁的黏膜层増厚为主,最厚处约为0.19cm,病变处食管壁的黏膜下层、固有肌层及外膜层清晰、连续、完整。病变处食管周围未见明显肿大的淋巴结。

超声诊断:

食管表浅平坦型病变(O-IIb,距门齿约25cm),考虑早期食管癌,病变主要位于食管的黏膜层,建议行内镜下治疗。

心得体会:

该患者经内镜检查后内镜下诊断早期食管癌并行ESD治疗,碘染色阳性灶给予射频消融治疗。目前我国比较公认的早期食管癌的定义是侵犯食管黏膜层及黏膜下层,无淋巴结转移的食管癌。而食管上皮内瘤变称为食管癌前病变,存在恶变的可能。

目前,消化内镜为早期食管癌及癌前病变的主要诊断方法,日本食管疾病学会将食管癌的内镜下分型分为3型,分别是I 型(隆起型)、Ⅱ型(平坦型)、Ⅲ型(凹陷型),其中把Ⅱ型(平坦型)又分为II a(浅表隆起型)、IIb(浅表平坦型)、II c(浅表凹陷型)。

近年来,消化内镜发展迅速,不仅作为检查手段,并且可进行内镜下微创治疗,逐渐取代外科手术,成为早期食管癌及癌前病变治疗的主要手段。

1.内镜黏膜切除术(EMR):食管EMR的绝对适应证为不超过黏膜肌层,范围<2/3周,目前EMR主要方法有注射后切除、注射抬举后切除、透明帽辅助内镜黏膜切除、套扎辅助内镜黏膜切除、黏膜多次分片切除等,临床目前以透明帽辅助内镜黏膜切除和套扎辅助内镜黏膜切除为最常用。EMR主要合并症为出血、穿孔。

2.内镜黏膜下剥离术(ESD):在早期食管癌中ESD的适应证:超过1.5 cm食管高级别瘤变;病变浸润深度局限为M1、M2、M3或SM1,且未侵犯血管及淋巴管的高、中分化鳞癌;Barrett食管伴有不典型增生及癌变;对于不能耐受或拒绝手术的高龄患者,浸润深度超过SM或低分化食管癌进行姑息性治疗。

ESD主要操作步骤分为病变标记、黏膜下注射、环形切开、黏膜下剥离以及创面的处理。其主要的术中合并症为出血、穿孔,术后常见合并症为感染、穿孔、出血以及食管狭窄。

3.射频治疗(RFA)主要是通过消融导管发射的电磁波的热能作用到病灶黏膜,是黏膜组织变性、坏死,从而治疗早期食管癌及癌前病变。其主要优势可用于治疗范围较大或累及食管全周、多发的病灶。并且因为其热能治疗深度无法达到黏膜下层,减少了穿孔及术后食管狭窄的发生。临床试验显示,RFA治疗Barrett食管根除率可达90%,术后3年随访,根治率仍达到85%。

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    2020-04-29 crystal0562
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    2019-12-04 zhouqu_8
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