RU2790240C1 - Method for endoscopic dissection of epithelial formations of the digestive tract - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to endosurgery. A circular marking of the boundaries of the neoplasm is carried out. In the submucosal layer injected saline, tinted with 0.25% solution of indigo carmine. Further, at a distance of 1.0-1.2 cm from the visible boundaries of the tumor, two initiating transverse incisions of the mucous membrane 1.5-2 cm long along the distal and proximal edges of the neoplasm are performed with an electrosurgical knife. A submucosal tunnel is formed, then the lateral edges of the neoplasm are mobilized with an electrosurgical knife, followed by cutting off the neoplasm from the lateral incisions, followed by processing of the post-resection defect.

EFFECT: method increases the effectiveness of treatment, reduces the risk of developing large post-resection lesions, and prevents recurrence of the disease.

1 cl, 2 ex

Description

The invention relates to medicine, namely to endosurgery and can be used for endoscopic dissection of the epithelial formations of the digestive tract.

A known method of removing neoplasms of the esophagus. The basic principle of this method is to create a tunnel between the mucous and muscular membranes from the oral to the anal edges of the lesion [1 - Gong J, Zhou BY, Liang CB, Zhou HJ, Wang HY, Tan YY, Liu DL. Comparison between tunneling and standard endoscopic submucosal dissection for treatment of large esophageal superficial neoplasm. Acta Gastroenterol Belg. 2019 Oct-Dec;82(4):469-474]. This method is accepted as analog

There is a known method of removing neoplasms of the digestive tract in a single block with the achievement of R0 resection both along the lateral edge and in depth, which is a very important traditional target value of endoscopic dissection in the submucosal layer of the esophagus [2 - Tan Y, Lu J, Lv L, Le M, Liu D. Current status of endoscopic submucosal tunnel dissection for treatment of superficial gastrointestinal neoplastic lesions. Expert Rev Gastroenterol Hepatol. 2020 Jun;14(6):453-462]. This method is taken as a prototype. The traditional method of dissection allows en bloc resection regardless of the size of the lesion, but it is time consuming and presents a high risk of developing large post-resection lesions. The main disadvantage of this method for large formations is poor visualization of the submucosal layer due to compression or twisting of the resected mucosa.

The goal is to increase the efficiency of the method while reducing the risk of developing large post-resection lesions.

The technical result is achieved by first carrying out a circular marking of the boundaries of the neoplasm with an indent of 0.4-0.6 cm from its visible edges, a saline solution tinted with a 0.25% solution of indigo carmine is injected into the submucosal layer, then at a distance of 1.0 -1.2 cm from the visible boundaries of the tumor with an electrosurgical knife, two initiating transverse incisions of the mucous membrane 1.5-2 cm long are made along the distal and proximal edges of the neoplasm, a submucosal tunnel is formed, then the lateral edges of the neoplasm are mobilized with an electrosurgical knife, followed by cutting off the neoplasm from the lateral incisions with subsequent treatment of the post-resection defect.

The method is carried out as follows

Early diagnosis of cancer and precancerous lesions of the gastrointestinal tract, combined with the development of endoscopic treatment methods, is one of the main tasks of modern endoscopy. Mucosal resection is the main method of endoscopic removal of epithelial neoplasms. Loop resection methods are used to remove neoplasms of small size and mostly benign nature. More complex methods of mucosal resection by dissection in the submucosal layer are more often used to remove an epithelial neoplasm as a single block. Such a need arises in the presence of a malignant lesion or the impossibility of its exclusion, as a rule, with large neoplasms without obvious signs of malignant transformation. Esophagus. There are a number of problems that arise when performing the traditional method of dissection of "complex" neoplasms of the esophagus. These include: 1) difficulty in visualizing the submucosal layer due to limited space and a thinner wall of the esophagus, as well as due to compression of the resected mucosa; 2) rapid resorption of the additional submucosal injection, leading to difficulties in dissecting the submucosal layer. A number of authors note the advantages of the tunnel method over the traditional one, these include: 1) a decrease in the rate of diffusion of the injected fluid into the submucosal layer, due to the economical initial incision of the mucosa and its almost complete obturation with the inserted endoscope; 2) providing a wider space between the mucous membrane and the muscle layer by creating a tunnel; 3) anal incision helps to determine the end of the tunnel and prevents resection of healthy tissue; 4) the ability to perform blunt dissection due to a transparent cap attached to the endoscope, as well as due to the gas cushion caused by insufflation, which increases the distance between the mucous membrane and the muscle layer [3 - Linghu, E.; Feng, X.; Wang, X.; Meng, J.; Du, H.; Wang, H. (2012). Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy, 45(1), 60-62].

An endoscope with a fixed distal cap is inserted into the lumen of a hollow organ (esophagus / stomach / large intestine), where an epithelial neoplasm is determined. With the help of an electrosurgical knife for dissection or a probe for argon plasma coagulation, a circular marking of the boundaries of the neoplasm is carried out with an indent of 0.4-0.6 cm from its visible edges. Perform an injection into the submucosal layer of saline, tinted with a 0.25% solution of indigo carmine. At a distance of 1-1.2 cm from the visible boundaries of the tumor, using an electrosurgical dissection knife, two initiating transverse mucosal incisions 1.5-2 cm long are sequentially made along the distal and proximal edges of the neoplasm. From the proximal to the distal incision of the mucosa, a submucosal tunnel is formed in relation to the axis of advancement of the apparatus using the traditional technique of dissection in the submucosal layer. After that, using an electrosurgical dissection knife, the lateral edges of the neoplasm are mobilized from the lumen of the tunnel into the lumen of the organ. At the final stage, lateral incisions of the mucosa are performed with complete cutting off of the neoplasm. If there are visible vessels in the area of the post-resection defect, they must be treated with hot biopsy forceps or a coagrasper.

preliminarily, a circular marking of the boundaries of the neoplasm is carried out with an indent of 0.4-0.6 cm from its visible edges; visible boundaries of the tumor with an electrosurgical knife, two initiating transverse incisions of the mucous membrane 1.5-2 cm long along the distal and proximal edges of the neoplasm are performed, a submucosal tunnel is formed, then the lateral edges of the neoplasm are mobilized with an electrosurgical knife, followed by cutting off the neoplasm from the lateral incisions, followed by processing of the post-resection defect .

