The Clinical Researth With Submucosal Tunneling Endoscopic Technology For Esophageal Diseases

The Part One:The Clinical Researth of Peroral Endoscopic Myotomy for Treatment of AchalasiaBackgroundAchalasia (AC) is a rare and typical primary esophageal motor disorder of esophageal disease, which is a neuromuscular dysfunction disease, etiology characterized manometrically by insuicient relaxation of the lower esophageal sphincter (LES) and loss of esophageal peristalsis. The main clinical manifestations include dysphagia to solids and liquids associated with regurgitation of bland undigested food or saliva. Substernal chest pain during meals in the setting of dysphagia, weight loss, and even heartburn may be accompanying symptoms. There is not definitive method to cure achalasia now. The main purpose of clinical treatment is to reduce pressure of the lower esophageal sphincter, so that the food can enter the stomach smoothly, which are aimed at reducing the hypertonicity of the LES by pharmacologic, endoscopic treatment such as endoscopic botulinum toxin injection and endoscopic pneumatic dilation, or surgical means, but the effect is very limited. Laparoscopic myotomy and pneumatic dilation (PD) are the most effective operations with a longer releave time with some complications such as esophageal perforation, gastroesophageal relux disease (GERD) and so on. In2010, Inoue et al first reported a new method to treat AC, named peroral endoscopic myotomy (POEM), with good effect in the near future, which attracts a great attention in the POEM. But But some people also questioned the safety of the new technology. LING endoscopic classification is a new AC endoscopic classification, which is made according to endoscopic performance for the POEM operation. AC is divided into three types, named LING-I type, LING-II type, LING-III type. The role and significance of the LING classification in the POEM was seldom reported. Although esophageal manometry is the gold standard to diagnose achalasia and the treatment effect, only a few patients are willing to accept this check again because of the complex process and obvious discomfort. Eckardt score and timed barium esophagram (TBE) are good evaluation method with some advantage of simple operation, good repeatability and tolerance. The Eckardt score can identify patient’s symptoms. TBE can judge the esophageal emptying ability by the means of the residual height of barium in esophagus in the different time.Although previous studies have confirmed that Eckardt score and TBE are good parameter to value the effect and recurrence after PD, there is not report about them in the POEM.Objective1. To investigate the feasibility and effectiveness of POEM in achalasia.2. To research the role and significance of LING classification in POEM operation.3. To study the role of the Eckardt scores and TBE on predicting the long term success after POEM in achalasia.MethodsIn2012February to2014March,33patients hospitalized in Department of Gastroenterology, Provincial Hospital Affiliated to Shandong University, comfirmed by radiography or endoscopy with the treatment of the POEM, were studied retrospectively. All the patients are divided into three groups according to LING classification standards, named LING-Ⅰ type, LING-Ⅱ type, LING-Ⅲ type. The operation time, length of tunnel and complications in every group were observed during the operation. All the patients underwent follow-up at the first, twelfth and twenty-fourth months after the POEM, the Eckardt score, Time Barium Esophagram (TBE) and endoscopic examination were used to evaluate the safety and effectiveness of the POEM.ResultThis group of33patients,1case accounted for the adhesion of the mucosa, submucosa and muscularis propria during the operation, which operate PD. the others fulfilled the POEM in the operation room with tracheal intubation under general anesthesia. the average operation time was62.8minutes,8cases of patients with mediastinal or subcutaneous emphysema during pre-or post-operation,1case with mucosal perforation closed by clips in the operation,6cases with the postoperative fever comtrolled by antibiotics during72hours, the average postoperative hospital stay was5.1day, no serious complications occured. The Eckardt score of preoperation and postoperation in the first month followed up was8.25±1.24,0.44±0.70(P<0.01). TBE of the first minute, the fifth minute between preoperation and postoperation was15.97±2.57cm,12.91±2.98cm and2.69±1.33cm,0.28±0.96cm, respectively (P<0.01). The Eckardt score and TBE of the first minute and the fifth minute, is0.39±1.08,2.55±1.03cm,0.36±1.09cm, in the twelfth month respectively, and0.33±0.49,1.5±1cm,0.25±0.45cm respectively in the twenty-fourth month samely. The operation time, length of tunnel had no significant difference (P>0.05).Although the preoperative and postoperative Eckardt score, TBE exists some differences in numerical value between the LING-I type and the LING-II type, there is no significant difference in statistics (P>0.05). Preoperative Eckardt score was significantly correlated with TBE (r=0.625, p<0.001). In the twelfth months,1case reoccured dysphagia, the Eckardt score was6, TBE of the first minute