内科学进展：消化系肿瘤内镜下诊治进展

1、消化系肿瘤内镜下诊治进展,主要内容,早期胃癌的内镜下诊治 消化道粘膜下肿瘤的内镜下诊治 十二指肠乳头部肿瘤的内镜下诊治 胰腺胆管肿瘤的内镜下诊治 消化系狭窄的内镜下治疗,早期胃癌的内镜下诊治 Diagnosis and Treatment by Endoscopy for Early Gastric Cancer,早期胃癌的定义,胃癌癌组织局限于粘膜和粘膜下层，而不论有无淋巴结转移。,type 0 - superficial polypoid, flat/depressed, or excavated tumors type 1 - polypoid carcinomas, usually a

2、ttached on a wide base type 2 - ulcerated carcinomas with sharply demarcated and raised margins type 3 - ulcerated, infiltrating carcinomas without definite limits type 4 - nonulcerated, diffusely infiltrating carcinomas type 5 - unclassifiable advanced carcinomas,Japanese Gastric Cancer Association

3、 (JGCA)； The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon. Gastrointestinal Endoscopy 2003 volume 58, NO. 6 (SUPPL), S3- S43,胃癌的TMN分期,Tis：原位癌 T1：粘膜下层以内 T2：肌层浆膜层以内 T3：浆膜受累 T4：侵犯周围结构,N0：无淋巴结转移 N1:1-6个淋巴结转移 N2：7-15个淋巴结转移 N3:15个以上淋巴结转移。,M0：无远处转移 M1：远处转

4、移:,I型：隆起型； II型：平坦型（再分成IIa、IIb、IIc即浅表隆起、浅表平坦和浅表凹陷三种亚型）； III型：凹陷型。,Schlemper RJ, Hirata I, Dixon MF. The macroscopic classification of early neoplasia of the digestive tract. Endoscopy 2002;34:163-8.,早期胃癌的形态分型,病变隆起高度一般2.5mm，直径2cm，无蒂或有亚蒂，隆起表面不平，呈颗粒或结节状。 需与Borrmann I型、间质瘤、良性息肉等相鉴别；,types 0-I: pedunculat

5、ed (Ip) or sessile (Is) in transverse section. In 0-Is the protrusion of the lesion (dark) is compared with the height of the closed cups of a biopsy forceps (2.5 mm); the dotted arrow passes under the top of the lesion. m, mucosa, mm, muscularis mucosae; sm, submucosa.,各型早期胃癌的内镜下特征I型早期胃癌,IIa型早期胃癌,为

6、扁平状隆起，病变隆起高度一般2.5mm。隆起形态不一，可呈圆形、椭圆形、葫芦形、马蹄形，色泽与周围粘膜相似或捎带苍白，表面可有出血、糜烂或白苔附着。,Sub-cardiac stomach: type 0-IIa, intramucosal carcinoma.,IIb型早期胃癌,病变隆起及凹陷均不明显。内镜特征是粘膜褪色，失去粘膜原有光泽；也可呈斑片状发红，触之易出血，表面常有粘液附着，直径多1cm。本型最少见。,最常见，占早期胃癌的1/3 1/2。 内镜下特征： 边界清楚，呈阶梯状凹陷； 凹陷周围有粘膜皱襞的变化，如突然中断、虫咬状中断、末端呈鼓槌样增粗等； 凹陷部表面凹凸不平； 癌灶大小

7、不一，大者10cm而不向深层扩散；小者1cm，易被误认为良性糜烂。,IIc型早期胃癌,Sub-cardiac stomach: type 0-IIc, submucosal adenocarcinoma.,Gastric cardia: type 0-IIc, submucosal adenocarcinoma (sm2).,type 0-IIc,Types IIa + IIcdepressed area in an elevated lesion,IIa+IIc型早期胃癌：病变为浅隆起，顶部有浅凹陷。需与IIa型早期胃癌、Borrmann II型胃癌、良性胃溃疡等相鉴别。,Sub-cardi

8、ac stomach: type 0-IIa + IIc, submucosal adenocarcinoma (sm1).,浅凹陷癌灶中有深凹陷为IIc+III早期胃癌。此型亦常见。内镜下深凹陷处有厚白苔被覆，其他改变与IIc型相同。 浅凹陷癌灶中有浅隆起为IIc + IIa早期胃癌。,IIc+III型早期胃癌IIc+IIa型早期胃癌,Sub-cardiac stomach: type 0-IIc + III, intramucosal carcinoma.,Type IIc + III: a small excavated zone in a depressed lesion,Lauren

