Kurapa kwe endoscopic kwe submucosal bundu remudumbu: pfungwa huru nhatu dzakapfupikiswa muchinyorwa chimwe chete

Matumbu emudumbu (SMT) emudumbu maronda akakwira anobva mu muscularis mucosa, submucosa, kana muscularis propria, uye anogonawo kuva maronda ari kunze kwechiedza. Nekuvandudzwa kwetekinoroji yezvekurapa, nzira dzekurapa dzekuvhiya dzechinyakare dzakapinda zvishoma nezvishoma munguva yekurapwa kusinganyanyi kupindira mumuviri, senge lKuvhiyiwa kweaparoscopic uye kuvhiyiwa kwerobhoti. Zvisinei, mukurapa, zvinogona kuwanikwa kuti "kuvhiyiwa" hakuna kukodzera varwere vese. Mumakore achangopfuura, kukosha kwekurapwa kwe endoscopic kwave kuchinyanya kutariswa. Shanduro yazvino yebvumirano yenyanzvi dzeChinese pamusoro pekuongorora nekurapa kwe endoscopic SMT yaburitswa. Chinyorwa chino chichadzidza muchidimbu ruzivo rwakakodzera.

1. Hunhu hwechirwere cheSMTzvematongerwo enyika

(1) Kuwanda kweSMT haina kuenzana munzvimbo dzakasiyana dzemudumbu, uye mudumbu ndiyo nzvimbo inonyanya kubatwa neSMT.

Kuwanda kwemarudzi akasiyana-siyanaZvikamu zvemudumbu hazvina kuenzana, uye chikamu chepamusoro chemudumbu ndicho chakanyanya kuwanda. Pazvikamu izvi, 2/3 zvinoitika mudumbu, zvichiteverwa negurokuro, duodenum, uye colon.

(2) Nyanzvi yezvemapfupaMhando dzeSMT dzakaoma, asi SMT zhinji maronda asina njodzi, uye mashoma chete ndiwo ane kenza.

A.SMT inosanganisira hapanaZvironda zve n-neoplastic zvakaita se ectopic pancreatic tissue uye zvironda zve neoplastic.

B. Pakati pekukuvara kwebundus, gastrointestinal leiomyomas, lipomas, Brucella adenomas, granulosa cell bundu, schwannomas, uye glomus bundu kazhinji hadzina njodzi, uye dziri pasi pe15% dzinogona kuonekwa senyama. Dzidza zvakaipa.

C. Kutsvoda kwemudumbuMatumbu e-l (GIST) uye matumbu e-neuroendocrine (NET) muSMT matumbu ane mukana wekuti aite zvakaipa, asi izvi zvinoenderana nehukuru hwawo, nzvimbo uye rudzi rwawo.

D. Nzvimbo yeSMT ine hukamakurudziro yezvirwere: a. MaLeiomyoma rudzi rweSMT rwunowanzoonekwa mugurokuro, rwunoverengera 60% kusvika 80% yeSMTs dzegurokuro, uye runowanzoitika pakati nepakati pegurokuro; b. Mhando dzezvirwere zveSMT dzemudumbu dzakaoma kunzwisisa, neGIST, leiomyoma uye ectopic pancreas ndiyo inonyanya kuwanikwa. Pakati peSMT yemudumbu, GIST inonyanya kuwanikwa mufundus nemumuviri wedumbu, leiomyoma inowanzo kuwanikwa mucardia nechikamu chepamusoro chemuviri, uye ectopic pancreas ne ectopic pancreas zvinonyanya kuwanikwa. Lipomas dzinowanikwa zvakanyanya mudumbu; c. Lipomas nema cysts zvinowanzoonekwa muzvikamu zvinodzika uye zvine bulbous zve duodenum; d. MuSMT yedumbu rezasi, lipomas dzinowanikwa muura, nepo NETs dzichiwanikwa mu rectum.

