Neuhaus H, Costamagna G, Devière J, Fockens P, Ponchon T, Rösch T
Evangelisches Krankenhaus Düsseldorf, Germany.
Endoscopy. 2006 Oct;38(10):1016-23. doi: 10.1055/s-2006-944830.
Endoscopic submucosal dissection (ESD) allows en bloc resection of lesions > 2 cm in diameter. However the procedure is difficult because of limited visualization of the cutting area. The aim of this study was to evaluate a new endoscope (the "R-scope") for ESD; this provides a second flexible section for improved positioning capability and two instrumentation channels for vertical lifting of the targeted mucosal area and horizontal cutting of the submucosa.
The R-scope was tested first for ESD of 17 predetermined gastric areas in eight anesthetized pigs. Clinical experience was then prospectively obtained in 10 patients with early gastric neoplasia. In both instances, dye-stained saline solution was used for repeated submucosal injection. Various types of knives were available for circumferential cutting of the mucosa to isolate the targeted lesion. The specimen was then lifted and the submucosal layer was dissected with the appropriate type of knife to achieve en bloc resection.
ESD succeeded in 14/17 animal cases (82 %), remained incomplete in two cases and failed in one because of an intractable perforation; a further two small perforations were clipped. In 10 patients (with nine early carcinomas and one adenoma, with a median diameter of 22 mm), lesions were completely resected in six cases. Surgery was necessary in two patients due to early and delayed perforation. Three other patients with small amounts of free air were conservatively managed but elective surgery was performed in two of these patients because of incomplete resection or deep submucosal tumor infiltration.
The R-scope facilitated ESD of large gastric areas in live animal testing and in a small series of patients However the procedure is technically demanding and time-consuming. It was also associated with a high risk of perforation; this may be related to an insufficient volume of solution being injected submucosally, excessively forceful lifting of the specimen, or the short learning period.
内镜黏膜下剥离术（ESD）可整块切除直径大于2cm的病变。然而，由于切割区域视野有限，该手术操作困难。本研究旨在评估一种用于ESD的新型内镜（“R-scope”）；它提供了一个额外的可弯曲部分以提高定位能力，以及两个器械通道，用于垂直提起目标黏膜区域和水平切割黏膜下层。
首先在8只麻醉猪的17个预定胃区域进行ESD测试，使用R-scope。然后前瞻性地纳入10例早期胃癌患者以积累临床经验。在这两种情况下，均使用染色盐水溶液进行反复黏膜下注射。可使用各种类型的刀具对黏膜进行环形切割以分离目标病变。然后提起标本，用合适类型的刀具解剖黏膜下层以实现整块切除。
17例动物病例中有14例（82%）ESD成功，2例未完成，1例因顽固性穿孔失败；另有2个小穿孔进行了夹闭处理。10例患者（9例早期癌和1例腺瘤，中位直径22mm）中，6例病变完全切除。2例患者因早期和延迟穿孔需要手术。另外3例有少量游离气体的患者采取保守治疗，但其中2例因切除不完全或黏膜下肿瘤浸润较深而接受了择期手术。
在动物活体测试和一小系列患者中，R-scope有助于大胃区域的ESD。然而，该手术技术要求高且耗时。它还伴有较高的穿孔风险；这可能与黏膜下注射溶液量不足、过度用力提起标本或学习期短有关。
