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早期胃癌的内镜诊断与内镜下粘膜切除术(4)
http://www.100md.com 2003年9月26日 好医生
     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。
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    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。

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