(3) Shandisa CT neMRI kuti uongorore, urape, uye uongorore bundu. Kune SMTs dzinofungidzirwa kuti dzinogona kuva nekenza kana kuti dzine bundu rakakura (refu).dhayamita > 2 cm), CT neMRI zvinokurudzirwa.

Dzimwe nzira dzekufungidzira mifananidzo, dzinosanganisira CT neMRI, dzakakoshawo pakuongorora SMT. Dzinogona kuratidza zvakananga nzvimbo yebundu, maitiro ekukura, saizi yeronda, chimiro, kuvapo kana kusavapo kwebulation, huwandu, homogeneity, mwero wekuvandudzwa, uye muganhu wemuganho, nezvimwewo, uye dzinogona kuona kana uye mwero weukobvu.Kuvharwa kwemadziro emudumbu. Chinonyanya kukosha ndechekuti, kuongororwa uku kunogona kuona kana paine kupinda kwezvikamu zviri pedyo zvegomarara uye kana paine metastasis muperitoneum yakapoteredza, lymph nodes nedzimwe nhengo dzemuviri. Ndiyo nzira huru yekuongorora, kurapa uye kuongorora fungidziro yegomarara.

(4) Kutorwa kwesampuli yenyama hakudzokororweyakagadzirirwa mishonga yeSMT isina njodzi inogona kuongororwa ne endoscopy yakajairika pamwe chete neEUS, yakadai se lipomas, cysts, uye ectopic pancreas.

Kune maronda anofungidzirwa kuti ane kenza kana kuti endoscopy yakajairika pamwe chete neEUS isingakwanise kuongorora maronda asina kenza kana kenza, EUS-guided fine-needle aspiration/biopsy inogona kushandiswa (endoscopic ultrasonography guided fine nKutsvaga/kuongorora kenza yemudumbu, EUS-FNA/FNB), kuongorora mucosal incision biopsy (mucosalincision-assisted biopsy, MIAB), nezvimwewo. Itai sampling ye biopsy yekuongorora pathological preoperative. Tichifunga nezvemiganhu yeEUS-FNA uye mhedzisiro inotevera pa endoscopic resection, kune avo vanokodzera kuvhiyiwa endoscopic, vachifunga kuti bundu rinogona kubviswa zvachose, mayuniti ane tekinoroji yekurapa endoscopic yakakura anogona kurapwa nevanoziva. Endoscopist inoita endoscopic resection zvakananga pasina kuwana kuongororwa kwepathological preoperative.

Chero nzira yekuwana sampuli dzezvirwere usati wavhiyiwa inokuvadza uye inokuvadza mucosa kana kukonzera kunamira kune submucosal tissue, nokudaro zvichiwedzera kuoma kwekuvhiyiwa uye zvichida kuwedzera njodzi yekubuda ropa, perfo.kuyerwa kweropa, uye kupararira kwebundu. Saka, biopsy isati yaitwa haisi chinhu chinodiwa nguva dzose. Zvakakosha, kunyanya kune SMTs dzinogona kuongororwa ne endoscopy yakajairika pamwe chete neEUS, dzakadai se lipomas, cysts, uye ectopic pancreas, hapana kudiwa kwekutora sampuli yenyama.

2.SMT endoscopic treatment

(1) Nheyo dzekurapa

Maronda asina lymph node metastasis kana kuti ane njodzi shoma yekubuda kwelymph node, anogona kubviswa zvachose achishandisa nzira dze endoscopic, uye ane njodzi shoma yekubuda kwemasero emasero uye kudzoka kwemasero akakodzera kubviswa kwemasero emasero kana kurapwa kuchidikanwa. Kubviswa kwegomarara zvachose kunoderedza gomarara rakasara uye njodzi yekubuda kwemasero emasero.Pfungwa yekurapa pasina bundu inofanira kutevedzerwa panguva yekubvisa endoscopic resection, uye kuvimbika kwekapisi rebundu kunofanirwa kuve nechokwadi panguva yekubvisa bundu.