and the fifth minute was8cm and5cm respectively, the symptom alleviates after PD. In the twelfth and Twenty-fourth month,3and2cases had symptoms of gastroesophageal reflux respectively, controlled by the oral proton pump inhibitor. Conclusion1. This study demonstrated that POEM seems to be a very safe and effective approach to treat esophageal achalasia with the characteristics of small injury, quick recovery and less complications etc.2. LING classification may have certain guiding function on the POEM operation in treatment of achalasia. Future studies should focus on larger-scale multicenter studies, and long-term results of POEM.3. Eckardt score, TBE has important value in diagnosing achalasia and predicting treatment of achalasia of the cardia disease flaccid effect judgment, there is a of long term success after POEM in achalasia. The part Two:The Clinical Researth with submucosal tunneling endoscopic technology in treating large area early esophageal cancer or precancerous lesionsBackgroundEsophageal cancer is derived from esophageal epithelial tumor, which is one of the most common malignant tumors in digestive tract. Along with the popularization and development of endoscope, more and more early esophageal cancer and precancerous lesions is detected. Endoscopic submucosal desection (ESD) has become the standardized method for en bloc resection of the early esophageal cancers in the ml and m2periods. Endoscopic ultrasonography (EUS) is important means to judge the depth of tumor invasion before operation. But resection of the large area of early esophageal cancer and precancerous lesions is very difficult and high risk. There are few reports in this field. Postoperative esophageal stricture is the main complications of the large area of esophageal mucosal resection, and there is no effective treatment method now. Although several methods such as endoscopic pneumatic dilation, oral prednisone have been reported in the late literatures, the effect is poor. The effect of the whole covered recyclable esophageal stent implantation to prevent esophageal stenosis is rarely reported.Objective1. To investigate the feasibility and effectiveness of submucosal tunneling endoscopic technology to treat large area early esophageal cancer or precancerous lesions.2. To detect the accuracy of endoscopic ultrasonography in diagnosis of early esophageal cancer.3. To examine the prevention function of the whole covered recyclable esophageal stent in the prevention of postoperative esophageal stenosis.MethodsA retrospective analysis of2011October to2014March,43patients hospitalized in Department of Gastroenterology, Provincial Hospital Affiliated to Shandong University, comfirmed by pathological examination. Endoscopic ultrasonography showed lesions confined to the mucosa and the metastases of lymph nodes have been excluded by the methods of the endoscopic ultrasonography examination and chest and abdominal CT examination. According to intraoperative esophageal mucosal resection area and the actual length, all patients were divided into two groups, control group, resected lesion range in the1/2-3/4whole circumference, or length in3～5cm; the treatment group, lesion range more than the3/4whole circumference or the length is more than5cm, the fully covered recyclable esophageal stent was implanted during the operation. During the operation, bleeding, perforation and other complications were observed. The rate of En bloc resection, histologically complete resection as well as the consistency of the ultrasonic endoscopic diagnosis with pathologic diagnosis was observed. All the patients are asked to follow up interval there months in the first year and six months in the next years to evaluate effect such as recurrence or metastasis.Results48lesions were resected in the43cases, which include10cases in the control group and33cases in the treatment group. The mean operation time is96.91±51.17min (range39-266min), which is59.90±14.54min(range39-266min) in the control group and108.12±53.10min(range39-266min) in the treatment group, there is a significant difference(p=0.022).The average length of resection is62.40±21.95mm, which is41.60±5.68mm in the control group and70.79±20.51mm in the treatment group, there is not a significant difference(p=0.32). en bloc resection rate was100%(48/48), postoperative pathology confirmed that squamous epithelial low grade intraepithelial neoplasia is7cases and early esophageal cancer is41cases, which include33cases limited in the mucosal epithelium,2cases limited in laminae propria,4cases limited in laminae muscularis mucosae,2cases infiltrated submucosa. The negative rate of the vertical and horizontal margin was100%(48/48) and93%(45/48) respectively. The accurate rate of endoscopic ultrasonography in diagnosis of invasive depth is87.5%(42/48) comparing to the postoperative pathologic diagnosis; intraoperative suspected perforation in3cases, postoperative delayed hemorrhage in1cases, postoperative pleural effusion in1cases, postoperative secondary infection and esophageal fistula in2cases. The prevention of stenosis by stent placement in33cases, all of the patients with the stent implantations exist esophageal mucosal hyperplasia