Stomach. In a retrospective study on 444 patients diagnosed with early gastric cancer, the effectiveness of tunnel and traditional methods of dissection was compared. 111 patients underwent tunnel dissection, 333 - traditional. The rate of resection of lesions with tunnel dissection was higher than with conventional dissection (19.3 mm2/min vs. 17.7 mm2/min, respectively). The authors also emphasize that there is no need to use traction techniques when performing a tunnel technique, which greatly simplifies and speeds up the operation process. The perforation rate was also significantly higher in the traditional dissection group (6.0%) than in the tunnel group (0.9%). En bloc resection was achieved in 100% of cases with tunnel dissection and 98.0% with traditional [4].

Preliminarily, a circular marking of the boundaries of the neoplasm is carried out with an indent of 0.4-0.6 cm from its visible edges; visible boundaries of the tumor with an electrosurgical knife, two initiating transverse incisions of the mucous membrane 1.5-2 cm long along the distal and proximal edges of the neoplasm are performed, a submucosal tunnel is formed, then the lateral edges of the neoplasm are mobilized with an electrosurgical knife, followed by cutting off the neoplasm from the lateral incisions, followed by processing of the post-resection defect .

Colon. A case of removal of an 18 cm LST rectal tumor by tunnel dissection is reported. The resected tumor was removed en bloc. The dimensions of the resected specimen were 179×108 mm. Operation time - 224 min. Histological examination revealed intramucosal carcinoma, the vertical and horizontal resection margins were clean. There were no complications during or after the operation. The authors argue that the method of creating a submucosal tunnel facilitates orientation in the submucosal space, which is important when removing large neoplasms of the rectum. Also, the method of tunnel dissection allows visualization and timely coagulation of the main trunks of blood vessels, and not their branches. In this regard, possible intraoperative bleeding is prevented, which improves the quality of the procedure.

Endoscopic dissection in the submucosal layer using the tunnel technique

An endoscope with a fixed distal cap is inserted into the lumen of a hollow organ (esophagus/stomach/colon), where an epithelial neoplasm is determined. Using an electrosurgical knife for dissection or using a probe for argon plasma coagulation, a circular marking of the boundaries of the neoplasm is carried out with an indent of 0.4-0.6 cm from its visible edges. Perform an injection into the submucosal layer of saline, tinted with a 0.25% solution of indigo carmine. At a distance of 1-1.2 cm from the visible boundaries of the tumor, using an electrosurgical dissection knife, two initiating transverse mucosal incisions 1.5-2 cm long are sequentially made along the distal and proximal edges of the neoplasm. From the proximal to the distal mucosal incision, a submucosal tunnel is formed in relation to the axis of advancement of the apparatus using the traditional technique of dissection in the submucosal layer. After that, using an electrosurgical dissection knife, the lateral edges of the neoplasm are mobilized from the lumen of the tunnel into the lumen of the organ. At the final stage, lateral incisions of the mucosa are performed with complete cutting off of the neoplasm. If there are visible vessels in the area of the post-resection defect, they must be treated with hot biopsy forceps or a coagrasper.

The method is confirmed by the following examples

Example 1

Patient K., 74 years old.

Complaints at the time of admission

Weakness, loss of appetite, heartburn.

Medical history

She considers herself ill for about 3 years, when she first began to notice recurrent heartburn, belching. On this occasion, she did not seek medical help. In 2019, due to the increase in complaints, she applied to the polyclinic at the place of residence. With endoscopy from 2019 - Esophagitis. She took therapy, complaints ceased to bother. February 14, 2020 with control EGDS: Fibrous esophagitis. A blastomatous lesion of the esophagus cannot be ruled out. Biopsy from 03/18/2020: Squamous Cr IN SITU.

Anamnesis of life

Chronic and past diseases: GB 2 tbsp; 2 tbsp; risk of CCO3; IHD: CH 2FC; COPD AMI - denies, stroke - denies.

Long-term medication: Nebilet 2.5 mg, Vals 160 mg, statins.

Allergic history: No features.

Surgical history: Appendectomy in 1972. For cataract in 2017, 2018.

Physical examination

General condition: Satisfactory.

General examination: Skin and visible mucous membranes are clean, of normal color. Peripheral lymph nodes are not enlarged. The musculoskeletal system without features.

Mental condition

Consciousness is clear, contact is available, oriented in space, time and self.

Neurological status

There are no cerebral, focal and meningeal symptoms.

Respiratory system

The chest is involved in the act of breathing, elastic on palpation. Comparative percussion: Pulmonary sound. The boundaries of the lungs and the mobility of the lower edge are within normal limits. On auscultation: vesicular breathing. There are no wheezes. NPV 16 per min.

Circulatory organs

The area of the heart and large blood vessels of the neck is not changed. The apical impulse is determined in the 5th intercostal space. Borders of the heart without features. Heart sounds are muffled. HR 78/min, Ps 78/min, rhythmic. BP 120 and 70 mmHg

Digestive organs

Swallowing is not difficult. The mucous membrane of the mouth is pale pink. The tonsils are not enlarged. The tongue is moist, slightly coated with a whitish coating. The abdomen is soft, painless in all departments. Shchetkin-Blumberg's symptom is negative. The liver is not enlarged. The spleen is not enlarged. The chair is regular, without pathological impurities.

Organs of the genitourinary system

The area of the kidneys is not changed. The kidneys are not palpable. Tapping symptom is negative. Urination is painless, urine is not macroscopically changed.

Height 158 cm, Weight 72 kg, Temperature 36.7°C.

