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内镜下治疗早期胃癌论文

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摘要:我国是胃癌的高发国家,虽然医疗水平在不断提高,可患者往往在就诊时已错过最好的治疗时机,而目前胃癌的诊断及治疗均首选消化内镜技术。近年来,消化内镜新兴技术的不断涌现并逐渐普及,也对内镜医师提出了更高的要求。本文对消化内镜技术治疗早期胃癌诊治的发展史、治疗原则、适应证以及术后处理进行阐述,与读者共勉。

关键词:早期胃癌;内镜;治疗;内镜下粘膜切除术;内镜下黏膜剥离术

本文引用格式:胥磊,芦永福.内镜下治疗早期胃癌[J].世界最新医学信息文摘,2019,19(71):128-129.

Endoscopic Treatment for Early Gastric Cancer

XU Lei,LU Yong-fu*

(Department of Gastroenterology,the Affiliated Hospital of Qinghai University,Xining Qinghai)

ABSTRACT:China is a country with a high incidence of gastric cancer.Although the medical level is constantly improving,patients often miss the best opportunity to treat gastric cancer.At present,digestive endoscopy technology is the first choice for diagnosis and treatment of gastric cancer.In recent years,the emerging technology of digestive endoscopy has been emerging and gradually popularized,which also puts forward higher requirements for endoscopists.This article describes the history,principles,indications and post-operative management of digestive endoscopy in the treatment of early gastric cancer.

KEY WORDS:Early gastric cancer;Treatment;Endoscopic mucosal resection;Endoscopic submucosal dissection

0引言

胃癌的发病率及病死率在所有肿瘤中均位列前茅,而中国更是高危国家,医疗水平虽然在不断地提高,可发现罹患胃癌的患者在就诊时,往往已错过最好的治疗时机,使大部分患者的预后都不太理想。在70年代,全球公认的胃癌主流治疗方法为扩大根治性手术,甚至在早期胃癌(early gastric cancer,EGC)中也是如此。随着日本和韩国在全国范围内广泛采用筛查[1]和80年代内窥镜技术的进步,早期胃癌的诊断人数也增加了。到目前为止,EGC的诊断及治疗均首选消化内镜技术[2]。

目前,内镜下的主流治疗有内镜下粘膜切除术(endoscopic mucosal resection,EMR)和内镜下黏膜剥离术(endoscopic submucosal dissection,ESD)。内镜下的治疗充分发挥了其在微创治疗方面的潜力,故在全球范围内得到越来越多的应用[3-7]。但并不是所有患者均适合内镜下治疗,内镜下治疗适用于淋巴结转移(lymph node metastasis,LNM)风险不高或较低的患者[8]。


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有报道宣称,内镜下治疗肿瘤是源于结直肠息肉切除术[9]。而事实是,1974年日本首次报道了第一次使用内镜切除有蒂或半有蒂的EGC[10]。所谓的“大块黏膜(strip biopsy)”技术是EMR的前身,最早应用于1984年[11]。而后为了获取充分活检组织的同时减少活检创伤,Hirao和ColLeagues在1988年开发出一种称为ERHSE(内镜切除,局部注射高渗盐水肾上腺素溶液)的技术,被称为ESD模型[12]。1992年,EMR与透明帽吸引法黏膜切除术(Endoscopic mucosal resection with cap,EMRC)开始应用于食管早期肿瘤(Early esophageal cancer,EEC)的切除,并直接应用于EGC切除[13,14]。而后又逐渐发展至使用多带结扎EMR技术(Endoscopic mucosal resection with ligation,EMRL)[15,16]。EMRC和EMRL技术相对各具特色。但是,当对大于2cm的病变进行切除时,便会提高术后的复发率[17,18]。

20世纪90年代末,日本国家肿瘤中心医院研制出绝缘尖端透热刀(IT刀),其刀尖选用陶瓷球构成,这样的设计使其在行ESD时,安全系数大大提高[19-20]。随后有研究证明,使用标准单通道内窥镜的ESD技术可对大面积病变组织病变进行“整体”剥离,无论肿瘤大小、位置或粘膜下纤维化,均可完全整块切除病变组织,从而能够实现精确的病理分期[21]。

1治疗原则

EGC是指癌组织限于胃黏膜层及黏膜下层,不论其范围大小和有否LNM。因LNM与EGC患者预后关系密切,所以在日本,胃切除术加淋巴结切除术才是治疗EGC的主流[22]。但如此广泛的手术会带来巨大的风险,同时还会降低患者术后的生活质量[23]。

有数据表明,仅侵犯粘膜或浅表粘膜下层EGC的5年生存率分别为99%和96%[24]。对于粘膜内癌患者,LNM的发生率可达3%,当肿瘤进一步侵犯深层黏膜时,风险会增加到20%[25]。因此,术前对患者病情的评估尤为重要,内镜下治疗更适用于EGC患者。

