常见消化道黏膜下肿物的临床特点及治疗方法

目的:探讨常见消化道黏膜下肿物(submucosal tumors,SMTs)的临床特点、治疗方式及安全性。方法:选择2014年5月至2016年3月在哈医大一院经内镜切除的并经病理及免疫组化明确诊断的消化道粘膜下肿物的患者共49例。所有患者术后3个月、6个月及12个月后随诊复查胃镜。统计每种肿物的患者临床症状,各种黏膜下肿物的性别分布、大小,及在消化道的分布。计算超声内镜的诊断率,总结病理结果。结果:49例患者中,间质瘤25例,类癌9例,平滑肌瘤8例,异位胰腺4例,脂肪瘤2例,颗粒细胞瘤1例。间质瘤分布以胃底、胃体多见。类癌以直肠最多见,胃内也可见。平滑肌瘤多分布于食管,也可见于胃。异位胰腺多分布于胃窦。通过内镜黏膜下挖除术(Endoscopic submucosal excavation,ESE)切除42例,粘膜下隧道切除术(Submucosal tunneling endoscopic resection,STER)切除4例,还有3例行内镜下黏膜切除(Endoscopic Mucosal Resection,EMR)。所有患者术后均无迟发性出血、严重感染及死亡病例发生。随访3-22个月,所有患者均无复发。结论:黏膜下肿物在内镜及超声内镜各有特点。超声内镜对黏膜下肿物的诊断与治疗具有重要的指导意义。双镜联合使SMTs的内镜下各种治疗方式(EMR、ESE、STER)更有安全保障,使患者受益最大。     

内镜黏膜切除术治疗低位直肠侧向发育型肿瘤随机对照研究

目的:探讨内镜黏膜切除术治疗低位直肠侧向发育型肿瘤的临床效果。方法:收集我院收治的低位直肠侧向发育型肿瘤患者40例,随机分为对照组和实验组,每组各20例,对照组患者给予常规内镜下粘膜切除术,实验组患者给予内镜反转黏膜切除术,治疗结束后,对所有患者的病变残留例数、手术时间以及住院时间、并发症发生情况、手术切除效果进行检测并比较。结果:与对照组患者相比,实验组患者复发率较低(P0.05),手术时间以及住院时间、并发症发生率较低(P0.05);两组患者切除效果相比较,实验组分次切除、肿瘤残留例数患者较少,完全切除患者例数较多(P0.05),两组患者的整块切除例数无差异(P0.05)。结论:内镜反转黏膜切除术对于低位直肠侧向发育型肿瘤患者的临床疗效优于常规内镜下粘膜切除术,对临床有指导意义。     

异位胰腺的诊治研究进展

异位胰腺是指在正常胰腺解剖位置以外的胰腺组织,产生机制尚不明确,多认为是在胚胎发育过程中的异常造成的。其常在外科手术或内镜检查时发现,多为单发。临床常无症状或非特异性症状包括腹痛、腹胀等,在小儿可表现为肠套叠和上消化道梗阻。近年来超声内镜的广泛应用为异位胰腺的术前诊断提供了新的、更加准确的方式。目前多认为无症状的患者可以随访;有症状、诊断不明的患者中,可以选择内镜下粘膜切除,腔镜下手术切除或开放手术切除。本文就相关研究进展进行综述。     

NBI及AFE在喉癌早期诊断中的应用

研究表明,喉癌的早期诊断、及时治疗不仅可以提高治愈率,而且也减少了患者的手术创伤和经济负担。积极开展喉癌的早期诊断研究具有重要的临床和社会意义。发现早期喉癌常规方法主要有电子喉镜、纤维喉镜、颈部CT及MRI检查,但并不能明显有效提高早期诊断率。而窄带成像(narrow band imaging,NBI)及自体荧光内镜(autofluorescence endoscopy AFE)是近几年用于喉癌早期诊断的两种新颖的内镜技术。NBI是一种通过变窄光波的波长,使粘膜上皮内乳头样毛细血管袢及粘膜下静脉的结构形成鲜明的对比,从而提高组织表面细微结构的对比度,便于发现病灶。而AFE技术是一种利用自发荧光聚集于病变组织的某个区域产生的差异强度,来区别正常组织与肿瘤性病变,从而用于肿瘤的早期诊断及识别癌前病变。因此,对NBI及AFE的进一步研究及认识对喉癌早期诊断提供非常重要的临床应用价值。     

