内镜下治疗食管胃底静脉曲张伴发上消化道肿物的经验

doi:10.3969/j.issn.1006-7795.2022.01.005

摘要/Abstract

摘要： 目的初步探讨肝硬化合并食管胃底静脉曲张同时伴发上消化道肿物的内镜下治疗效果。方法回顾性收集首都医科大学附属北京友谊医院消化分中心自2010 年 1月至 2021 年7月经内镜治疗食管胃底静脉曲张的18例上消化道肿物患者临床资料,根据上消化道肿物切除术后病理结果显示,包括早期食管癌4例,早期胃癌6例,胃增生性息肉8例。静脉曲张应用LDRf分型方法进行诊断,食管静脉曲张采用套扎术或硬化术治疗,胃底静脉曲张采用栓塞术治疗,上消化道肿物采用内镜下黏膜切除术(endoscopic mucosal resection,EMR)、内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)治疗,总结病例的临床表现、实验室检查、内镜下表现、内镜下治疗方法、病理结果、随访等情况。结果 18例患者肝功能Child-Pugh分级,A级15例,B级3例,国际标准化比值(international normalized ratio,INR)均小于1.5,所有病例中消化道肿物位于食管或胃底曲张静脉之上或临近部位4例,8例患者曾有食管胃底静脉曲张破裂出血病史,进行了食管或胃底静脉曲张内镜下治疗,其中5例患者先行内镜下食管或胃底静脉曲张内镜下治疗,在治疗后1~6个月择期复查胃镜,观察食管或胃底静脉曲张好转后,对上消化道肿物采用EMR或ESD治疗,随访观察内镜下食管及胃底静脉曲张治疗、EMR或ESD术中及术后均未发生出血、穿孔等严重并发症,病灶均完整切除,术后病理均显示切缘干净,在上消化道肿物切除术后12个月的随访中,无患者死亡。结论 EMR、ESD对于肝硬化存在食管胃底静脉曲张伴发上消化道早癌、息肉等肿物的治疗是安全有效的,选择合适时机进行食管胃底静脉曲张内镜下干预,可降低术后出血等并发症。

关键词: 肝硬化, 食管胃底静脉曲张, 上消化道肿物, 内镜下黏膜切除术, 内镜黏膜下剥离术

Abstract: Objective To investigate the effect of endoscopic treatment for liver cirrhosis complicated with esophageal and gastric varices accompanied by upper gastrointestinal(GI) mass. Methods Clinical data of 18 patients were retrospectively collected, who underwent menstrual endoscopic treatment for esophageal gastric varices with upper gastrointestinal neoplasm in Beijing Friendship Hospital, Capital Medical University, Department of Gastroenterology since January 2010 to July 2021. The pathological results after upper gastrointestinal neoplasm resection indicated 4 cases of early esophageal cancer, 6 cases of early gastric cancer, and 8 cases of gastric hyperplastic polyp. The varices were diagnosed with LDRf classification method. The esophageal varices were treated with ligation operation or hardening treatment. The gastric varices were treated with embolization. The upper gastrointestinal tract neoplasm was treated with endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The clinical manifestations, laboratory examination, endoscopic performance, endoscopic treatment, pathological results, and follow-up were summarized and analyzed. Results A total of 18 patients (10 males and 8 females) were aged 37-81 years old, with an average age of (65.88±9.09) years old. According to Child-Pugh grading of liver function, there were 15 patients with grade A and 3 patients with grade B, 4 patients with platelet less than 50×10⁹/L, 3 patients with prothrombin time activity (PTA) less than 60%, and international normalized ratio (INR) of all the cases was less than 1.5. Among all the cases, 4 cases had the digestive tract neoplasm located at the end of the esophagus or stomach varicose vein on or close to, and 8 patients had a history of ruptured esophageal gastric varices bleeding and underwent the esophageal or gastric varices endoscopic treatment, five of which were treated with leading endoscopic esophageal or gastric varices endoscopic treatment. The patients underwent elective review gastroscope after treatment one to six months. The upper digestive tract masses were treated with EMR or ESD after the improvement of esophageal or gastric varices. Follow-up observation was made on the endoscopic treatment of esophageal and gastric varices, and no bleeding, perforation or other serious complications occurred during or after EMR or ESD. The lesions were completely removed, and the postoperative pathology showed that the incision margin was clean. None of the patients died at 12 months of follow-up after upper GI mass resection. Conclusion EMR and ESD are safe and effective for the treatment of esophageal and gastric varices with upper digestive tract early cancer and polyps and other masses in cirrhosis. Endoscopic intervention of esophageal and gastric varices at an appropriate time could reduce postoperative bleeding and other complications.

Key words: cirrhosis, esophagogastric varices, upper gastrointestinal mass, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD)

中图分类号:

程芮, 朱思莹, 刘思茂, 周艳华, 宗晔, 李鹏, 张澍田. 内镜下治疗食管胃底静脉曲张伴发上消化道肿物的经验[J]. 首都医科大学学报, 2022, 43(1): 22-27.

Cheng Rui, Zhu Siying, Liu Simao, Zhou Yanhua, Zong Ye, Li Peng, Zhang Shutian. Experience in endoscopic treatment of esophageal and gastric varices with upper gastrointestinal mass[J]. Journal of Capital Medical University, 2022, 43(1): 22-27.

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