(2) Zviratidzo

i.Mamota ane mukana wekuita zvakaipa anofungidzirwa nekuongororwa usati wavhiyiwa kana kusimbiswa ne biopsy pathology, kunyanya ayo anofungidzirwa kuti ane GIST nekuongorora bundu rehurefu hwe ≤2cm usati wavhiyiwa uye mukana mudiki wekudzoka uye metastasis, uye mukana wekubviswa zvachose, inogona kubviswa ne endoscopically; kune bundu rine dhayamita refu. Kune GIST inofungidzirwa kuti ine njodzi shoma >2cm, kana lymph node kana metastasis iri kure isina kuongororwa pamberi pekuvhiyiwa, nekuda kwekuona kuti bundu rinogona kubviswa zvachose, kuvhiyiwa kwe endoscopic kunogona kuitwa nevanoongorora endoscopic vane ruzivo muyuniti ine tekinoroji yekurapa endoscopic yakakura.

ii. Zviratidzo (semuenzaniso, kubuda ropa, kuvharika) SMT.

iii. Varwere vane mamota anofungidzirwa kuti haana njodzi nekuongororwa vasati vavhiyiwa kana kuti vakasimbiswa nechirwere, asi vasingakwanise kuteverwa nguva dzose kana kuti vane mamota anokura mukati menguva pfupi panguva yekutevera uye vane chido chakasimba chekuva nechirwere.e yekurapa endoscopic.

(3) Zvipingamupinyi

i. Kuziva maronda andibatainonatswa kusvika kuma lymph nodes kana kunzvimbo dziri kure.

ii. Kune vamwe vane SMT vane lymph yakajekanodekana kuti kupararira kwemasero ari kure, biopsy inodiwa kuti pave nechirwere, izvo zvinogona kuonekwa sekusabvumirana.

iii. Mushure mekuvhiyiwa kwakadzamaPakuongorora, zvakaonekwa kuti mamiriro acho haana kunaka uye kuvhiyiwa kwe endoscopic hakugoneki.

Maronda asina kunaka akadai se lipoma ne ectopic pancreas kazhinji haakonzeri zviratidzo zvakaita sekurwadziwa, kubuda ropa, uye kuvharika.MT inoonekwa sekukura kwevhu, maronda, kana kuti inowedzera nekukurumidza munguva pfupi, mukana wekuti ive gonda rine kenza unowedzera.

(4) Sarudzo yenzira yekubvisa tsvinad

Kubviswa kwemusungo weEndoscopic: KweSMT iri pamusoro, inobuda mugomba sezvinoonekwa neEUS neCT bvunzo dzisati dzaitwa, uye inogona kubviswa zvachose panguva imwe chete nesnare, endoscopic snare resection inogona kushandiswa.

Ongororo dzemuno nedzekunze dzakaratidza kuti yakachengeteka uye inoshanda muSMT yepamusoro pasi pe2cm, ine njodzi yekubuda ropa kwe4% kusvika 13% uye kubookanjodzi ye2% kusvika 70%.

Kuchera kwemudumbu mudumbu uchishandisa endoscopic submucosal, ESE: Kune maSMT ane dhayamita refu ≥2 cm kana kana kuongororwa kwemifananidzo yepamberi pekuvhiyiwa kwakadai seEUS neCT kuchisimbisa kutiKana bundu rabuda mugomba, ESE inogoneka kubvisa SMTs dzakakosha kuburikidza ne endoscopic sleeve rese.

