Submucosal tunnel dissection through the pyloric ring for removal of a sessile duodenal adenoma adjacent to a scar
Submucosal tunnel dissection through the pyloric ring for removal of a sessile duodenal adenoma adjacent to a scar
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DOI：
10.1055/s-0033-1344557
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发表时间：
2013-09
期刊：
影响因子：
9.3
通讯作者：
P. Jin;J. Sheng;Ai‐qin Li;K. Fu
中科院分区：
文献类型：
--
作者：
P. Jin;J. Sheng;Ai‐qin Li;K. Fu
切除瘢痕附近的无蒂十二指肠腺瘤的环内镜粘膜下剥离术（ESD）治疗十二指肠肿瘤通常很困难，因为十二指肠壁薄且管腔狭窄[1]。由于慢性溃疡或活检而在肿瘤附近留下的疤痕通常会使情况变得更加严峻。我们报告一位52岁男性十二指肠腺瘤的病例，食道胃管镜检查显示十二指肠球部前壁有一无蒂息肉，估计大小为4×3cm（●”图1）。病变延伸至幽门管，息肉附近有消化性溃疡瘢痕。放大窄带成像显示管状小凹模式和不规则绒毛结构（●”图2）。活组织检查显示息肉是一个管状绒毛状腺瘤伴中度发育不良。采用ESD进行清除。透明质酸钠用于粘膜下注射，并且使用Dual-Knife（Olympus Corp.，东京，日本）用于粘膜切除和粘膜下剥离（●”视频1）。文献中曾报道，采用后屈操作的ESD对累及幽门管的肿瘤更有效[2]。然而，在我们的患者中，由于瘢痕形成的球状畸形和病变尺寸较大，无法通过后屈充分到达病变边缘，也无法获得粘膜下剥离平面。因此，我们首先从胃侧进行ESD，采用前视图，通过幽门环解剖粘膜下隧道（●”图3）。正如预期的那样，即使注射透明质酸钠，瘢痕附近的部分也没有很好地抬起，并且在剥离该部分的过程中经常发生动脉出血。在止血过程中遇到两个小穿孔，在充分的粘膜下剥离后使用夹子闭合（●”图4）。实现了整块切除，切除的标本大小为4.5×3.5cm（●”图5）。手术时间157分钟。组织学检查显示，管状绒毛状腺瘤伴轻度至中度异型增生已完全切除（●”图6）。患者在住院8天期间成功接受保守治疗。术后无严重并发症发生。最后一张图1.白色光显微照片，一位52岁男性，十二指肠球部前壁上的无蒂息肉。
ring for removal of a sessile duodenal adenoma adjacent to a scar Endoscopic submucosal dissection (ESD) for duodenal neoplasms is generally difficult because of the thin wall and narrow lumen of the duodenum [1]. A scar near the neoplasm due to chronic ulcer or biopsies often makes the situation more formidable. We report the case of a duodenal adenoma in a 52-year-old man. Esophagogastroduodenoscopy (EGD) had shown a sessile polyp on the front wall of the duodenal bulb, with an estimated size of 4×3cm (●" Fig.1). The lesion extended to the pyloric canal, and there was a peptic ulcer scar near the polyp.Magnifying narrowband imaging showed a tubular pit pattern and irregular villous structure (●" Fig.2). Biopsy demonstrated that the polyp was a tubulovillous adenoma with moderate dysplasia. ESD was employed for its removal. Sodium hyaluronate was used for submucosal injection, and a Dual-Knife (Olympus Corp., Tokyo, Japan) was used for mucosal resection and submucosal dissection (●" Video 1). It has previously been reported in the literature that ESD using the retroflexion maneuver is more effective for tumors involving the pyloric canal [2]. However, the margin of the lesion in our patient could not be adequately reached with retroflexion, and the submucosal dissection plane could not be obtained because of the bulbous deformity created by the scar and the large size of the lesion. We therefore performed ESD from the gastric side first with a forward view, dissecting a submucosal tunnel through the pyloric ring (●" Fig.3). As expected, the part adjacent to the scar was not lifted well even when sodium hyaluronate was injected, and arterial bleeding occurred frequently during dissection of this part. Two mini-perforations were encountered during hemostasis, and clips were used for closure after adequate submucosal dissection (●" Fig. 4). En bloc resection was achieved and the size of the resected specimen was 4.5×3.5cm (●" Fig.5). The whole procedure timewas 157minutes. The histologic study showed complete resection of a tubulovillous adenoma with mild to moderate dysplasia (●" Fig.6). The patient was successfully treated conservatively during a hospital stay of 8 days. No serious complication was seen thereafter. The last folFig.1 White light photomicrograph of a sessile polyp on the front wall of the duodenal bulb in a 52-year-old man.