9、分型： 肠型（intestinal type） differentiated type (well or moderately differentiated adenocarcinoma or papillary adenocarcinoma)； 弥漫型（diffuse type） undifferentiated type (poorly differentiated adenocarcinoma, signet-ring cell carcinoma, or mucinous cell carcinoma)； 混合型（mixed type）。,早期胃癌的病理分型,胃癌的特殊病理类型,Ade

10、nosquamous carcinoma Squamous cell carcinoma Carcinoid tumor Other tumors,胃粘膜上皮瘤变的维也纳分类Revised Vienna classification of epithelial neoplasla for esophagus, stomach, and colon,The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon. Gastrointestinal Endosc

11、opy 2003 volume 58, NO. 6 (SUPPL), S3- S43,无上皮内瘤变： 胃息肉：非肿瘤性息肉（增生性、错构瘤性、炎性） 慢性萎缩性胃炎和肠上皮化生 胃溃疡 残胃 不肯定上皮内瘤变： 胃粘膜上皮不典型增生 上皮内瘤变： 胃息肉：肿瘤性息肉（腺瘤性：管状、乳头状）,胃癌前状态/病变,早期胃癌的内镜下诊断,内镜下诊断早期胃癌的手段,内镜白光直视下观察 white-light endoscopy(WLE) ； 染色内镜Chromoendoscopy ； 放大内镜与窄带成像 Magnification Endoscopy and Narrow-Band Imaging （M

12、E-NBI）； 最佳光谱成像技术Optimal band imaging system(OBI)； 超声内镜Endoscopic ultrasonography ； 自体荧光内镜Autofluorescence Endoscopy(AFE) ； 共聚焦激光显微内镜confocal laser endomicroscopy（ CLE）； 细胞内镜Endocytoscopy； 磁导胶囊内镜magnetically guided capsule endoscope 。,直视观察conventional endoscopic predictionor white-light endoscopy(WLE

13、),早期胃癌的内镜表现缺乏特征性； 全面观察，重视微小性或凹陷型病变及表浅糜烂点，多活检； 具有发现早期胃癌的意识； 重点活检部位： 隆起病变：病灶顶部或基底部； 平坦病变：病灶中心； 凹陷病灶：凹陷内侧壁。,直视观察判断浸润深度区分T1m和T1sm,T1m 期内镜下标准：隆起或凹陷表面光滑；边缘轻度隆起；向病变中心集中的皱襞光滑并逐渐变细。 smooth surface protrusion or depression, slight marginal elevation, and the smooth tapering of converging folds. T1sm期内镜下标准：表面不

14、规则；边缘明显隆起；向病变中心集中的皱襞呈鼓槌样、或突然中断、或皱襞融合。 irregular surface, marked marginal elevation, and clubbing/abrupt cutting/fusion of converging folds.,Endoscopic prediction of tumor invasion depth in early gastric cancer. Gastrointest Endosc 2011;73:917-27.,Characteristic endoscopic features of mucosal cancer.

15、 A, Smooth surface protrusion. B, Shallow and even depression. C, Chromoendoscopy image of lesion in B. D, Erosion with slight marginal elevation.,粘膜内癌,黏膜内癌内镜下特征：A：隆起表面光滑；B/C：浅而平的凹陷；D：糜烂凹陷边缘轻度隆起。,Characteristic endoscopic features of submucosal invasive cancer. A, Irregular/nodular surface protrusio

16、n. B, Irregular/nodular surface depression. C, Deep ulcer with marked marginal elevation. D, Fusion of converging folds. E, Abrupt cutting of converging folds. F, Clubbing of converging folds.,粘膜下浸润癌,黏膜下浸润癌内镜下特点：A：隆起表面不规则或结节样；B：凹陷表面不规则或结节样；C：溃疡较深，边缘明显隆起；D：集中皱襞融合；E：集中皱襞突然截断；F：集中皱襞呈鼓槌样。,直视观察判断浸润深度临床价值

17、,总准确率78.0% (1642/2105)； T1m内镜下分期： 敏感性85.5%； 特异性73.9%； 阳性预测值82.0%； 阴性预测值78.5%。 T1sm内镜下分期： 敏感性72.6%； 特异性81.9%； 阳性预测值71.9%； 阴性预测值82.4%。,染色内镜Chromoendoscopy,常用染料： 亚甲兰； 靛胭脂； 醋酸。,染色内镜原理,对比法：如靛胭脂 色素不能使胃粘膜着色，而仅滞留于胃粘膜皱襞和沟凹之间，与橘红色胃粘膜形成强烈对比，显示出黏膜面的凹凸变化及其立体结构，借以观察极微小的病变。 染色法：如亚甲蓝 亚甲蓝可与癌细胞所分泌的粘液紧密结合，并向癌组织间隙侵入。 细

