Barker Kevin B, Arnold Hays L, Fillman Eric P, Palekar Nicole A, Gering Scott A, Parker Allan L
Gastroenterology Service, Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX 78234, USA.
Gastrointest Endosc. 2005 Aug;62(2):224-7. doi: 10.1016/s0016-5107(05)00557-2.
Endoscopic band ligation for bleeding small-bowel vascular lesions has been reported as safe and efficacious based on small case series. There have been several other published case reports of band ligators used for bleeding lesions, usually Dieulafoy's lesions, in the stomach, the proximal small bowel, and the colon. In addition, this method has been used for postpolypectomy bleeding stalks. There has never been a critical look at the anatomic consequences of banding in the thinner sections of bowel.
The purpose of this study is to define the anatomic and histologic consequences of applying band ligator devices to the small and the large bowel. Fresh surgical specimens, both large and small bowel, that were excised because of neoplastic lesions were transported to our endoscopy unit where one end of the intact bowel was sutured shut. A standard upper endoscope was passed via the open end, and the bowel was closed tightly with rubber band ties. The bowel then was insufflated, and band ligators were applied to unaffected mucosa by using a standard technique. Photodocumentation from inside and outside the bowel was obtained. Some of the band polyps were cut above the band, and some were cut below the band in the fresh state. Some were fixed in formalin and examined microscopically. Histologic sectioning occurred at the level of the bands.
The results were striking in that there were large holes (1 cm) in the fresh ileum specimen. There was gross serosal entrapment manifested by visible puckers on the outer surfaces of the specimens, especially in the small bowel and the right colon. The left colon, anatomically thicker, was less affected. The histologic evaluation revealed inclusion by the band ligator of the muscularis propria and serosa on the small bowel, the muscularis propria in the right colon, and the submucosa in the left colon.
Based on these findings, we conclude that band ligator devices are not safe in the small bowel and the right colon but probably are safe in the thicker left colon.
基于小样本病例系列报道，内镜下套扎术治疗小肠血管性病变出血被认为是安全有效的。还有其他几篇关于使用套扎器治疗胃、近端小肠和结肠出血性病变（通常为Dieulafoy病变）的病例报告发表。此外，该方法已用于息肉切除术后出血的蒂部。但从未有人对在较薄肠段进行套扎的解剖学后果进行过批判性研究。
本研究的目的是确定将套扎器应用于小肠和大肠的解剖学和组织学后果。因肿瘤性病变而切除的新鲜手术标本，包括小肠和大肠，被运至我们的内镜室，完整肠段的一端被缝合关闭。通过开放端插入标准上消化道内镜，并用橡皮筋扎紧肠段。然后向肠段内充气，采用标准技术将套扎器应用于未受影响的黏膜。获取肠段内外的照片记录。一些带蒂息肉在新鲜状态下在套扎上方或下方进行切割。一些固定在福尔马林中进行显微镜检查。组织学切片在套扎水平进行。
结果令人震惊，新鲜回肠标本上出现了大的孔洞（1厘米）。标本外表面可见明显褶皱，表现为严重的浆膜嵌入，尤其是在小肠和右结肠。解剖学上较厚的左结肠受影响较小。组织学评估显示，套扎器包绕了小肠的固有肌层和浆膜、右结肠的固有肌层以及左结肠的黏膜下层。
基于这些发现，我们得出结论，套扎器在小肠和右结肠不安全，但在较厚的左结肠可能是安全的。