两种内镜手术对消化道神经内分泌肿瘤的切除效果及安全性评价

目的:探讨内镜下两种手术方法对消化道神经内分泌肿瘤的切除效果和安全性。方法:选取64例消化道神经内分泌肿瘤患者,随机分为A组和B组,每组各32例。A组接受内镜下黏膜切除术,B组接受内镜下黏膜剥离术。分析和比较两组所切除组织的病理学检查结果、手术时间、切除肿瘤的直径和厚度、治疗费用、住院时间、肿瘤完全切除率、垂直切缘阴性率以及并发症的发生率。结果:A组的手术时间为(8.95±1.63) min,治疗费用为(2127.70±468.31)元,均显著少于B组(P0.05);两组患者切除肿瘤直径和厚度、住院时间、垂直切缘阴性率对比差异均没有统计学意义(P0.05);B组的肿瘤完全切除率为93.75%,显著高于A组(P0.05);A组并发症发生率为3.13%,显著低于B组(P0.05)。结论:两种内镜下手术方式均可有效清除消化道神经内分泌肿瘤病灶。内镜下黏膜切除术的手术时间、费用及并发症的发生率更少低,而内镜下黏膜剥离术能够更彻底地清除肿瘤组织。     

隧道法内镜下粘膜下剥离术治疗食道粘膜下肿瘤的临床价值

摘要 目的：探讨隧道法内镜下粘膜下剥离术治疗食道粘膜下肿瘤的临床价值。方法：2014年2月至2017年9月选择在本院诊治的食道粘膜下肿瘤患者172例，根据手术方法的不同分为观察组100例与对照组72例。观察组给予隧道法内镜下粘膜下剥离术，对照组给予内镜粘膜下剥离术治疗，记录与随访两组的预后情况。结果：两组手术时间对比无差异(P>0.05)，观察组的术中出血量、术后禁食天数与术后住院时间显著少于（短于）对照组(P<0.05)。观察组术后3 d的并发症发生率为3.0 %，显著低于对照组的15.3 %(P<0.05)。观察组术后1 d与术后14 d的血清IL-2、sIL-2R含量都显著低于对照组(P<0.05)。随访2年，观察组的1年与2年复发率分别为2.0 %和6.0 %，显著低于对照组的8.3 %和15.3 %(P<0.05)。结论：隧道法内镜下粘膜下剥离术治疗食道粘膜下肿瘤能减少创伤，减少并发症的发生，降低复发率，并促进患者免疫功能的恢复。     

胃炎性纤维性息肉的临床特征及内镜下诊治

摘要 目的：研究胃炎性纤维性息肉（IFP）的临床特征及内镜下诊断和治疗情况。方法：收集2010.1.1~2021.1.1陕西省人民医院确诊的11例IFP,重点分析其超声内镜表现及临床特征,探索其内镜下治疗价值。结果：IFP多发生在胃窦,均发生于40岁以上人群,男女比例无明显差别,平均直径1.2 cm,大部分临床无症状,有时可引起出血或腹痛。超声内镜示其为粘膜下隆起,孤立、界清,表面多光滑,均起源于粘膜下层,呈低回声,界清,类圆形;内镜下粘膜挖除术治疗IFP,手术时间短,恢复快,并获得完整的标本,术后病理有助确诊。结论：胃炎性纤维性息肉多发生40岁以上人群,多为胃窦孤立的粘膜下病变,多无症状,超声内镜有助于IFP的术前精确评估,内镜下粘膜挖除术是治疗IFP一项安全有效的方法,术后病理最终确诊。     

