Department of Gastroenterology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Japan.
Gastric Cancer. 2011 Oct;14(4):378-84. doi: 10.1007/s10120-011-0065-x. Epub 2011 Jun 14.
Early gastric cancer located from the pyloric ring to inside the duodenal bulb (DB) is not easily treated by endoscopic submucosal dissection (ESD). The endoscope needs to be reversed inside the DB to set the resection line at a safe distance from the anal side. Because of the space limitations and limited flexibility of conventional endoscopy (CE), there have been increasing possibilities of complications. Here we report a new ESD technique using a transnasal endoscope (TN-E) that is reversed inside the DB.
The subjects were 5 patients with early gastric cancer or adenoma, at locations ranging from the pyloric ring to inside the DB, who were all treated by ESD. We compared results in these patients (TN-E group) with results in five patients with similar disease characteristics who were treated by ESD before July 2008, when the TN-E treatment method was introduced (CE group). In the TN-E group, after marking by CE, we switched the endoscope to the TN-E, and performed the reversing procedure inside the DB, and cut the anal side of the lesion in a semicircle. We switched back to CE to dissect the remaining half on the oral side. We compared the average resection time, en-bloc resection rate, and safety margin between the TN-E and CE groups.
Reversing inside the DB and the anal-side procedures proved easy and there were no complications. No bleeding or perforation occurred. The average resection times and en-bloc resection rates were not different between the two groups. All the resections by the TN-E were more than 5 mm away from the tumor margin, whereas a resection rate with a safety margin of more than 5 mm was 80% by CE.
In conclusion, the TN-E was safe and effective for use inside the DB. ESD using the TN-E contributed to accurate pathological diagnosis, because the size of the resected specimen was sufficient to prevent the burning effect caused by the ESD.
位于幽门口至十二指肠球部（DB）以内的早期胃癌，内镜黏膜下剥离术（ESD）不易处理。需要将内镜反转至 DB 内部，将切除线设置在远离肛门侧的安全距离处。由于常规内镜（CE）的空间限制和有限的灵活性，并发症的可能性越来越大。在此，我们报告了一种新的 ESD 技术，该技术使用可在 DB 内部反转的经鼻内镜（TN-E）。
研究对象为 5 例早期胃癌或腺瘤患者，病变部位从幽门口至 DB 内部，均采用 ESD 治疗。我们将这些患者（TN-E 组）的结果与 2008 年 7 月之前采用 ESD 治疗的 5 例具有相似疾病特征的患者（CE 组）的结果进行比较。在 TN-E 组中，CE 标记后，我们将内镜切换至 TN-E，并在 DB 内部进行反转操作，将病变的肛门侧切成半圆形。我们切换回 CE 以解剖口腔侧的剩余半部分。我们比较了 TN-E 组和 CE 组的平均切除时间、整块切除率和安全边缘。
DB 内部反转和肛门侧操作被证明是简单的，没有并发症。没有出血或穿孔发生。两组的平均切除时间和整块切除率没有差异。TN-E 组的所有切除均距离肿瘤边缘超过 5mm，而 CE 组的安全边缘大于 5mm 的切除率为 80%。
总之，TN-E 在 DB 内部使用是安全有效的。使用 TN-E 的 ESD 有助于准确的病理诊断，因为切除标本的大小足以防止 ESD 引起的灼伤效应。