内镜下治疗的主要优点是通过肿瘤组织的完整切除,对其进行肿瘤浸润深度、肿瘤分化程度和淋巴管或血管的病理学评估,从而提供准确的病理分期,预测LNM风险程度,能够综合权衡LNM或远处转移的风险与外科手术治疗的风险中的利弊,但是却不能一定排除未来的外科手术治疗[26-29]。

2适应证

目前EMR主要适用于无溃疡性改变,且拟切除黏膜直径≤2 cm的病变[30]。目前较为公认的ESD绝对适应证为直径≤2cm且无溃疡的分化型黏膜内癌。而ESD相对适应证包括:①无论病灶大小有无合并溃疡的分化型黏膜内癌;②直径≤2cm且无合并溃疡的未分化型黏膜内癌;③直径≤3cm合并溃疡的分化型黏膜内癌;④直径≤3cm且无合并溃疡的分化型浅层黏膜下癌(SM1,黏膜下层浸润深度<500m)。另外还包括病灶≥2cm的胃黏膜上皮内高级别瘤变,EMR术后复发及难以再次行EMR的病变,高龄、有手术禁忌证或可能有淋巴结转移的黏膜下癌及拒绝手术的姑息治疗[31]。与EMR相较,ESD因不受病变大小和溃疡的制约,可实现完整剥离病变组织并给病理提供充分样本,有助于肿瘤的治愈性切除。一项Meta分析显示[32],ESD在完整切除率和完全切除率均明显高于EMR,局部复发率也显著降低。

3术后处理

对于符合适应证的术后患者需每年行胃镜检查随访,而对于符合相对适应证的术后患者需每半年行超声内镜(Endoscopic ultrasonography,EUS)和腹部CT检查,随访3年,尤其是对于微小粘膜下浸润小于500m的病变,分化的EGC浸润小于3cm,无淋巴血管累及,未发现淋巴结转移(95%CI:0-2.5%)。但这一结果是对符合相对适应证被确定有较低淋巴结转移风险的患者进行手术切除的病例回顾性研究,这便意味着只要病变符合组织学评估的相对标准,LNM发生率便可高达95%[33-35]。有研究表明,EMR治疗直径小于2cm的EGC的远期效果与外科手术治疗效果相当[36,37]。还有报道表示,符合绝对适应证的患者与符合相对适应证的患者均接受内镜下治疗后长期生存率和远期效果相似[38]。其5年生存率分别为92%和93%,两组的总生存率无显著差异。两组的多变量风险比为1.10(95%CI:0.67-1.81)。为判断LNM风险和远期效果,在病理学评估后,值得注意的是,病理外侧缘阳性而进行的非治愈性内镜切除与存在LNM高度相关的病理因素的非治愈性内镜切除,其两种治疗效果完全不同,若侵犯至粘膜下层或存在淋巴血管受累,则以根治性手术切除加淋巴结清扫作为标准治疗,因为LNM有可能影响患者的预后。还有研究表明,即使是高龄患者(>75年)行非治愈性内镜切除EGC后,其生存率有所提高[39]。在肿瘤治疗中,完全治愈疾病是非常重要的。然而,外科手术治疗在降低疾病风险的同时也降低了患者的生活质量,还会使患者在术后的日常生活和社会康复遇到困难[40]。但一味地考虑到外科手术操作的风险和术后生活质量的下降,增加内镜切除适应症,可能会导致有大约10%患者出现转移和复发。

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胃和小肠被统称为“第二个大脑”,它们对身体的消化和吸收功能至关重要。胃不仅有储存功能,还可以外分泌消化和吸收食物所必需的胃酸,内分泌胃泌素和生长激素释放肽。胃切除术导致消化酶和激素分泌减少或缺乏,导致小肠压力增加。术后的后遗症不仅包括众所周知的倾倒综合征,还包括慢性肠道运动失调、消化不良和吸收不良。因此,如果治疗方法在治愈率无差异的前提下有其他选项,在选择治疗方法时应认真考虑患者术后的生活质量。肿瘤的完全治愈固然非常的重要,但是将治疗的重点完全放在完全治愈上,却忽略患者术后的生活质量,这可能会给患者术后的日常生活或重新融入社会带来困难。临床中,在考虑治疗方案的同时也要综合考虑患者的年龄、并发症、人生观、价值观和家庭观念等因素,故一定要考虑以下几点:第一,ESD是否真的具有微创性;第二,医生尝试的“完全性”治疗,如胃切除,是否对病人有益;第三,考虑治疗方案的同时,是否也考虑了患者的接受程度。

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