Kroh M, Hall R, Udomsawaengsup S, Smith A, Yerian L, Chand B
Department of General Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
Surg Endosc. 2008 Nov;22(11):2498-502. doi: 10.1007/s00464-008-9804-4. Epub 2008 Mar 6.
The optimal management of Barrett's esophagus, a precursor to esophageal adenocarcinoma, remains controversial. Current therapy includes surveillance and ablative or resection techniques of varying safety and efficacy. This study aimed to determine the feasibility of a new catheter-based, endoscopic water jet ablation technique.
A high-pressure flexible catheter that can be passed through the working port of a standard gastroscope was used. The catheter had micro-drilled holes on one side near the tip. A 1-cm water jet was delivered under foot pedal control and endoscopic view at pressures adjusted from 150 to 400 psi. After approval from the authors' Institutional Review Board, tissue segments from fresh esophagectomy specimens were ablated by the catheter without use of an endoscope. Using gross appearance and histologic analysis, variable ablation pressures and times were evaluated.
Using variable pressures and times, 11 ablation sessions were performed: 5 for normal esophagus, 4 for normal stomach, and 2 across the gastroesophageal junction in the setting of Barrett's esophagus. Ablation pressures of 150 to 300 psi for 30 to 60 s resulted in selective ablation of mucosa with preservation of the submucosa and muscularis propria. The depth of the ablation was determined by gross inspection at the time of ablation and confirmed by histologic evaluation. There was no embedding of epithelial cells in the muscularis propria. In a single normal esophagus specimen, a jet applied at 400 psi for 120 s in a confined area resulted in gross perforation.
Selective ablation of esophageal and gastric epithelium using a catheter-based water jet ablation technique is feasible. The preliminary data from this study investigating a nonendoscopic technique show that the mucosa can be removed with preservation of the underlying submucosa and muscular layers. Further studies are warranted that focus on defining more precisely the pressure and duration required for optimal results and the practical application of this technique endoscopically.
巴雷特食管是食管腺癌的癌前病变，其最佳治疗方案仍存在争议。目前的治疗方法包括监测以及安全性和有效性各异的消融或切除技术。本研究旨在确定一种新的基于导管的内镜水刀消融技术的可行性。
使用一种可通过标准胃镜工作通道的高压柔性导管。该导管在靠近尖端的一侧有微孔。在脚踏控制和内镜观察下，以150至400磅力/平方英寸的压力输送1厘米的水刀。经作者所在机构审查委员会批准后，在不使用内镜的情况下，用该导管对新鲜食管切除标本的组织切片进行消融。通过大体外观和组织学分析，评估不同的消融压力和时间。
使用不同的压力和时间进行了11次消融操作：5次针对正常食管，4次针对正常胃，2次针对巴雷特食管情况下的胃食管交界处。150至300磅力/平方英寸的消融压力持续30至60秒可导致黏膜选择性消融，同时保留黏膜下层和固有肌层。消融深度在消融时通过大体检查确定，并经组织学评估证实。固有肌层中未发现上皮细胞植入。在一个正常食管标本中，在一个受限区域以400磅力/平方英寸的压力喷射120秒导致了大体穿孔。
使用基于导管的水刀消融技术选择性消融食管和胃上皮是可行的。本研究对一种非内镜技术的初步数据表明，可以在保留其下方黏膜下层和肌层的情况下切除黏膜。有必要开展进一步研究，更精确地确定获得最佳效果所需的压力和持续时间，以及该技术在内镜下的实际应用。