内镜粘膜下剥离术治疗消化道隆起性病变——附58例病例分析

目的:探讨内镜黏膜下剥离术治疗消化道隆起性病变的疗效和安全性。方法:对内镜发现的58例消化道隆起性病变(食管8例,胃26例,十二指肠2例,结肠10例,直肠12例)进行超声内镜检查后(24例位于固有肌层,18例病变位于黏膜下层,4例病变位于黏膜肌层,12例病变位于黏膜层),均进行ESD治疗。结果:48例成功完成ESD治疗,完整切除率达83%,病变最大直径0.5~5.7cm(平均2.9cm),手术时间15~130min(平均74.2min),术中无1例出现皮下气肿,内镜难以控制的大出血,术后未出现迟发性消化道出血,无腹膜炎发热(消化道瘘和胸腔腹腔继发感染)等并发症发生;术中发现2例病变部分突出腔外(底)均转外科手术;2例病变已向深部浸润(胃窦),均转外科手术;术中消化道穿孔6例(胃窦胃底和十二指肠),均转外科急症开腹手术。所有ESD剥离病变包膜完整,基底和切缘未见病变累及。术后随访31例,无1例复发及病变残留。结论:ESD治疗消化道隆起性病变疗效可靠、安全,可以一次性完整地切除病变,提供完整的病理学资料。     

15例Dieulafoy病的内镜下诊断及治疗

目的:探讨消化道内窥镜对于胃Dieulafoy病的诊断和治疗作用。方法:对山东省立医院近3年收治的15例Dieulafoy病的临床资料进行回顾性分析。结果:13例内镜下止血治疗成功,无再出血(随访时间为12个月到36个月);1例内镜下治疗后再次出血,给予第二次内镜治疗后,随访18个月未再出血;1例因患者家属商议后坚持行外科手术治疗(近端胃切除术)。结论:内镜下治疗可作为处理胃Dieulafoy病的首选方案,仔细而谨慎的内镜下操作有助于提高胃Dieulafoy病的诊断。     

放大内镜对结节性胃炎的诊断价值

随着内镜技术的发展,放大内镜在临床中的应用尤为受到重视,并越来越多运用于临床诊断。目前新型的放大内镜可清晰显示消化道粘膜腺管开口和微细血管等细微结构的变化,从而,发现和诊断普通内镜难以发现的一些早期病变,特别是早期恶性肿瘤及其癌前病变。近年来在放大内镜检查中加上染色对比技术及窄带成像等技术,使放大内镜的运用得到进一步拓展。本文就放大内镜对结节性胃炎及其相关病变的诊断价值作一综述。     

Heading toward the Right Direction—Solution Package for Endoscopic Submucosal Tunneling Resection in the Stomach

Background

The emerging submucosal tunneling and endoscopic resection (STER) technique provides definitive histological diagnosis as well as a therapeutic method for the gastric submucosal tumors (SMTs). We aim to present our experience and discuss key technical issues of STER.

Methods

45 patients with gastric SMTs arising from MP received STER. First, a mucosal incision was made 3cm proximal to the tumour, a submucosal tunnel was subsequently built from the incision to the tumor. The tumor was gradually exposed and dissected from surrounding tissue and retrieved from the tunnel. The initial mucosal incision was closed by metal clips. For SMTs in the gastric fundus near cardia, the submucosal tunnel was built from lower esophagus, through the angle of His, to the tumor for resection.

Results

STER was successfully performed in 43 patients; the other two were converted to surgery. Mean operating time was 79.3min (range 45–150min). Mean tumor size was 1.4cm (range 0.5–5cm). Of the total 47 resected SMTs, 36 were GISTs, 10 were leiomyomas and 1 was schwannoma. Complete resection was achieved in all patients. Intra-procedural peumoperitoneum occurred in 3 cases because of iatrogenic perforation, no special treatment was given. 7 patients presented with mild abdominal pain/distention and fever were given antibotics. No severe post-operative complication happened. No tumor recurrence occurred in the median 11 month follow-up period.

Conclusion

Based on short-term follow-up observation, STER is a feasible, safe and minimally invasive method for the diagnosis and treatment of small (<3cm) SMTs in gastric body, antrum and proximal cardia.     