Results of laboratory studies

Biochemical research

Total protein 63.0 (62.0-81.0) g/l; Albumin 36.1 (32.0-46.0) g/l; ALT 8.0 (10.0-28.0) U/l; ACT 19.0 (19.0-36.0) U/L; Bilirubin total 20.8 (5.0-21.0) µmol/l; Direct bilirubin 4.7 (0.0-3.4) µmol/l; Bilirubin indirect 16.1 (0.0-15.9) µmol/l; Glucose 7.07 (4.10-6.40) mmol/l; Creatinine 75 (53-106) µmol/l; Urea 4.90 (2.90-8.20) mmol/l; Potassium 4.03 (3.50-5.10) mmol/l; Sodium 141.5 (136.0-145.0) mmol/l; Chlorine 107.0 (98.0-107.0) mmol/l; Alpha-amylase 148 (28-100) U/l; C-reactive protein 32.52 (0.00-5.00) mg/l

Immunohematological study

Primary determination of the blood group AB0 (test in the department) 0 (I); Blood type AB0 0 (I); Rh factor Rh Positive. (Rh+); RBC Kell antigen Negative; Anti-erythrocyte antibodies Not detected.

Linked immunosorbent assay

HIV, HbsAg, HCV, RW - negative

Clinical blood test

Hemoglobin 12.1 (12.0-14.0) g/dl; Erythrocytes 4.27 (3.90-4.70) 10^6/µl; Wed hemoglobin content in erythrocytes 28.4 (27.0-31.0) pg; Average erythrocyte volume 82.8 (80.0-100.0) fl; Wed erythrocyte hemoglobin concentration 34.3 (30.0-38.0) g/dl; Hematocrit 35.4 (36.0-42.0)%; Platelets 154 (180-320) 10^3/µl; Average platelet volume 10.40 (7.40-12.00) fl; Leukocytes 11.06 (4.00-9.00) 10^9/l; Neutrophils 87.90 (48.00-78.00)%; Eosinophils 0.1 (0.5-5.0)%; Monocytes 3.8 (3.0-11.0)%; Lymphocytes 7.50 (19.00-37.00)%; Basophils 0.2 (0.0-1.0)%; Neutrophils abs. 9.72 (2.00-7.50) 10^9/l; Eosinophils abs. 0.01 (0.02-0.30) 10^9/l; Monocytes abs. 0.42 (0.09-0.60) 10^9/l; Abs. lymphocytes 0.83 (1.20-3.00) 10^9/l; Basophils abs. 0.02 (0.00-0.07) 10^9/l; LEUKOCYTE FORMULA; Stab neutrophils 3.0 (1.0-6.0)%; Segmented neutrophils 82.0 (47.0-72.0)%; Eosinophils 1.0 (0.5-5.0)%; Lymphocytes 8.0 (19.0-37.0)%; Monocytes 5.0 (3.0-11.0)%; Basophils 1.0 (0.0-1.0)%

Coagulogram

APTT - 34.4

PTV - 13.6

MHO - 1.04

Results of instrumental studies

Computed tomography of OGK and OBP

Area of limited ground glass of both lungs (probably secondary genesis). Small focal seals on the right. Diffuse changes in the pancreas, liver. Left ovarian cyst. Iliac enostosis

ECG protocol

Sinus rhythm, with heart rate 60 min. Normal EOS.

Endoscopy Protocol

1) Esophagogastroduodenoscopy, Biopsy, diagnostic, 2) Endosonography, diagnostic

Under conditions of intravenous sedation, Pentax EG-2990i is freely passed into the esophagus, and then into the stomach.

The lumen of the esophagus expands well with air insufflation. The mucous membrane of the esophagus to the level of 23 cm from the incisors is pink, smooth, shiny. From this level and up to 28 cm from the incisors, a circular area of metaplastic mucosa is determined, the relief of which is bumpy in places. A biopsy was taken -2fr (bottle No. 2). In the lower third of the esophagus at the level of 36 cm from the incisors, a superficial ulcer 6 × 8 mm in size is determined, the edges of which are somewhat infiltrated. A biopsy was taken -2 fr (bottle No. 1). The elasticity of the tissue in this area is reduced. The cardia gapes, the dentate line is located 1 cm above the level of the esophageal opening of the diaphragm - at a distance of 37 cm from the incisors.

When scanning the esophagus at a frequency of 7.5-10 MHz, the wall is structural, the differentiation of the layers is not disturbed, hypoechoic infiltration is noted within the mucous layer at the level of the middle third of the esophagus. Paraesophageally defined lymph node size 12×8 mm.

The lumen of the stomach is not deformed, it easily expands when insufflated with air. In the lumen of the stomach on an empty stomach, a moderate amount of mucous content. The mucous membrane was washed with a solution of espumizan, the contents were aspirated. The gastric mucosa is pale pink, in the antrum it has a spotted appearance. The folds are of medium size, twisted, longitudinally oriented. Peristalsis is satisfactory, symmetrical. The angle has not changed. The pylorus is rounded, not deformed, closes completely, opens sufficiently.

The duodenal bulb is medium in size, not deformed, the mucosa is pink, the walls are smooth, elastic, there is bile in the lumen. The exit from the bulb is free.

Postbulbar sections: duodenal mucosa is pink, medium-sized folds, elastic, bile in the lumen. The OBD area is not visually changed.

Conclusion: Ulcer of the esophagus. Metaplasia of the middle third of the esophagus. Chronic gastritis. Enlarged paraesophageal lymph node. The final diagnosis is based on the results of a morphological study.

Endoscopy Protocol

1) Rectosigmocolonoscopy, diagnostic

In the perianal region without features. The tone of the anal sphincter is preserved. Hemorrhoidal nodes are expressed. Under conditions of intravenous sedation, the colonoscope was inserted into the dome of the caecum. Baugin's valve is lip-shaped, the mucosa is not changed. In all parts of the colon, a moderate amount of turbid liquid content, aspiration (preparation grade Harefield B). The tone of the colon is normal. Gaustration is well expressed, uniform. The mucosa of the rectum, sigmoid, descending, transverse, ascending colon, caecum is pink, the vascular pattern is not changed. In the middle third of the sigmoid colon, an epithelial neoplasm type 0-1s is determined, up to 8 mm in size.