in different degrees (33/33). There is1cases of recurrence (1/43) during the follow-up period, which operated by ESD again with the pathological diagnosis of low grade intraepithelial neoplasia. Postoperative stenosis in6cases,14%(6/43),3cases in the control group and3case in the treatment group.5cases was treated with the Savary-Gilliard dilator and2cases was implanted the whole covered esophageal stents again.1case was caused by the mucosal hyperplasia and endoscopic submucosal resection was operated with the pathological diagnosis of the false epithelium tumor.Conclusion1. Endoscopic mucosal desection is one of the effective methods in the treatment of early esophageal cancer/precancerous lesions with the large area with the good safty and effectiveness. Compared with the classical submucosal dissection, the submucosal tunneling endoscopic dissection is superior to the classical submucosal dissection in the operation time, resecting speed, en bloc resection and complete resection rate, which is an important supplement to the classic mucosal resection.2. Endoscopic ultrasonography can well judge the infiltration depth of early esophageal carcinoma, having a good accordance with the pathological diagnosis in87.5%.3. The fully covered recyclable esophageal stent implantation plays an important role in the prevention of the postoperative stenosis with large area of mucosal resection with fewer complications such as esophageal mucosal hyperplasia. The Part Three:The Clinical Researth with Submucosal Tunneling Endoscopic Desection for Eophageal Eubmucosal TumorsBackgroundEophageal submucosal tumors (SMTs) are smooth intraluminal protrusions with a covering of normal mucosa with an estimated prevalence of0.006-0.3%. Currently, endoscopic ultrasound (EUS) and biopsy is the tool of choice for the diagnosis of eophageal SMTs. Open surgery, thoracoscopy and laparoscopy have been used to treat esophageal SMTs. Currently, endoscopic techniques, such as EMR and ESD are used to resect lesions<2cm. However, the efficacy of endoscopic techniques is limited as larger lesions must be resected in piecemeal (not en bloc), and resection of tumors originating from the muscularis propria may carry a relatively high risk for hemorrhage and perforation. Submucosal tunneling endoscopic resection (STER) is a novel minimally invasive endoscopic technique for the removal of gastrointestinal SMTs, especially those that originate from the muscularis propria.Objective1. This research is to detect the safety and efficacy for STER to treat esophageal muscularis propria tumors. 2. This research is to discover the indication for the STER and to identify potential modifications to the procedure that may improve the safety and efficacy of the technique.3. This research is to ascertain the pathologic type of the tumors from the esophageal muscularis propria.MethodsThis study enrolled36patients with esophageal SMTs originating from the muscularis propria of the digestive tract from March2012to March2014. All patients received intravenous anesthesia with propofol and underwent STER. Histopathological specimens were evaluated by hematoxylin&eosin and immunohistochemical staining. All patients underwent follow-up endoscopy at3,6, and12months.ResultsThirty-six lesions were located in the esophagus. EUS findings revealed that all lesions originated from the muscularis propria layer. Samples sufficient for histopathology were obtained from all tumors. Immunohistochemical analyses identified35cases of leiomyoma and1GIST. The GIST had fewer than five mitoses per50high-power fields, suggesting a low risk for recurrence.En bloc resection was successful in all cases. The mean procedure time was60.52±30.32min (range,21-112min). The mean size of the tumors was17.3±0.69mm (range,6-42mm). Mean postoperative length of hospital stay was4.6±2.1days (range,3-16days). Mean follow-up duration was12.9±5.7months (range,3-22months). No residual tumor or recurrence was observed by endoscopy or EUS during the follow-up period.During the procedure, STER was associated with minor immediate bleeding in all cases; this was successfully managed by electrocoagulation. No patients experienced delayed bleeding postoperatively. Subcutaneous emphysema is a major complication of STER. In this study, subcutaneous emphysema occurred during the preliminary stages when performing STER. CO2was used for insufflations, as the gas could be absorbed quickly without the need for any intervention. On postoperative day3, contrast media swallow revealed a pseudo-diverticulum. Endoscopic examination showed that the mucosa covering the tunnel was putrescent and had formed an ulcer. A gastrointestinal nutrition tube was placed into the duodenum, and the patient recovered after16days without further surgery.Conclusion1. STER is a relatively safe and feasible technique for the diagnosis and treatment of esophageal SMTs. STER is associated with short operating times and rapid healing.2. Indication for the STER to resect the tumers from the esophageal muscularis propria is≤3cm in the diameter.3. The most of the esophageal submucosal tumors is esophagus leiomyoma, the STER is a new method to diagnose and treat esophageal submucosal tumors.