Early duodenal adenocarcinoma resembling a submucosal tumor cured with endoscopic resection: a case report

ABSTRACT: INTRODUCTION: Primary adenocarcinomas resembling submucosal tumors are rare in the gastrointestinal tract. Almost all the submucosal tumor-like adenocarcinomas previously reported invaded the submucosa or deeper. Therefore, submucosal tumor-like lesions are usually treated by surgical resection, and those that arise in the duodenum have been treated by pancreaticoduodenectomy. CASE PRESENTATION: A 65-year-old Japanese man was diagnosed with a submucosal tumor-like adenocarcinoma in his duodenum. We considered it possible that the tumor invasion was limited to the mucosal or submucosal layers and could be removed by endoscopic resection. Tumor histopathology revealed a well-differentiated adenocarcinoma confined to the muscularis mucosae with no lymphovascular invasion. Complete resection of the carcinoma was achieved and there has been no recurrence three years after endoscopic resection. CONCLUSIONS: We suggest that submucosal tumor-like adenocarcinomas arising in nonampullary duodenal sites should be diagnosed carefully with a view to possible endoscopic resection.     

Neuroendocrine tumor in gastric adenoma: a diagnostic pitfall mimicking invasive adenocarcinoma

ABSTRACT: Neuroendocrine tumor (NET) in adenoma of the gastrointestinal tract is a rare mixed glandular-endocrine neoplasm and has uncommonly been described mostly in the colon. Histologically, this tumor is composed of a predominant proportion of benign adenomatous component and a small portion of well-differentiated NE component. Only three cases of NET in gastric adenoma have been reported in the literature. We present 4 cases of NET in gastric adenoma mimicking invasive adenocarcinoma. The NETs were 0.62 mm to 4.1 mm in size and located at the basal lamina propria, muscularis mucosa and submucosa. Histologically, NETs consisted of nests, cords, tubules, and clusters of cells that predominantly interposed between the foveolar base without disturbing the overall polyp architecture. The lesions were completely removed by endoscopic submucosal dissection in three cases and in one case, subtotal gastrectomy was performed because endoscopic biopsy was invasive adenocarcinoma. The patients' clinical course was uneventful without an evidence of recurrence or metastasis. The recognition of NET in gastric adenoma will help avoid potential diagnostic pitfalls masquerading as invasvie adenocarcinomas posed by their infiltrative pattern into submucosa.Virtual slidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1688552293761001.     

腹腔镜切除与内镜联合治疗胃肠道肿瘤的效果观察

目的：分析腹腔镜联合内镜治疗胃肠道肿瘤的可行性和临床效果。方法：对我院收治的行腹腔镜切除与内镜联合治疗的75例胃肠道肿瘤患者的临床资料进行回顾性分析,其中腹腔镜与胃镜联合治疗34例,腹腔镜与肠镜联合治疗41例。总结分析治疗效果。结果：75例患者中有72例手术成功,3例患者因肿瘤位置不佳中转开腹,腹腔镜与胃镜联合平均手术时间（72.8±12.7）min,出血量5~30mL,术后无吻合口瘘、吻合口出血、腹腔感染等并发症,住院时间（7.5±0.5）d。结论：腹腔镜联合内镜治疗胃肠道肿瘤具有创伤小、手术安全的特点,是一种有效、安全的治疗手段,值得临床推广应用。     

Endoscopic Biopsy in Gastrointestinal Neuroendocrine Neoplasms: A Retrospective Study

Background

Gastrointestinal neuroendocrine neoplasms (GI-NENs) are often located in the deep mucosa or submucosa, and the efficacy of endoscopic biopsy for diagnosis and treatment of GI-NENs is not fully understood.

Objective

The current study analyzed GI-NENs, especially those diagnosed pathologically and resected endoscopically, and focused on the biopsy and cold biopsy forceps polypectomy (CBP) to analyze their roles in diagnosing and treating GI-NENs.

Methods

Clinical data of all GI-NENs were reviewed from January 2006 to March 2012. Histopathology was used to diagnose GI-NENs, which were confirmed by immunohistochemistry.

