【病例演示】全内脏反位！罕见“镜面人”早期胃癌的ESD
导读
内脏反位是一种先天性畸形，分为全内脏反位（SIT）和部分内脏反位。其中全内脏反位指心、肝、脾、胃、肾等全部内脏左右颠倒，跟正常人的镜面像相似，所以俗称“镜面人”，十分罕见。当全内脏反位的人出现器官疾病，需要手术时，特殊的解剖结构会带来很大的挑战。来自东京医科大学Yohei Koyama等人报告了一例SIT早期胃癌患者的内镜黏膜下剥离术，与大家分享。
Endoscopic submucosal dissection of early gastric cancer in a patient with situs inversus totalis
全内脏反位患者的早期胃癌内镜黏膜下剥离术
Situs inversus totalis (SIT)is defined as the complete mirror-image transposition of the thoracic and abdominal viscera. It is a relatively rare congenital anomaly with an incidence of approximately 1 per 4000 to 8000 persons.
全内脏反位（SIT）指胸腔和腹腔内脏完全颠倒，相当于正常人的镜中像。这是一种相对罕见的先天性异常，每4000-8000人中约有1例发生。
Endoscopic submucosal dissection (ESD) is widely performed as a treatment for early gastric cancer. This strategy uses the effective countertraction produced by gravity, which enables dissections to be performed quickly and safely. However, in patients with SIT, this conventional method is difficult to perform because of the inverted position of the stomach. Previously, Miyaoka et al reported the usefulness of an inverted overtube in patients with SIT, but this overtube is not currently available because it has been discontinued. Herein, we report a patient with SIT and gastric cancer who underwent ESD.
内镜黏膜下剥离术（ESD）广泛用作早期胃癌的治疗方法。该策略利用重力产生的有效反牵引力，可以快速安全地进行剥离。但是，在SIT患者中，由于胃的位置发生了颠倒，很难像常规那样进行ESD。之前，Miyaoka等人报告了可使用倒置的外套管对SIT患者进行早期胃癌的ESD，但由于该报告中使用的倒置外套管已停用，目前无法使用该方法进行ESD。本文报告了一例SIT胃癌患者ESD的病例。
A 74-year-old man with SIT presented to our hospital for further evaluation of suspected gastric cancer identified on screening EGD performed at another hospital.
患者，男，74岁，全内脏反位，之前在另一家医院进行EGD筛查时发现可疑胃癌，为了进一步评估来我院就诊。
We performed EGD using a magnifying endoscope (GIF-H290Z; Olympus, Tokyo, Japan), and an 8-mm reddish, depressed lesion was observed on the posterior wall of the antrum. The demarcation line was identified clearly by indigo carmine dye (Figs. 1A and B).
使用放大内镜进行了EGD，在胃窦后壁观察到一个8 mm的发红凹陷型病变。靛蓝胭脂红染色后可清楚识别分界线（图1A和B）。
Figure 1. A, B, An 8-mm, reddish, depressed lesion was observed on the posterior wall of the antrum. The demarcation line was identified clearly by indigo carmine dye.
图1. A，B，在胃窦后壁观察到一个8 mm的红色凹陷型病变。靛蓝胭脂红染色后可清楚识别分界线。
Magnifying narrow-band imaging displayed an irregular microsurface and microvascular patterns surrounded by the demarcation line. No metastatic lesions were displayed on CT (Figs. 2A and B).
放大窄带成像显示不规则微表面和微血管结构。CT未发现转移性病变（图2A和B）。
Figure 2. A, B, CT scan showed situs inversus totalis, and no metastasis lesion was seen.
图2. A，B，CT扫描显示全内脏反位，未见转移性病变。
Early-stage gastric cancer was strongly suspected on the basis of the endoscopic findings. The entire procedure of ESD is shown in Video, available online at www.VideoGIE.org.
根据内镜检查结果，强烈怀疑早期胃癌。ESD的整个过程见视频。
操作视频
When the patient was positioned in the left decubitus position, the lesion was hidden by gastric fluid because it was located on the gravitational side. Furthermore, a clear endoscopic view and good countertraction could not be obtained in this position (Fig. 3). Therefore, we performed ESD with the patient in the right lateral decubitus position, and the operator stood on the opposite side (Fig. 4).