Conclusion: Epithelial neoplasm of the sigmoid colon. Routine endoscopic removal is recommended.

Histological examination results

1) Crushed deformed fragments of moderately differentiated squamous cell carcinoma, with severe leukocyte infiltration, invasion into the underlying stroma. Conclusion: Invasive moderately differentiated squamous cell carcinoma of the esophagus with keratinization.

2) A fragment of moderately differentiated squamous cell carcinoma with cornification foci, leukocyte infiltration foci, without underlying stroma. A fragment of the mucous membrane of the esophagus with the underlying stroma, stratified squamous epithelium with signs of severe dysplasia, pronounced inflammatory infiltration in the underlying stroma. Conclusion: High grade esophageal squamous intraepithelial neoplasia.

Oncologist's consultation

The patient is 74 years old, diagnosed with cancer cT1in situ N0M0IIIst 2 class.

Surgeon's consultation

Cancer of the midthoracic esophagus cT1aN0M0 (moderately differentiated squamous cell carcinoma). The patient is indicated for planned surgical treatment - endoscopic resection of the esophageal mucosa.

Based on complaints, anamnesis, laboratory and instrumental research data, the patient was diagnosed with:

Basic C15.4 Cancer of the midthoracic esophagus cT1aN0M0., Ia class. group

Concomitant I11.9 Hypertensive disease stage 2; 2 tbsp.; risk of CCO3. ischemic heart disease. SN 2FC. COPD

D12.5 Epithelial neoplasm of the sigmoid colon.

The patient is recommended to perform surgery in the amount of endoscopic resection of the mucosa by the method of tunnel dissection in the submucosal layer.

The patient is informed about the expected scope of the operation, the likelihood of its change in accordance with the intraoperative situation. The patient agreed to the operation.

Operation protocol (duration of intervention 3 h 10 min)

Under endotracheal anesthesia with the patient in the supine position, the device was passed into the esophagus. At a level of 20 cm from the incisors and further circularly to a level of about 28 cm and a "tongue" to a level of 30 cm, a neoplasm with a pronounced violation of the vascular pattern is determined, in places with proliferative growth without signs of deep invasion. A similar neoplasm, occupying about 2/3 of the circumference, is determined at a distance from 33 cm to the level of 40 cm, cardia at a distance of about 41 cm. Taking into account the preliminary data on the absence of invasive growth, a decision was made to perform endoscopic removal of these neoplasms as prescribed by the attending physicians. At the first stage, a marking was made with an indent of about 0.4 cm from the distal neoplasm, and after performing a submucosal injection, a distal mucosal incision was made, then, after creating access to the submucosal space, a tunnel was formed along the proximal edge under the neoplasm to the level of the distal incision, after which it was expanded and the final cut was performed tumors at the edges of the neoplasm. A mucosal defect about 9 cm long, occupying about 3/4 of the circumference of the esophagus. Next, the marking of the distal and proximal edges of the circular tumor, which is located proximal to the previous one with an indent of 0.6 cm, is performed. Injection into the submucosal layer of saline solution tinted with 0.25% indigo carmine solution. At a distance of 1 cm from one formation and 1.2 cm from the visible borders of another formation, using an electrosurgical dissection knife, two initiating transverse mucosal incisions 1.5-2 cm long are sequentially made along the distal and proximal edges of the neoplasm. After a circular incision of the mucosa along the distal edge, a semicircular incision of the mucosa was made along the proximal edge, and a tunnel was formed up to the distal incision. Further, the tunnel was gradually expanded by 3/4 of the circumference, and after the completion of the proximal circular incision, its final removal was performed in a single block. In the control post-resection defect after removal of the proximal tumor with a length of about 13-14 cm of a circular nature. A fragment of a circularly preserved mucosa between two areas of resection, about 1-1.5 cm long. There are no signs of perforation or bleeding. Additional hemostasis was performed using coagrasper. Post-resection defects were additionally treated with Gaviscon emulsion.

Results of pathohistological examination

Macroscopic description

1) A fragment of the esophageal mucosa with a neoplasm (spread out on a substrate)

2) A fragment of the mucosa of the esophagus with a neoplasm (removed circularly, fixed on the syringe; proximal edge at the base of the syringe, distal - at the distal part of the syringe)

Microscopic description

1) Fragments of the ulcerated mucous membrane of the esophagus with underlying stroma, represented by stratified squamous epithelium with severe dysplasia and signs of microinvasive tumor growth in the subepithelial zone, no more than 0.1 cm, with severe lymphocytic infiltration.

2) Fragments of non-keratinizing moderately differentiated squamous cell carcinoma, with growth into the muscularis mucosa, marked leukocyte infiltration, the presence of lymphoid follicles with light reproduction centers, invasion into the underlying stroma.

Morphological conclusion

Multifocal nonkeratinizing moderately differentiated squamous cell carcinoma of the esophagus. The resection margins are intact.

Control x-ray examination of the esophagus, stomach

The contrast novatrizoate 760 mg/ml-60.0 freely fills the stomach through the esophagus. In the lower third of the esophagus, the site of retraction after surgery, streaks were not detected.

Conclusion: Cancer of the midthoracic esophagus cT1aN0M0.

In the postoperative period, the patient underwent the following drug therapy:

Antacids and antiulcer drugs: Gaviscon susp., [20 ml]

NSAIDs: Ketorolac solution 3%, [30 mg - 1 ml]

Others: Aminocaproic acid solution 5%, [10000 mg - 200 ml] 2 r. in a day

Postoperative period without complications, the patient's condition is satisfactory. The patient was discharged under the supervision of a therapist, surgeon, gastroenterologist at the place of residence.