Results

67.96% GI-NENs were diagnosed pathologically by endoscopy. Only 26.21% were diagnosed pathologically by biopsies before treatment. The diagnostic rate was significantly higher in polypoid (76.47%) and submucosal lesions (68.75%), than in ulcerative lesions (12.00%). However, biopsies were only taken in 56.31% patients, including 51.52% of polypoid lesions, 35.56% of submucosal lesions and 100.00% of ulcerative lesions. Endoscopic resection removed 61.76% of GI-NENs, including six by CBP, 14 by snare polypectomy with electrocauterization, 28 by endoscopic mucosal resection (EMR) and 15 by endoscopic submucosal dissection (ESD). 51.52% polypoid GI-NENs had infiltrated the submucosa under microscopic examination. CBP had a significantly higher rate of remnant (33.33%) than snare polypectomy with electrocauterization, EMR and ESD (all 0.00%).

Conclusions

Biopsies for all polypoid and submucosal lesions will improve pre-operative diagnosis. The high rate of submucosal infiltration of polypoid GI-NENs determined that CBP was inadequate in the treatment of GI-NENs. Diminutive polypoid GI-NENs that disappeared after CBP had a high risk of remnant and should be closely followed up over the long term.     

Duodenal somatostatinoma of the ampulla of vater diagnosed by endoscopic fine needle aspiration biopsy: a case report

BACKGROUND: Duodenal somatostatinoma is a rare neuroendocrine neoplasm. A better prognosis can be obtained if these tumors are resected at an early clinical stage. Endoscopic punch biopsy has been the method most commonly used for the preoperative diagnosis of neuroendocrine duodenal tumors. To the best of our knowledge, endoscopic fine needle aspiration biopsy (FNAB) of duodenal somatostatinoma has not been reported before. CASE: A 41-year-old, black female presented with upper gastrointestinal bleeding as well as elevated bilirubin, liver enzymes and glucose. Computed tomography, esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP) detected a mass at the region of the ampulla of Vater partially obstructing the pancreatic duct. The initial punch biopsy yielded only intestinal mucosa. Subsequent endoscopic FNAB suggested the diagnosis of a neuroendocrine neoplasm, as confirmed by additional punch biopsies. Immunohistochemical and electron microscopic studies disclosed somatostatin production by the tumor, which was resected through a modified Whipple procedure. The patient recovered fully. CONCLUSION: This case demonstrates the usefulness of endoscopic FNAB in diagnosing submucosal gastrointestinal neuroendocrine tumors.     

超声内镜对消化道隆起性病变的诊断价值

目的:探讨超声内镜(EUS)对消化道隆起性病变的诊断价值。方法:回顾性分析2013年2月到2017年6月于我院行EUS检查并经内镜下黏膜剥离术(ESD)、内镜粘膜切除术(EMR)或超声内镜引导下细针穿刺(EUS-FNA)获取诊断的293例有消化道隆起性病变的患者,分析病变的超声特点,对比病变的诊断结果。结果:在293例患者中,270例超声诊断与最终诊断相符,EUS诊断消化道隆起性病变的准确性为92.3%。在多种隆起性病变中,以平滑肌瘤(30.7%)及间质瘤(32.4%)最多见,超声对平滑肌瘤及间质瘤的诊断准确性分别为87.8%、95.8%。结论:EUS对消化道隆起性病变是一种有效的、准确的初步诊断方法。     

胃肠道间质瘤的分子分型及靶向治疗

胃肠道间质瘤（gastrointestinal stromal tumors,GISTs）是消化道常见的间叶肿瘤,不同于消化道真正的平滑肌瘤、神经源性肿瘤,其发生主要与Kit基因和血小板衍生生长因子受体α（platelet-derived growth factor receptor alpha,PDGFRα）基因突变有关。KIT靶点的发现使得胃肠道间质瘤治疗进入新治疗模式。伊马替尼与舒尼替尼,均为酪氨酸激酶抑制剂,分别被批准为进展期GISTs治疗的第一线及第二线靶向治疗药物。本文就GISTs的分子生物学分型以及分子靶向药物治疗进展作一概述。