ESE inotevera tsika dzehunyanzvi dzeendoscopic submucosal dissection (ESD) uye endoscopic mucosal resection, uye nguva dzose vanoshandisa "flip-top" incision yakatenderedza bundu kubvisa mucosa yakafukidza SMT uye kuburitsa bundu racho pachena. , kuzadzisa chinangwa chekuchengetedza kusimba kwebundu, kuvandudza kusimba kwekuvhiyiwa, uye kuderedza matambudziko panguva yekuvhiyiwa. Kune bundu ≤1.5 cm, chiyero chakakwana chekuvhiyiwa kwe100% chinogona kuwanikwa.

Submucosal Tunneling Endoscopic Resection, STER: Kune SMT inobva mu muscularis propria mugurokuro, hilum, curvature shoma yedumbu, gastric antrum uye rectum, izvo zviri nyore kugadzira matunnel, uye dhayamita yakachinjika iri ≤ 3.5 cm, STER inogona kuva nzira yekurapa inofarirwa.

STER tekinoroji itsva yakagadzirwa zvichibva pakushandisa muromo ne endoscopic esophageal sphincterotomy (POEM) uye ikuwedzera kweESD tech.biology. Mwero wekubviswa kweSTER kubva muropa kusvika pa97.59% pakurapwa kweSMT unokwira kusvika pa84.9%.

Endoscopic Yakazara Ukobvu Resection, EFTR: Inogona kushandiswa kuSMT uko zvakaoma kugadzira mugero kana uko dhayamita yepamusoro yebundu iri ≥3.5 cm uye isingakodzeri STER. Kana bundu rikabuda pasi peganda repepuru kana kukura kunze kwechikamu chegomba, uye bundu rikaonekwa kuti rakanamatira zvakasimba paserosa layer panguva yekuvhiyiwa uye risingakwanise kuparadzaniswa, rinogona kushandiswa. EFTR inoita kurapwa kwe endoscopic.

Kusunga zvakanaka kweboorwaNzvimbo mushure meEFTR ndiyo kiyi yekubudirira kweEFTR. Kuti uongorore nemazvo njodzi yekudzoka kwegomarara uye kuderedza njodzi yekupararira kwegomarara, hazvikurudzirwi kucheka nekubvisa muenzaniso wegomarara rakabviswa panguva yeEFTR. Kana zvichidikanwa kubvisa gomarara muzvidimbu, gomarara rinofanira kutanga ragadziriswa kuderedza njodzi yekumera kwegomarara uye kupararira kwaro. Dzimwe nzira dzekusunga masero dzinosanganisira: suture yesimbi, suture yekusukwa, nzira yekusunga masero, nzira ye "purse bag suture" yetambo yenylon yakasanganiswa nesimbi, system yekuvhara simbi yerake metal (over the scope clip, OTSC) suture yeOverStitch nedzimwe tekinoroji itsva dzekugadzirisa kukuvara kwemudumbu uye kugadzirisa kubuda ropa, nezvimwewo.

(5) Matambudziko mushure mekuvhiyiwa

Kubuda ropa panguva yekuvhiyiwa: Kubuda ropa kunoita kuti hemoglobin yemurwere iderere neanopfuura 20 g/L.
Kudzivirira kubuda ropa kwakanyanya panguva yekuvhiyiwa,Jekiseni rakakwana remudumbu rinofanira kuitwa panguva yekuvhiyiwa kuti tsinga dzeropa dzakakura dzionekwe pachena uye kuti ropa riome nemagetsi. Kubuda ropa panguva yekuvhiyiwa kunogona kurapwa nemapanga akasiyana-siyana ekucheka, simbi dzinoshandiswa pakubvisa ropa, uye kudzivirira kubuda ropa kwetsinga dzinoshandiswa panguva yekuvhiyiwa.

Kubuda ropa mushure mekuvhiyiwa: Kubuda ropa mushure mekuvhiyiwa kunoratidzwa nekurutsa ropa, melena, kana ropa mutsvina. Muzviitiko zvakakomba, kuvhunduka kweropa kunogona kuitika. Kunowanzoitika mukati mevhiki imwe chete mushure mekuvhiyiwa, asi kunogonawo kuitika mavhiki maviri kusvika mana mushure mekuvhiyiwa.

