放大胃镜在ESD残端血管处理中的作用回顾性队列研究

Observation of stump vessels on ESD wounds by magnifying endoscopy:a retrospective cohort study

摘要:

目的 探讨放大胃镜对内镜黏膜下剥离术（Endoscopic submucosal dissection，ESD）中残端血管的精准识别以及高效预处理的重要性。方法 从2024年1—9月在江苏省中医院消化内镜中心行ESD治疗的647例患者中进行筛选，纳入术前诊断（光学活检或病理活检）为早期胃癌需ESD治疗的患者。将患者根据使用的胃镜功用类型分为两组，常规治疗型胃镜创面观察组和放大胃镜创面观察组；在放大胃镜创面观察组中，全程使用同一根放大胃镜诊断及治疗，白光弱放大模式下观察术后创面，精准辨认残端血管，予组织夹夹闭裸露残端血管根部，继而热钳适当处理剩余术后创面即可。统计两组在性别、年龄、病变部位、形态分型、病变长径、术后残端血管发现率、术后迟发性出血及穿孔等方面的差异性。结果 研究共纳入160例患者，常规治疗型胃镜创面观察组126例，放大胃镜创面观察组34例，两组在性别、年龄、病变部位、形态分型、病变长径方面差异无统计学差异（P＞0.05）；并发症方面，两组均无穿孔病例；常规治疗型胃镜创面观察组中有4例迟发性出血，放大胃镜创面观察组清晰观察到41.2%（14/34）的术后创面存在残端血管，弱放大下，通过组织夹精准夹闭，未出现迟发性出血。结论 应用放大胃镜发现隐匿残端血管，可有效避免或降低胃ESD术后迟发性出血的几率，未来有望实现内镜诊疗操作一体化，提高成本效益比。

Abstract:

Objective To investigate the significance of magnifying endoscopy in the precise identification of stump vessels and efficient treatment methods during endoscopic submucosal dissection (ESD). Methods A total of 647 patients who underwent ESD treatment at the Digestive Endoscopy Center of Jiangsu Provincial Hospital of Traditional Chinese Medicine from January to September 2024 were selected for the study, and those with preoperative diagnosis (optical biopsy or pathological biopsy) of early gastric cancer requiring ESD treatment were included. Patients were divided into two groups according to the functional type of gastroscopy used: the conventional treatment gastroscopy and wound observation group, and the magnifying gastroscopy and wound observation group..In the magnifying gastroscopy and wound observation group, the same magnifying gastroscopy was used throughout the procedure for both diagnosis and treatment. The postoperative wound was observed under the low-magnification mode to accurately identify stump vessels ends. The tissue clip was then applied to occlude the exposed root of the stump vessels ends, followed by appropriate thermal forceps.The differences of gender, age, location of lesions, morphological type, length of lesions, the rate of vascular finding in the stump, delayed postoperative bleeding and perforation were analyzed. Results A total of 160 patients were enrolled in the study. The conventional treatment gastroscopy and wound observation group comprised 126 cases, while the magnifying gastroscopy and wound observation group included 34 cases. No statistically significant differences were observed between the two groups in terms of gender, age, lesion location, morphological classification, or lesion diameter (P>0.05). Regarding complications, neither group experienced perforation. Among the conventional treatment group, 4 cases of delayed bleeding were reported, whereas the the magnifying gastroscopy group clearly demonstrated stump vessels in 41.2% (14/34) of postoperative wounds. Under low-magnification mode, precise clamping with tissue clips was performed, and no delayed bleeding occurred. Conclusion The magnifying gastroscopy identify occult stump vessels can effectively prevent or reduce the incidence of delayed bleeding post-gastric ESD. It is expected to achieve integration of endoscopic diagnosis and treatment procedures.The cost-benefit ratio can be improved.