18、胞在异型分化的过程中，分化程度越差，分泌粘液逐渐增多，其着色的程度逐渐加重。 反应法：如碘溶液 为一种利用色素在特定消化道黏膜环境中起特异化学反应的方法，如碘溶液中所含的碘与食管上皮中的糖原起反应而变成棕褐色。,染色内镜的优点,良、恶性染色不同，容易鉴别； 对癌变区域判断更准确，可提高活检阳性率； 能观察胃小区大小、形态及排列方式； 能显示粘膜表面的细小凹凸结构。,Chromoendoscopy with indigo carmine dye added to acetic acid in the diagnosis of gastric neoplasia: a prospective co

19、mparative study.Gastrointest Endosc 2008;68:635-41.),A representative lesion viewed by different endoscopic modalities. A, Conventional view. B, Chromoendoscopic view with indigo carmine dye. C, Chromoendoscopic view with acetic acid. D, Chromoendoscopic view with indigo carmine dye added to acetic

20、acid. E, Macroscopic view of the resected specimen sprayed with indigo carmine dye added to acetic acid. F, Macroscopic view indicating histopathologic tumor area; red line, tumor area. Note that only chromoendoscopic view with indigo carmine dye added to acetic acid allows recognition of the entire

21、 border of the lesion.,Performance of different endoscopic observational modalities in diagnosis of the 3 types of gastric lesions,放大内镜与窄带成像Magnification Endoscopy and Narrow-Band Imaging,主要观察胃小凹及黏膜小血管: 1. Microvascular (MV) architecture 2. Microsurface (MS) structure Vessel plus Surface (VS) classi

22、fication system,Clinical Application of Magnification Endoscopy and Narrow-Band Imaging in the Kenshi Yao, MD, PhD. Upper Gastrointestinal Tract: New Imaging Techniques for Detecting and Characterizing Gastrointestinal Neoplasia. Gastrointest Endoscopy Clin N Am, 18 (2008) 415433,(1) optimal design

23、of center wavelength (415 nm and 540 nm) is helpful for visualizing superficial microvessels and superficial microstructure in high contrast; (2) narrowing bandwidth can improve the contrast of these microvessels.,窄带成像(NBI)的原理,Microsurface patterns,1. Regular microsurface pattern (RMSP): presence of

24、 a clear regular linear, tubular, or villous pattern 2. Irregular microsurface pattern (IMSP): significant irregularity of the linear, tubular, or villous pattern 3. Absent microsurface pattern (AMSP): flat or nonstructural type with absence of MS pattern,stomach,Body：honeycomb-like subepithelial ca

25、pillary network (SECN，上皮下毛细血管网) pattern with collecting venules. More precisely, a polygonal loop of subepithelial capillary surrounds each gastric pit, and these loops form a honeycomb-like network beneath the epithelium and converge onto a collecting venule（CV，集合小静脉）. Antrum: coil-shaped SECN.,Mag

26、nified endoscopic findings with NBI in the normal gastric mucosa. (A) Normal gastric body mucosa demonstrates a honeycomb-like SECN pattern with collecting venules (CVs; one of the CVs is indicated by an arrow) and a round or oval crypt-opening pattern. (B) Normal gastric antral mucosa represents a

27、coil-shaped SECN pattern without any collecting venules and a linear or reticular crypt-opening pattern.,正常胃体粘膜： 蜂窝状上皮下毛细血管网（SECN）伴集合细静脉（CV）；隐窝开口：圆形或卵圆形。,正常胃窦粘膜： 线圈样上皮下毛细血管网无集合细静脉； 隐窝开口：线形或网格形。,正常胃粘膜,胃体萎缩性胃炎,正常胃体粘膜,(A) IMVP and IMSP. A clear demarcation line (arrows) is noted at the margin of the ca

28、ncerous mucosa. Within the demarcation line, a distinctly irregular tubular MS structure is visualized and MV loops, which are irregular in their morphology and face in an irregular direction, are evident.,早期胃癌 A,(B) IMVP and IMSP. There is a demarcation line (arrows) between the noncancerous and ca