Example 2

Patient E., 63 years old.

Complaints at the time of admission

Periodic discomfort in the epigastric region.

Medical history

When performing endoscopy at the place of residence from September 2020, a gastric polyp up to 15 mm in dm was detected, according to histological examination: tubular adenoma of the stomach with low-grade epithelial dysplasia. During additional examination in the Demikhov City Clinical Hospital with EGDS: in the subcardial region along the posterior wall, a neoplasm on a wide base up to 1.5 cm, the mucosa above it is rough, with a biopsy - a morphological picture of hyperplasia of the gastric mucosa with high-grade dysplasia, suspicious of intramucosal cancer. When performing endoscopy at the Loginov Medical Research Center: in the region of the cardia, along the greater curvature, an epithelial neoplasm about 2 cm in size is determined on a wide base, with an uneven surface, easily contact bleeding.

Anamnesis of life

Chronic and past diseases: Varicose veins of the lower extremities. Hypertonic disease.

Long-term use of drugs: perindopril, bisoprolol, eliquis, lerkamen

Allergic history: No features.

Surgical history: Phlebectomy of the veins on the right side.

Epidemiological history: Contact with infectious patients denies. She denies fever in the last 3 months. Malaria, tuberculosis, dysentery, viral hepatitis A - denies. Measles vaccination - in childhood. He denies contact with measles patients for 21 days. Insect bites within 1 month denies. Suction of ticks within a month denies.

Animal bites in the last month.

Physical examination

General condition: Satisfactory.

General examination: Skin and visible mucous membranes are clean, of normal color. Peripheral lymph nodes are not enlarged. The musculoskeletal system without features.

Mental condition

Consciousness is clear, contact is available, oriented in space, time and self.

Neurological status

There are no cerebral, focal and meningeal symptoms.

Respiratory system

The chest is involved in the act of breathing, elastic on palpation. Comparative percussion: Pulmonary sound. The boundaries of the lungs and the mobility of the lower edge are within normal limits. On auscultation: vesicular breathing. There are no wheezes. NPV 18 min.

Circulatory organs

The area of the heart and large blood vessels of the neck is not changed. The apical impulse is determined in the 5th intercostal space. Borders of the heart without features. Heart sounds are muffled. HR 76/min, Ps 80/min, rhythmic. BP 120 and 60 mmHg

Digestive organs

Swallowing is not difficult. The mucous membrane of the mouth is pale pink. The tonsils are not enlarged. The tongue is moist, slightly coated with a whitish coating. The abdomen is soft, painless in all departments. Shchetkin-Blumberg's symptom is negative. The liver is not enlarged. The spleen is not enlarged. The chair is regular, without pathological impurities.

Organs of the genitourinary system

The area of the kidneys is not changed. The kidneys are not palpable. Tapping symptom is negative. Urination is painless, urine is not macroscopically changed.

Height 186 cm, Weight 86 kg, Temperature 36.8°C.

Results of laboratory studies

Biochemical research

Total protein 81.9 (62.0-81.0) g/l; Albumin 49.2 (32.0-46.0) g/l; Glucose 6.17 (4.10-6.40) mmol/l; Creatinine 103 (71-115) µmol/l; Urea 6.23 (2.90-8.20) mmol/l; Potassium 5.07 (3.50-5.10) mmol/l; Sodium 143.3 (136.0-145.0) mmol/l; Chlorine 103.6 (98.0-107.0) mmol/l; Calcium total 2.59 (2.15-2.55) mmol/l

Immunohematological study

Primary determination of the blood group AB0 (test in the department) 0 (I); Primary determination of the Rh factor (test in the department) Not determined; Blood type AB0 0 (I); Rh factor Rh Positive. (Rh+); RBC Kell antigen Negative; No anti-erythrocyte antibodies were found.

Linked immunosorbent assay

Antibodies to HIV 1,2 and HIV1 antigen p24 were not detected; Hepatitis B (HBs antigen) not detected; Hepatitis C (anti-HCV) Detected; Antibodies to Treponema pallidum were not detected;

Clinical blood test

Hemoglobin 16.7 (13.0-16.0) g/dl; Erythrocytes 5.44 (4.00-5.00) 10 l6/µl; Wed hemoglobin content in erythrocytes 30.7 (27.0-31.0) pg; Average erythrocyte volume 91.4 (80.0-100.0) fl; Wed erythrocyte hemoglobin concentration 33.6 (30.0-38.0) g/dl; Hematocrit 49.8 (40.0-48.0)%; Platelets 256 (180-320) 10^3/µl; Average platelet volume 9.40 (7.40-12.00) fl; Leukocytes 9.80 (4.00-9.00) 10^9/l; Neutrophils 62.30 (48.00-78.00)%; Eosinophils 1.5 (0.5-5.0)%; Monocytes 7.0 (3.0-11.0)%; Lymphocytes 26.50 (19.00-37.00)%; Basophils 0.7 (0.0-1.0)%; Neutrophils abs. 6.11 (2.00-7.50) 10^9/L; Eosinophils abs. 0.15 (0.02-0.30) 10^9/l; Monocytes abs. 0.69 (0.09-0.60) 10^9/l; Abs. lymphocytes 2.60 (1.20-3.00) 10^9/L; Basophils abs. 0.07 (0.00-0.07) 10^9/l

Coagulogram

APTT 36.5 (25.4-36.9) sec; MHO 1.45 (0.90-1.20); Prothrombin according to Quick 60.0 (70.0-130.0)%; Prothrombin time 15.9 (9.4-12.5) sec; Thrombin time 15.2 sec; Fibrinogen calculated 3.82 (2.00-4.00) g/l

