【详细视频】胃内镜黏膜下剥离术的四方等牵引技术

Endoscopic submucosal dissection in the stomach under equal multi-traction from four directions

胃内镜黏膜下剥离术的四方等牵引技术

Although endoscopic submucosal dissection (ESD) has become widespread because of its higher cure rate for nonmetastatic gastrointestinal tumors, it is technically challenging. Therefore, several traction techniques have been developed. We report a case in which multi-traction was useful for gastric ESD.

因对非转移性胃肠道肿瘤的治愈率较高，内镜黏膜下剥离术（ESD）已广泛开展，但技术难度较大。为此已开发出了多种牵引技术。本文介绍了一种多方牵引技术，可有效用于胃ESD。

A 77-year-old man visited our hospital because of abdominal discomfort. Esophagogastroduodenoscopy revealed superficial gastric cancer at the greater curvature of the antrum ([Fig. 1 a]), where endoscope instability is expected during ESD. ESD was performed using an IT knife-2 (Olympus, Tokyo, Japan) under equal traction from four directions in order to secure the submucosal layer.

患者，男，77岁，因腹部不适来我院就诊。行上消化道内镜检查，于胃窦大弯处见浅表胃癌（[图1a]），预计在此处进行ESD，操作过程中内镜无法保持稳定。为了确保充分暴露黏膜下层，从四个方向建立等牵引，随后使用IT Knife-2进行ESD。

Fig. 1 Endoscopic view. a The superficial gastric cancer at the greater curvature of the antrum before endoscopic submucosal dissection (ESD). b, c The lesion under four-point traction. d, e Post-ESD ulcer and resected specimen.

图1. 内镜图像。a. 内镜黏膜下剥离术（ESD）前胃窦大弯处的浅表胃癌。b,c. 四点牵引下的病变。d,e. ESD后溃疡和切除的标本。

After circumferential mucosal incision and sufficient cutting of the submucosal layer, four-point traction was established using an SB clip (Sumitomo Bakelite Co., Ltd., Tokyo, Japan) and DT hood (Adachi Co., Ltd., Osaka, Japan), which stores two elastic strings consisting of seven rings ([Fig. 2]). The first ring of the first string was fixed to the opposite intact mucosa by the first clip through the endoscope.

环周切开黏膜并充分切开黏膜下层后，使用SB夹和DT透明帽建立四基点牵引。DT透明帽内有两根结成7个环的弹性绳（[图2]）。通过内镜使用第一个钛夹将第一根绳的第1个环固定在对侧完好黏膜上。

The second ring was fixed to the left anal edge of the lesion by the second clip. Next, the fifth ring was fixed to the right anal edge of the lesion by the third clip, and the sixth ring was fixed to the opposite intact mucosa by the fourth clip. Thus, two-point traction was created in a U-shaped manner ([Fig. 1 b]).

使用第二个钛夹将第2个环固定在病变肛侧左边缘。接着，用第三个钛夹将第5个环固定在病变肛侧右边缘，并用第四个钛夹将第6个环固定在对侧完好黏膜上。至此，已建立U形两点牵引（[图1b]）。

Next, two-point traction in the oral bilateral edge of the lesion was similarly created using the second string. After completing equal four-point traction from four directions ([Fig. 3]), one-piece resection was performed under more effective traction and without adverse events ([Fig. 1 c, d, e], [Video 1]). Histopathological findings included intramucosal well-differentiated adenocarcinoma with a negative cut margin.

接下来，将第二根绳子以相似的方式在病变口侧两边也建立两点牵引。完成四个方向的等四点牵引后（[图3]），形成了更有效的牵引，然后进行一次性完整切除，未发生不良事件（[图1 c，d，e]）（[视频1]）。组织病理学结果显示黏膜内高分化腺癌，切缘阴性。

Fig. 2 The DT hood. a, b The device stores two strings in its side pockets for use in traction. c Each string consists of seven rings.

图2. DT透明帽。a,b. 该装置内两侧各有一根用于牵引的弹性绳。c. 每根绳由7个环组成。

Fig. 3 Schematic illustration of four-point traction.

图3. 四基点牵引技术示意图。

Video 1 We performed gastric endoscopic submucosal dissection (ESD) under equal four-point traction from four directions. Traction was created by endoclips and a DT hood, which facilitated safe ESD despite the difficulty of an unstable endoscope.

视频1. 因为内镜不稳定，难以进行ESD，采用内镜钛夹和透明帽从四个方向建立等四点牵引，随后安全进行胃内镜黏膜下剥离术（ESD）。 

视频涉及手术操作，无法在本文直接发布