29、ncerous mucosa. Within the demarcation line, an irregular papillary MS structure can be noted. Furthermore, MV loops, which are irregular in shape and size, can be identified in each irregular papillary structure.,早期胃癌 B,(C) IMVP and AMSP. The specific MS pattern is absent; however, MV loops, which

30、are irregular in shape and size, form an irregular reticular morphology.,早期胃癌 C,Diagnostic criterion for superficial gastric neoplasia by magnifying endoscopy combined with narrow-band imaging:,Disappearance of fine mucosal structure(FMS); Microvascular dilation; Microvascular heterogeneity in shape

31、.,Magnifying endoscopy with narrow-band imaging achieves superior accuracy in the differential diagnosis of superficial gastric lesions identified with white-light endoscopy: a prospective study. Gastrointest Endosc 2010;72:523-9,111例患者201处病变,Pathologically non-cancer,Pathologically adenocarcinoma,f

32、ine mucosal structure(FMS): presence; Microvascular dilation(+); Microvascular heterogeneity (-).,fine mucosal structure(FMS):disappearance; Microvascular dilation(+); Microvascular heterogeneity (+).,ME-NBI诊断胃癌的临床意义,应用ME-NBI上述三联标准诊断胃癌： 敏感性92.9%； 特异性94.7%。 均明显高于内镜直视下判断(WLE敏感性42.9%，特异性61.0%，P0.0001).

33、 结论： ME-NBI对 胃部浅表性病变判断其良、恶性有很高的临床价值。 ME-NBI achieved superior accuracy in the differential diagnosis of superficial gastric lesions identified with WLE. Thus, ME-NBI may increase the diagnostic value of endoscopy in a population at high risk of gastric cancer.,超声内镜Endoscopic ultrasonography,能比较准确判断早

34、期胃癌的浸润深度和淋巴结转移情况；,Normal five-layer wall pattern from gastric antrum. Layer 1: Interface layer, superficial mucosa (hyperechoic/bright). Layer 2: Deep mucosa (hypoechoic/dark). Layer 3: Submucosa (hyperechoic/bright). Layer 4: Muscularis propria (hypoechoic/dark). Layer 5: Serosa (hyperechoic/bright

35、).,Diagnostic accuracy of EUS for tumor (T) and nodal (N) staging of gastric cancer. Adapted with permission from M. Kida,Correct diagnosis of T staging. A case of well-differentiated adenocarcinoma. A, Endosopic image of EGC showing 25-mm protruding mass located in the posterior wall of antrum. B,

36、EUS image of the lesion, showing the hypoechoic mucosal mass with intact submucosal layer. Surgical specimen obtained by radical subtotal gastrectomy confirmed the EGC confined to the mucosal layer.,影响因素：,Undifferentiated histopathologic features; Large tumor size. Lesions located in the mid one thi

37、rd of the stomach larger than 3 cm had significantly higher probability of overstaging. Poorly differentiated histologic diagnosis had a significantly higher probability of understaging.,Clinicopathologic factors influence accurate endosonographic assessment for early gastric cancer. Gastrointest En

38、dosc 2007;66:901-8,Incorrect diagnosis of T staging: A case of signet-ring cell carcinoma. A, Endoscopic image of EGC, showing 10-mm depressed lesion located in the posterior wall of angle. B, EUS image of the lesion, showing the hypoechoic mucosal mass with intact submucosal layer. Surgical specime

39、n obtained by radical subtotal gastrectomy confirmed the EGC confined to the submucosal layer.,Comparison of EUS features of malignant vs. benign lymph nodes,Malignant Round or oval Flat, triangular, “draping” Homogeneous, Sharp borders Size 10 mm,Benign triangular, “draping” hypoechoic Heterogeneou

40、s, centrally hyperechoic Poorly defined borders Size 10 mm, Intact intranodal vasculature,自体荧光内镜Autofluorescence Endoscopy(AFE),原理：利用肿瘤组织自体荧光光谱的改变与正常组织作出区别。 内源性荧光基团：胶原、NAD+/NADH、黄素、色氨酸、弹性蛋白质、卟啉、脂褐素等。,自体荧光内镜Autofluorescence Endoscopy(AFE),In 62 patients serially assessed with WLI, AFI, and magnifying

41、 endoscopy with narrow band imaging (ME-NBI), the addition of AFI and ME-NBI to WLI increased the detection rate of early gastric neoplasias by 12.8%.,Gastrointest Endosc 2009;70:899-906,共聚焦激光显微内镜 Confocal Laser Endomicroscopy, CLE,技术核心：是在内镜头端加上一个极小的激光共聚焦显微镜。 特点：提供放大1000倍的图像，在内镜检查时进行活组织表面下成像，为体内组织提供