当患者位于左侧卧位时，受重力影响，病变被胃液掩盖。而且，左侧卧位时，无法获得清晰的内镜视野和良好的反牵引力（图3）。因此，我们选择使患者处于右侧卧位，然后进行ESD，操作员站在对面（图4）。
Figure 3. Endoscopy room setup in the left lateral decubitus position.
图3. 左侧卧位时的内镜室设置。
Figure 4. Endoscopy room setup in the right lateral decubitus position. The operator stood on the opposite side.
图4. 右侧卧位时的内镜室设置。操作员站在对面。
A mixture of glycerol and indigo carmine was used for the submucosal injection. An electrosurgical generator (VIO 300D; ERBE Elektromedizin GmbH, Tubingen, Germany) was set at endocut I (effect 3, duration 3, interval 3) for mucosal incision and forced coagulation and at effect 3, 50 W for submucosal dissection. A circumferential mucosal incision was performed with a 2.0-mm dual knife (KD-650L; Olympus) and an insulated-tip knife (KD-611L; Olympus).
使用甘油和靛蓝胭脂红的混合物进行黏膜下注射。使用电外科发生器（VIO 300D；ERBE），对于黏膜切开和强力电凝，设置为Endocut I（效果3，持续时间3，间隔3）；对于黏膜下剥离，设置为效果3，50 W。使用2.0 mm双刀和IT刀进行黏膜圆周形切开。
First, the lesion's lateral margins were marked with a dual knife in forced coagulation mode (effect 3, 30 W). A mucosal incision was made as a pre-cut on the distal side using a dual knife. Next, an insulated-tip knife was inserted into the incision, and circumferential dissection was performed. Submucosal dissection was then performed with an insulated-tip knife.
首先，在强力电凝模式下（效果3，30 W）用双刀标记病变的侧缘。使用双刀在远端建立黏膜切口，作为预切。接下来，将IT刀插入切口中，并进行圆周形剥离。然后用IT刀进行黏膜下剥离。
In the right lateral decubitus position, a clearer endoscopic view and good traction were obtained during ESD, and the tumor was successfully removed en bloc in 15 minutes. There were no procedure-associated adverse events. Histopathologic examination of the resected specimen led to the diagnosis of L, Gre, 25 × 25 mm, Type 0-IIc, 8 × 8 mm, tub1, T1a (M), pUL0, Ly0, V0, pHM0, pVM0, according to the Japanese classification of gastric carcinoma (Figure 5, Figure 6, Figure 7).
在患者处于右侧卧位时，ESD期间获得更清晰的内镜下视野和良好的牵引力，15分钟内成功将肿瘤整块切除。没有出现与操作相关的不良事件。对切除样本进行的组织病理学检查，根据日本胃癌分类诊断为L，Gre，25×25 mm，0-IIc型，8×8 mm，tub1，T1a（M），pUL0，Ly0，V0，pHM0，pVM0（图5，图6，图7）。
Figure 5. The resected specimen. The histologic imaging in the yellow box is shown in Figure 6.
图5.切除样本。黄框部分的组织学成像如图6所示。
Figure 6. A panoramic view. The red line indicates intramucosal lesion. The magnified imaging in the yellow box is shown in Figure 7.
图6.全景图。红线表示黏膜内病变。黄框部分的放大成像如图7所示。
Figure 7. In the mucosal layer, well-differentiated adenocarcinoma was seen.
图7.在黏膜层中，可见高分化腺癌。
In conclusion, ESD in the right lateral decubitus position for patients with SIT is a simple, effective method that does not require other traction devices.
总之，对于SIT患者，右侧卧位的ESD是一种简单有效的方法，不需要其他牵引装置。
Reference:
Koyama Y, Kawai T, Matsumoto T, Fukuzawa M, Itoi T. Endoscopic submucosal dissection of early gastric cancer in a patient with situs inversus totalis. VideoGIE. 2020 Jun 9;5(8):347-349. doi: 10.1016/j.vgie.2020.04.021. PMID: 32821864; PMCID: PMC7426708.
本文翻译为来自柳叶新潮团队编辑整理，仅供学习交流，欢迎个人转发至朋友圈。