Clinical analysis of urine

Clinical analysis of urine Protein 0.1 (neg.) g/l; Nitrites not detected; Glucose was not detected. (0-1.7) mmol/l; Ketone bodies were not found; Bilirubin not found; Urobilinogen Norm (0-34) µmol/l; pH 5.0 (5.0-7.0) units pH; Transparency is complete; Color dark yellow; Rel. Density 1.021 (1.010-1.025) relative. units; MICROSCOPY OF URINE SEDIMENT: PATHOLOGY; Leukocytes [a/m] 5 (0-16) 1/µl; Mucus [a/u] 65 (0-28) 1/µl; Transitional epithelium [a/m] 1 (0-0) 1/µl; Erythrocytes [a/m] 9 (0-11) 1/µl

Polymerase chain reaction (PCR)

Material: Throat swab

SARS Coronavirus RNA Not detected

Antibodies to SARS-Cov-2

AT IgM to Coronavirus (SARS-CoV-2) 0.31 (<= 2.0 - "negative"; >2.0 - "positive"); AT IgG to Coronavirus (SARS-CoV-2) 66.45 (0-10.00 U/ml "negative"; >10.00 U/ml "positive") U/l

Results of instrumental studies

ECG protocol

Sinus rhythm, heart rate 57 beats. min. EOS is normal.

Endoscopy Protocol

Esophagogastroduodenoscopy diagnostic

The apparatus was freely passed into the esophagus. Mucous membrane is not changed. Veins of a gullet are not expanded. The level of the esophageal-gastric junction is 40 cm from the incisors. Z-line is clear, uneven. The cardia does not close completely. In the region of the cardia, along the greater curvature, an epithelial neoplasm about 2 cm in size is determined on a wide base, with an uneven surface, easily bleeding on contact, a biopsy was previously performed (morphological picture of hyperplasia of the gastric mucosa with high-grade dysplasia, suspicious for intramucosal cancer). The stomach is not deformed, it straightens well during insufflation. In the lumen of the stomach a small amount of transparent contents. The folds of the mucosa are longitudinal, tortuous, and almost completely straighten out during insufflation. The gastric mucosa is pink with foci of hyperemia, the vascular pattern is not changed, in the antrum the mucosa is somewhat hyperemic. During inversion examination: the cardia completely covers the apparatus, no pathological expansion of the veins of the fornix of the stomach was detected, the mucosa was not changed. The gatekeeper is not deformed, closes, we pass freely. The bulb of the duodenum is rounded, the mucosa is not changed. The postbulbar parts of the duodenum are not deformed, the mucosa is pink. In the lumen of the intestine there are traces of unchanged bile.

Conclusion: Epithelial neoplasm of the cardia. Focal gastritis. Duodenogastric reflux.

Oncological Council

The patient has a clinical and instrumental picture of a malignant neoplasm of the cardia. The patient was examined. The patient is planned to be provided with high-tech medical care in the amount of endoscopic electrosurgical removal of a gastric neoplasm.

Based on complaints, anamnesis, laboratory and instrumental research data, the patient was diagnosed with:

Basic C16.0 Malignant neoplasm of the cardia, Ia class. group

Concomitant I11.9 Hypertension. Varicose veins.

The patient is recommended to perform surgery in the amount of endoscopic resection of the mucosa by tunnel dissection in the submucosal layer.

The patient is informed about the expected volume of the operation, the likelihood of its change in accordance with the intraoperative situation. The patient agrees to the operation.

Operation protocol (duration of intervention 2 h 35 min)

Under ETN in the position of the patient on the back, the apparatus was passed into the esophagus and stomach. At the level of the cardiac region, immediately behind the transition line, an adenomatous neoplasm with an altered mucosal structure about 2×3 cm in size is determined. Taking into account the localization, a decision was made to perform a tunnel dissection. Preliminary, a circular marking of the boundaries of the neoplasm is carried out with an indent of 0.4-0.5 cm from its visible edges; visible boundaries of the tumor with an electrosurgical knife, two initiating transverse incisions of the mucous membrane 1.5-2 cm long along the distal and proximal edges of the neoplasm are performed, a submucosal tunnel is formed, then the lateral edges of the neoplasm are mobilized with an electrosurgical knife, followed by cutting off the neoplasm from the lateral incisions, followed by processing of the post-resection defect .

The control showed no signs of full-thickness perforation and bleeding. Additional coagulation of visible large vessels was performed. The area of muscle dissection (from holding the instrument) in the area of the cardia was closed using two hemostatic clips.

Results of pathohistological examination

Macroscopic description

A fragment of the mucosa 6.5-4.5 cm, irregularly shaped, flattened on the substrate. In the mucosal area of 2.5-2.0 cm focal thickening, gray, bumpy. The vertical edge of the resection is marked with blue ink.

Microscopic description

Fragment of the gastric mucosa with a portion of the mucosa of the esophageal-gastric junction and the mucosa of the esophagus. In the area of the esophageal-gastric junction, infiltrative growth of carcinoma, represented by well-formed tubular glands, with invasion within the mucous membrane, without invasion into the tunica muscularis mucosae, in the mucous membrane outside the tumor, pronounced lymphoplasmacytic infiltration, moderately pronounced neutrophilic infiltration, multiple foci of intestinal metaplasia , atrophy of the own glands of the mucous membrane. No signs of tumor growth were found in the horizontal and vertical resection margins. There were no reliable signs of intravascular and perineural growth.

Morphological conclusion

Highly differentiated tubular adenocarcinoma (low-grade) of the esophageal-gastric junction, with invasive growth within the lamina propria against the background of chronic atrophic gastritis with foci of intestinal metaplasia. No signs of tumor growth were found in the surgical resection margins. pT1a LVI0 Pn0 R0.

Control x-ray examination of the esophagus, stomach

Trazograph 60 ml.

The act of swallowing is not disturbed. The esophagus is freely passable. The tone of the esophagus is preserved, the mucosal folds are longitudinal, not thickened, smooth, the walls are elastic, the lumen is not expanded. Cardia closes. In the area of the cardia, two postoperative clips are determined. The stomach on an empty stomach is empty, its shape and position are not changed. The walls are elastic. Peristalsis of medium depth. The evacuation is timely. The relief of the mucosa is longitudinal. Bulb 12 p intestines of the correct form. The width of the lumen of 12 p of the intestine is not changed, the folds are not thickened.