42、快速、可靠的诊断。 可以有效地将胃癌或高级别上皮内瘤变等肿瘤性病变和非肿瘤性病变区别开来。,共聚焦激光显微内镜 confocal laser endomicroscopy, CLE,probe-based CLE (pCLE) , integrated CLE (iCLE). off-line CLE real-time iCLE Since real-time iCLE involved endomicroscopic observation combined with white-light imaging, iCLE was termed as meaning WLE plus CLE,

43、 in contrast to off-line CLE.,胃肿瘤性病变特征Cancer/HGIN lesions,Architecture: Irregularity in glandular size and shape; disorganised or destroyed pits and glands Cells: Irregular cells with disordered appearance; severe stratification; loss of cell polarity Microvessels: Irregular in shape and calibre,Dia

44、gnostic value of confocal laser endomicroscopy for gastric superficial cancerous lesions ，Gut 2011;60:299e306.,胃非肿瘤性病变特征 Non-cancerous lesions,Architecture: Orderly ranged glands with regular pit patterns, or mildly heterogeneous in arrangement and distribution Cells: Regular in shape and size; mild

45、ly increase in epithelial stratification; normal cell polarity Microvessels: Normal calibre, honey-comb like or coil-shaped,A：正常幽门腺黏膜； B：肠化黏膜； C：低级别上皮内瘤变； D: 高级别上皮内瘤变,Confocal laser endoscopic images with normal mucosa, intestinal metaplasia (IM), low-grade intraepithelial neoplasia (LGIN) and high-

46、grade intraepithelial neoplasia (HGIN) after intravenous fluorescein injection. (A) Normal mucosa with pyloric glands. Cobble-like appearance with regular columnar cells. (B) Intestinal metaplasia: villous-like appearance with goblet cells. (C) Low-grade intraepithelial neoplasia: black atypical cel

47、ls, variably sized glands with mild unevenness of the epithelium, and increased fluorescein leakage. (D) High-grade intraepithelial neoplasia: obviously abnormal glands with black atypical cells, disorganised polarity, irregular in epithelial heights, and distorted micro-vessels.,IIc型早期胃癌,Endoscopic

48、, histological and confocal laser endomicroscopy (CLE) images of an early gastric cancer. White light endoscopy (WLE) view of an antral Paris 0eIc lesion (A). Corresponding histology specimen showed a poorly differentiated adenocarcinoma (H irregular, short-branched microvessels (D).,CLE 诊断胃癌的临床意义,从

49、上皮（Cells）、腺体（Architecture）和微血管（Microvessels）三个方面进行分析制定的诊断标准，对胃表浅癌/高级别上皮瘤变可作出可靠诊断： 敏感性88.9%（WLE:72.2%, p0.05 ）； 特异性99.3%（WLE:95.1%, p0.05 ）； 准确性98.8%（WLE:94.1%, p0.05 ）。,磁导胶囊内镜magnetically guided capsule endoscope， MGCE,Blinded nonrandomized comparative study of gastric examination with a magneticall

50、y guided capsule endoscope and standard videoendoscope.Gastrointest Endosc. 2012 Feb;75(2):373-81. Epub 2011 Dec 9.,早期胃癌的内镜下治疗,内镜下治疗的适应症,Gastrointestinal epithelial neoplasia: Vienna revisited. Gut 2002;51:130131,内镜下切除术的种类,内镜下黏膜切除术 EMR（endoscopic mucosal resection） 内镜下黏膜下层剥离术 ESD（endoscopic submucos

51、al disection）,推荐EMR适应症,高分化或中分化腺癌，I、IIa、IIb型病变，直径2cm； IIc型病变，直径1cm且无溃疡或瘢痕。,EMR优势,操作简单 创伤小 并发症少 疗效确切等,内镜下黏膜下层剥离术（ESD）,完整切除病变组织，避免多块切除所造成的病灶残留，并导致复发； 确切的病理评估，包括有无淋巴管侵入，水平和垂直方向切缘是否阴性，能决定是否进一步手术治疗。,ESD的适应症,分化型黏膜内癌，无溃疡或溃疡疤痕不论大小； Well-differentiated intramucosal adenocarcinoma without ulceration or ulcer s

