【日本专家实操演练】POEM 食管憩室切除

本文报告了昭和大学江东丰州病院进行的一例POEM+食管憩室切除，在线发表于2020年9月25日。

For esophageal diverticula with symptoms, thoracoscopic or laparoscopic surgery is usually performed. Epiphrenic diverticulum is often acquired because of the pressure caused by esophageal motility disorders. We devised a method of endoscopic esophageal diverticulum resection by applying the peroral endoscopic myotomy (POEM) and POEM + fundoplication technique, thus enabling a safer and less-invasive treatment that was equivalent to surgical treatments.

对于有症状的食管憩室，通常进行胸腔镜或腹腔镜手术。食管动力障碍引起的食管内压力的变化常常会引发食管憩室。昭和大学江东丰州病院的研究人员设计了一种通过经口内镜下肌切开术（POEM）和POEM+胃底折叠术技术进行的内镜下食管憩室切除方法，实现了与外科手术治疗等效但更安全，创伤更小的治疗。

Case presentation

病例展示

A 47-year-old man presented with reflux symptoms after meals. The patient underwent an EGD (Fig. 1), a CT scan (Fig. 2), high-resolution manometry (Fig. 3), barium esophagogram (Fig. 4), and 24-hour pH monitoring. EGD showed an epiphrenic diverticulum and resistance in passing through the esophagogastric junction.

患者为一例47岁的男性，饭后出现反流症状。患者接受了EGD（图1）、CT扫描（图2）、高分辨率食管测压（图3）、食管钡餐造影（图4）和24小时pH监测。EGD显示，在穿过食管胃交界处，存在一膈上食管憩室并遇到阻力。

图1

术前内镜结果

A. The esophagogastric junction

A. 食管胃交界处

B. An epiphrenic diverticulum at 9 o’clock position

B. 9点钟方向存在一膈上食管憩室

C. The observation inside the diverticulum

C. 观察憩室内部

图2

术前CT

The epiphrenic diverticulum was located on the left side of the esophagus and behind the heart, with no extrinsic compression. The maximum diameter was 40 mm

膈上食管憩室位于食道的左侧、心脏的后方，未发现外源性压迫，最大直径为40毫米

图3

High-resolution manometry demonstrated almost normal peristalsis

高分辨率测压显示食管蠕动几乎正常

图4

Barium esophagogram showed delay in the passage of barium at the edge of the diverticulum and stasis of barium in the diverticulum.

钡食道造影显示，钡剂通过憩室边缘时出现延迟，并提示钡剂滞留于憩室

A CT scan revealed that the diverticulum occurred just above the esophagogastric junction and was located at the left side of the esophagus and behind the heart. There was no organic disease, such as presence of malignancy and extrinsic compression. High-resolution manometry showed almost normal peristalsis. Barium esophagogram showed delay in the passage of barium and stasis of barium in the diverticulum. The 24-hour pH monitoring revealed no evidence of GERD.

CT扫描显示憩室恰好在食管胃交界处的上方，位于食道的左侧、心脏的后方。未发现恶性肿瘤或外源性压迫等器质性病变。高分辨率测压显示蠕动几乎正常。钡食道造影显示，钡剂通过延迟并且滞留于憩室中。24小时pH监测并未发现GERD的迹象。

The patient was diagnosed with an epiphrenic diverticula with esophagogastric junction outflow obstruction. We suspected that direct reflux of food and saliva remaining in the diverticulum caused his reflux symptoms, in addition to the obstruction. Hence, we performed standard POEM and endoscopic esophageal diverticulum resection. This procedure was approved by the Showa University Research Ethics Committee.

患者的最终诊断为：膈上食管憩室伴食管胃交界处流出道梗阻。研究人员怀疑，除了梗阻这一原因外，患者残留于憩室内的食物和唾液直接反流，也引发了其反流症状。因此，研究人员对其进行了标准的POEM和内镜下食管憩室切除术。该术式方案得到了昭和大学研究伦理委员会的批准。

Endoscopic method

内镜下方法

This procedure was carried out using a single-channel therapeutic endoscope (GIF-Q260J; Olympus Corp, Tokyo, Japan) with a super soft hood (Space Adjuster; TOP Corp, Tokyo, Japan) as a distal attachment. A mucosal incision was made on the oral side of the diverticulum using a triangle-tip knife with water jet function (Olympus Corp) to create a submucosal tunnel according to standard POEM technique.