Conclusion: Condition after endoscopic removal of a gastric neoplasm on 02/08/2021. No CT streaks were detected.

Postoperative period without complications, the patient's condition is satisfactory.

The patient was discharged under the supervision of a therapist, surgeon, gastroenterologist at the place of residence.

Control endoscopic examination 3, 9 months after surgery showed no signs of disease recurrence.

Example 3

Patient P., 62 years old.

Complaints at the time of admission

Intermittent abdominal discomfort.

Medical history

During a routine examination during colonoscopy up to the dome from September 20, 2021, directly from the anal canal, with spread to the rectum, a creeping epithelial neoplasm with a nodular component, about 15 × 20 mm in size, is determined. The sizes of dominant knots are up to 8 mm. Neoplasm Surface 2 and Type Pro JNET. On examination, there are no endoscopic findings for a malignant lesion. No biopsy was performed due to the proposed endoscopic removal.

Anamnesis of life

Chronic and past diseases: Hypertension 1 tbsp., 1 tbsp.

Long-term use of drugs: lozap.

Allergic history: No features.

Surgical history: 2012-Hysterectomy (KOA), 1996-Caesarean section (KOA).

Epidemiological history: Contact with infectious patients denies. She denies fever in the last 3 months. Malaria, tuberculosis, dysentery, viral hepatitis A - denies. Measles vaccination - in childhood. He denies contact with measles patients for 21 days. Insect bites within 1 month denies. Suction of ticks within a month denies.

Animal bites in the last month.

Physical examination

General condition: Satisfactory.

General examination: Skin and visible mucous membranes are clean, of normal color. Peripheral lymph nodes are not enlarged. The musculoskeletal system without features.

Mental condition

Consciousness is clear, contact is available, oriented in space, time and self.

Neurological status

There are no cerebral, focal and meningeal symptoms.

Respiratory system

The chest is involved in the act of breathing, elastic on palpation. Comparative percussion: Pulmonary sound. The boundaries of the lungs and the mobility of the lower edge are within normal limits. On auscultation: vesicular breathing. There are no wheezes. NPV 14 min.

Circulatory organs

The area of the heart and large blood vessels of the neck is not changed. The apical impulse is determined in the 5th intercostal space. Borders of the heart without features. Heart sounds are muffled. HR 74/min, Ps 76/min, rhythmic. BP 130 and 85 mmHg

Digestive organs

Swallowing is not difficult. The mucous membrane of the mouth is pale pink. The tonsils are not enlarged. The tongue is moist, slightly coated with a whitish coating. The abdomen is soft, painless in all departments. Shchetkin-Blumberg's symptom is negative. The liver is not enlarged. The spleen is not enlarged. The chair is regular, without pathological impurities.

Organs of the genitourinary system

The area of the kidneys is not changed. The kidneys are not palpable. Tapping symptom is negative. Urination is painless, urine is not macroscopically changed.

Height 162 cm, Weight 90 kg, Temperature 36.5°C.

Results of laboratory studies

Biochemical research

Glucose 4.54 (4.10-5.90) mmol/l; Creatinine 84 (53-106) µmol/l; Urea 4.68 (2.90-8.20) mmol/l; Sodium 139.4 (136.0-145.0) mmol/l; Chlorine 106.0 (98.0-107.0) mmol/l; Calcium total 2.37 (2.15-2.55) mmol/l

Immunohematological study

Primary determination of the blood group AB0 (test in the department) 0 (I); Blood type AB0 0 (I); Rh factor Rh Positive. (Rh+); RBC Kell antigen Negative; No anti-erythrocyte antibodies were found.

Linked immunosorbent assay

Antibodies to HIV 1,2 and HIV1 antigen p24 were not detected; Hepatitis B (HBs antigen) not detected; Hepatitis C (anti-HCV) not detected; Antibodies to Treponema pallidum were not detected.

Clinical blood test

Hemoglobin 15.3 (12.0-14.0) g/dL; Erythrocytes 4.79 (3.90-4.70) 10^6/µl; Wed hemoglobin content in erythrocytes 32.0 (27.0-31.0) pg; Average erythrocyte volume 93.0 (80.0-100.0) fl; Wed erythrocyte hemoglobin concentration 34.5 (30.0-38.0) g/dl; Hematocrit 44.4 (36.0-42.0)%; Platelets 277 (180-320) 10^3/µl; Average platelet volume 7.40 (7.40-12.00) fl; Leukocytes 5.30 (4.00-9.00) 10^9/l; Neutrophils 67.30 (48.00-78.00)%; Eosinophils 2.0 (0.5-5.0)%; Monocytes 6.5 (3.0-11.0)%; Lymphocytes 23.80 (19.00-37.00)%; Basophils 0.4 (0.0-1.0)%; Neutrophils abs. 3.57 (2.00-7.50) 10^9/L; Eosinophils abs. 0.11 (0.02-0.30) 10^9/l; Monocytes abs. 0.35 (0.09-0.60) 10^9/l; Abs. lymphocytes 1.26 (1.20-3.00) 10^9/l; Basophils abs. 0.02 (0.00-0.07) 10^9/l

Coagulogram

APTT 34.1 (25.4-36.9) sec; MHO 1.07 (0.90-1.20); Prothrombin according to Quick 99.0 (70.0-130.0)%; Prothrombin time 12.2 (9.4-12.5) sec; Thrombin time 13.2 (11.0-17.8) sec; Fibrinogen according to Clauss 3.62 (2.00-4.00) g/l