52、car (no size limitation) 分化型黏膜内癌，伴溃疡或溃疡疤痕，直径3cm； Well-differentiated intramucosal carcinoma with ulceration or ulcer scar 3 cm 分化差的黏膜内癌直径2cm IIa型， 1cm的IIb和IIc型。无淋巴管累及证据。 Tumor diameter 2 cm in type IIa lesions and 1 cm in type IIb and IIc lesions 黏膜下层浅层浸润的分化型腺癌，直径3 cm，无淋巴及血行转移证据。 Patients with sm1 l

53、esions (minute submucosal invasion 500 mm) with well-differentiated carcinoma 3 cm Patients with no evidence of lymphatic or venous involvement,注：分化型：指分化好者，包括高分化和中分化；分化差者包括低分化、未分化、印戒细胞癌和粘液细胞癌。 N akajima T. Gastric cancer treatment guidelines in Japan. Gastric Cancer. 2002;5:15. Soetikno RM, Gotoda T

54、, Nakanishi Y, Soehendra N. Endoscopic mucosal resection. Gastrointest Endosc. 2003;57(4):56779. Hirasawa T, Gotoda T, Miyata S etal. Incidence of lymph node metastasis and the feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric. Cancer 2009; 12: 14852.,胃癌的TMN

55、分期,ESD的禁忌症,严重心肺疾病、血液病、凝血功能障碍及服用抗凝剂患者，纠正前； 病变基底部（黏膜下层）黏膜下注射局部无明星隆起、抬举较差，提示病变基底部黏膜下层与肌层间有粘连，肿瘤可能浸润至肌层。,ESD的基本操作步骤,标记 黏膜下注射 预切开 边缘切开 剥离 创面处理 标本处理,录像,术后复查,术后二月,ESD术中并发症预防及处理,术中出血 术中穿孔,ESD术中出血处理,ESD引起出血的概率高达7%； 术中出血； 术后出血。,ESD术前、术中患者管理： 术前停用抗凝药物； 治疗前一周应用PPI制剂； 对高血压患者用药将收缩压控制在120-140mmHg，可减轻出血风险。 止血措施及相关器

56、械： 止血钳（双极、单级）、热活检钳、氩离子血浆凝固术（APC）、金属止血夹、特殊内镜（具有喷水功能、多处弯曲功能内镜、双钳道内镜）,ESD术中穿孔,ESD术中穿孔发生率 ESD术中穿孔高危因素 ESD术中穿孔处理措施,ESD术中穿孔发生率,胃穿孔发生率：90/1629(5.5%)。 83例止血夹封闭成功； 7例外科手术； 27例内镜下未完全切除和4例术后局部复发者，行外科手术治疗，9例有腹水，细胞学检查无1例发现癌细胞。,Ikehara等，日本国立癌症中心，1996-2003年,ESD术中穿孔高危因素,高危因素： 病变位于胃体中上部，合并溃疡形成及肿瘤直径3cm。 肿瘤位于胃上、中1/3者穿

57、孔发生率显著高于胃下1/3者（7%8%对1%）； 肿瘤直径3cm者显著高于3cm者（8%对3%)； 有溃疡者显著高于无溃疡者（6%对3%）,ESD术中穿孔处理措施,金属夹夹闭穿孔： 内镜下缝合系统； 双环圈套绳结扎技术； 气腹的处理。,金属夹夹闭穿孔,用金属夹完全夹闭穿孔部位的“缩缝术”； 大网膜充填修补法。 小穿孔：吸引； 大穿孔：内镜进入腹膜腔钳取网膜入胃腔内。,“8”字形双环配合金属夹技术； 尼龙绳配合金属夹技术； 三爪金属夹技术。,金属夹缩缝术,2个月后,1个月后,Omentoplasty for gastrotomy closure after natural orifice tra

58、nsluminal endoscopic surgery procedures. Gastrointest Endosc 2009;70:131-40,“8”字形双环配合金属夹技术,A, The specially designed stainless steel ring with a figure-of-8 shape (8-ring). B and C, One of the 2 rings of the 8-ring is grasped with the Resolution clip beforehand. D, The Resolution clip with the 8-rin

59、g is loaded inside the sheath.,EMR and details of endoscopic closure of the mucosal defect with a combination of the 8-ring and 2 Resolution clips.,Chromoendoscopy with 0.4% indigo carmine dye demonstrates a flat lesion, 10mmin diameter, in the cecum. A, Magnified chromoendoscopy shows a type II pit pattern suggestive of a large hyperplastic polyp. EPMR was performed to remove this lesion. B, Unfortunately, EPMR resulted in a deep resection defect that suggested potential colonic perforation (the deepest pa