使用单通道治疗性内窥镜（GIF-Q260J; Olympus Corp, Tokyo, Japan），内镜远端附件使用超软透明帽（Space Adjuster; TOP Corp, Tokyo, Japan）。使用具有喷水功能的三角形刀（Olympus Corp）在憩室的口侧进行粘膜切口，并根据标准POEM技术操作建立黏膜下隧道。

The tunnel was created beyond the diverticulum to the gastric side, and endoscopic myotomy including the lower esophageal sphincter was performed. In the diverticulum, the muscle layer was deficient. The diverticulum was endoscopically dissected from the mediastinal pleura and was pulled to adduct into the esophageal lumen by the snare traction method (Fig. 5).

隧道越过憩室延伸到胃侧，并进行内镜下肌切开术，包括食管下括约肌。在憩室内，肌层不足。从纵隔胸膜进行内镜下切除，并通过圈套器牵引的方法将憩室拉入食管腔内（图5）。

图5

POEM+憩室切除

A. The diverticulum was endoscopically dissected from the mediastinal pleura by snare traction method.

A. 从纵隔胸膜切开，并使用圈套器牵引的方法进行内镜下切除

B. The muscle layer was deficient in the diverticulum.

B. 憩室内肌层不足

To close the deficient muscle layer in the diverticulum, the muscle layer at the entry of the diverticulum was stitched together by using the endoscopic suturing method using an endoscopic needle holder (E650007, prototype; Olympus Corp).

为了封闭憩室中缺损的肌层，使用内窥镜持针器（E650007, prototype; Olympus Corp）进行内镜下缝合，将憩室入口处的肌层缝合在一起。

We prepared a surgical suture needle (VLOCL0804; Covidien, Mansfield, Mass, USA) with a self-made anchor made from a fragment of PLEDGET (commonly used in cardiovascular surgery) (Fig. 6). By pulling back the endoscope and the device, the suture was tightened. The inverted diverticulum was then removed using a snare, and the mucosal defect was closed with clips (Fig. 7).

研究人员准备了一个手术缝合针（VLOCL0804; Covidien, Mansfield, Mass, USA），该缝合针带有PLEDGET片段制成的自制锚钉（通常用于心血管手术）（图6）。通过拉回内镜和设备，收紧缝合线。然后利用圈套器切除反转至食管腔内的憩室，并用夹子闭合黏膜缺损（图7）。

图6

At the entry of the diverticulum, the deficient muscle layer was closed by stitching with the endoscopic suturing method (A) using a needle holder (B).

在憩室开口处，使用持针器（B）进行内镜下缝合（A）缺损的肌层

图7

A. The inverted diverticulum was removed by a snare.

A. 使用圈套器切除反转至食管管腔的憩室

B. Histopathologic results of the resected specimen showed epithelial hyperplasia with inflammation.

B. 切除标本的组织病理学结果显示上皮增生伴炎症

Progress

进展

After the procedure, the patient started eating on the fourth day and was discharged on the seventh day. His reflux symptoms improved immediately. Two months after the procedure, barium esophagogram (Fig. 8) and EGD showed neither delayed barium outflow nor the recurrence of diverticulum.

手术后，患者在第四天开始进食，并在术后第七天出院。患者的反流症状立即得到改善。手术后两个月，食管钡餐图（图8）和EGD均未显示钡剂流出延迟或憩室复发。

图8

Barium esophagogram view before procedure (A), 2 days after the procedure (B), and 2 months after the procedure (C). It showed a marked improvement in the passage of barium.

术前（A），术后2天（B）和术后2个月（C）的食管钡餐透视。钡剂通过情况得到显著改善。

Conlusion

结论

In summary, we report a successful case of diverticulum resection for epiphrenic diverticulum, which was equivalent to surgical treatments. This procedure is an extension of POEM, POEM + fundoplication, and peroral endoscopic tumor resection; hence, we were able to do this procedure in a minimally invasive and safe way (Video 1).

总而言之，本文报告了一例成功切除膈上食管憩室的病例，有效性与外科手术相当。术式方案为POEM、POEM +胃底折叠术以及经口内镜肿瘤切除术的扩展; 并且以微创和安全的方式进行了整个治疗过程（视频1）。

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