Clinical analysis of urine

Protein 0.1 (neg.) g/l; Leukocytes were not found; Nitrites not detected; Erythrocytes are not found.; Glucose was not detected. (0-1.7) mmol/l; Ketone bodies were not found; Bilirubin not found; Urobilinogen norm (up to 17) µmol/l; pH 5.0 (5.0-7.0) units pH; Transparency is complete; Yellow color; Rel. Density 1.025 (1.010-1.025) relative. units; MICROSCOPY OF URINE SEDIMENT: NORM; Leukocytes [a/m] 2 (0-27) 1/µl; Mucus [a/m] 4 (0-28) 1/µl; Erythrocytes [a/m] 7 (0-11) 1/µl

Determination of tumor markers

Alpha-fetoprotein 19.6 (0.0-7.0) IU/ml; SA 125 9.0 (0.0-35.0) U/ml; SA 19-9 9.6 (0.0-30.0) U/ml; SA 72-4 9.840 (0.000-6.000) U/ml; Cancer embryonic antigen (CEA) 1.0 (0.0-5.0) ng/ml;

Results of instrumental studies

ECG protocol

Sinus rhythm. Heart rate 62 beats per minute. Normal EOS

Based on complaints, anamnesis, laboratory and instrumental research data, the patient was diagnosed with:

Primary D12.6 Colon polyps.

Concomitant I11.9 Hypertension 1 tbsp., 1 tbsp.

The patient is recommended to perform surgery in the amount of endoscopic resection of the mucosa by the method of tunnel dissection in the submucosal layer.

The patient is informed about the expected scope of the operation, the likelihood of its change in accordance with the intraoperative situation. The patient agreed to the operation.

Operation protocol (duration of intervention 2 h 35 min)

Under intravenous anesthesia in the position of the patient on the left side, the apparatus was inserted into the rectum. At the level of the distal part of the ampulla of the rectum, a neoplasm up to 3 cm in diameter is determined, located with the distal edge in the anal canal. A submucosal injection was made into the area of the neoplasm, a circular marking of the boundaries of the neoplasm is preliminarily carried out with an indent of 0.5 cm from its visible edges, a saline solution, tinted with a 0.25% solution of indigo carmine, is injected into the submucosal layer, then at a distance of 1.1 cm from the visible of the tumor boundaries with an electrosurgical knife, two initiating transverse incisions of the mucous membrane 1.7 cm long along the distal and proximal edges of the neoplasm are made, a submucosal tunnel is formed, then the lateral edges of the neoplasm are mobilized with an electrosurgical knife, followed by cutting off the neoplasm from the lateral incisions, followed by processing of the post-resection defect.

During the extraction, a large number of venous hemorrhoidal plexuses and arterial vessels are noted. After removal of the neoplasm, no signs of bleeding and damage to the muscle layer were detected during control. Additional hemostasis with prophylactic coagulation of large vessels.

Results of pathohistological examination

Macroscopic description

The material was sent on a backing. It is represented by an irregularly shaped exophthalous formation with a large bumpy surface measuring 4.2 * 3.2 cm and a height of 1.0 cm. The exophytic formation is located extremely close to the resection margins, less than 0.1 * 0.2 cm. The fragment was traversed by serial cuts along the length, totally.

Microscopic description

In an exophytic volumetric, macroscopically creeping formation of the colon mucosa on a wide base, the boundaries of which along all edges of the resection are covered with colonic epithelium, with signs of focal mild atrophy of the crypts, with a proper muscular plate of the epithelium with stromal edema and full-blooded vessels of the microvasculature. There are crypts with a violation of histo-architectonics, rebuilt in the area of education according to the type of tubular and elongated glandular structures of various sizes, lined with proliferating cylindrical epithelium, the cell nuclei of which are elongated, hyperchromic, in the lumen of the crypts - apoptotic bodies. The number of goblet cells in the epithelium is markedly reduced. The perpendicular orientation of the cells with respect to the basement membrane is preserved. The muscular plate surrounds the basal sections of the enlarged cystic-glandular structures that protrude into it somewhat.

Conclusion: tubulo-villous adenoma of the colon mucosa with low grade dysplasia of the glandular epithelium.

Morphological conclusion

tubulo-villous adenoma of the mucous membrane of the colon (rectum) with low grade dysplasia of the glandular epithelium.

Postoperative period without complications, the patient's condition is satisfactory.

The patient was discharged under the supervision of a therapist, surgeon, gastroenterologist at the place of residence.

According to the proposed method, endoscopic dissection of epithelial formations was performed in 53 patients. Postoperative complications were not revealed. During the follow-up observation of the recurrence of the disease is not observed, which confirms the achievement of the purpose of the invention.

Information sources

1. Gong J, Zhou BY, Liang CB, Zhou HJ, Wang HY, Tan YY, Liu DL. Comparison between tunneling and standard endoscopic submucosal dissection for treatment of large esophageal superficial neoplasm. Acta Gastroenterol Belg. 2019 Oct-Dec;82(4):469-481.

2. Tan Y, Lu J, Lv L, Le M, Liu D. Current status of endoscopic submucosal tunnel dissection for treatment of superficial gastrointestinal neoplastic lesions. Expert Rev Gastroenterol Hepatol. 2020 Jun;14(6):453-462.

3. Linghu, E.; Feng, X.; Wang, X.; Meng, J.; Du, H.; Wang, H. (2012). Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy, 45(1), 60-62.

Claims (1)

A method for endoscopic dissection of epithelial formations of the digestive tract, including surgical treatment of the formation, characterized in that a circular marking of the boundaries of the neoplasm is preliminarily carried out with an indent of 0.4-0.6 cm from its visible edges, a saline solution tinted with 0.25% is injected into the submucosal layer -ny solution of indigo carmine, then at a distance of 1.0-1.2 cm from the visible boundaries of the tumor with an electrosurgical knife, two initiating transverse incisions of the mucous membrane 1.5-2 cm long along the distal and proximal edges of the neoplasm are made, a submucosal tunnel is formed, then with an electrosurgical knife mobilization of the lateral edges of the neoplasm is carried out, followed by cutting off the neoplasm from the lateral incisions, followed by processing of the post-resection defect.