Kubuda ropa mushure mekuvhiyiwa kunowanzoenderana nezvinhu zvakaita sekutadza kudzora BP mushure mekuvhiyiwa uye ngura yetsinga dzeropa dzasara neacid yemudumbu. Pamusoro pezvo, kubuda ropa mushure mekuvhiyiwa kune chekuitawo nenzvimbo yechirwere, uye kunowanzoitika mudumbu nemudumbu uye mudumbu.

Kunonoka kubooka: Kazhinji kunoratidzwa nekubuda kwedumbu, kurwadziwa kwakanyanya mudumbu, zviratidzo zveperitonitis, fivha, uye kuongororwa kwemifananidzo kunoratidza kuunganidzwa kwegasi kana kuwedzera kwegasi zvichienzaniswa nezvaimboitwa kare.

Zvinowanzoenderana nezvinhu zvakaita sekukwenya maronda zvisina kunaka, kuonda kwemaronda zvakanyanya, kumuka nekukurumidza kuti usafambe-fambe, kudya maearl zvakanyanya, kusadzora shuga muropa, uye kuputsika kwemaronda neacid yemudumbu. a. Kana ronda rakakura kana rakadzika kana ronda riine fis.Kana paine shanduko dzakafanana, nguva yekuzorora pamubhedha nenguva yekutsanya inofanira kuwedzerwa zvakakodzera uye kubviswa kwemudumbu kunofanira kuitwa mushure mekuvhiyiwa (varwere mushure mekuvhiyiwa kwemudumbu kwakaderera vanofanira kubudiswa mvura muchubhu yekubuda kwemusana); b. Varwere vane chirwere cheshuga vanofanira kudzora shuga yavo yeropa zvakanyanya; avo vane maburi madiki uye hutachiona hushoma hwepachipfuva nepadumbu vanofanira kupiwa mishonga yakadai sekutsanya, kudzivirira hutachiona, uye kuderedzwa kweasidhi; c. Kune avo vane effusion, chipfuva chakavharwa uye dumbu rinoboorwa zvinogona kuitwa. Machubhu anofanira kuiswa kuti mvura irambe yakatsetseka; d. Kana hutachiona husingakwanise kuwanikwa munzvimbo imwe chete mushure mekurapwa kwakachengetedzwa kana kuti huchibatanidzwa nehutachiona hwakakomba hwedumbu, laparoscopy yekuvhiya inofanira kuitwa nekukurumidza sezvinobvira, uye kugadziriswa kweboorwa uye kubuda kwemvura mudumbu kunofanira kuitwa.

Matambudziko ane chekuita negasi: Kusanganisira subcutaneous emphysema, pneumomediastinum, pneumothorax uye pneumoperitoneum.

Kuvhiyiwa kwepamuviri panguva yekuvhiyiwa (kunoratidzwa se emphysema pachiso, pamutsipa, pamadziro echipfuva, uye pamabhurugwa) uye mediastinal pneumophysema (s).Kubuda kwe epiglottis kunogona kuwanikwa panguva yekuongororwa kwegastroscopy) kazhinji hazvidi kurapwa kwakakosha, uye emphysema inowanzopera yega.

Pneumothorax yakanyanya inoitika dkuvhiyiwa kwemhepo [kumanikidzwa kwemhepo kunodarika 20 mmHg panguva yekuvhiyiwa

(1mmHg=0.133kPa), SpO2<90%, yakasimbiswa neX-ray yechipfuva chiri pamubhedha], kuvhiyiwa kunogona kuenderera mberi mushure mekuvhiyiwa kwechipfuva chakavharwa.zera.

Kune varwere vane pneumoperitoneum iri pachena panguva yekuvhiyiwa, shandisa tsono yepneumoperitoneum kuboora nzvimbo yeMcFarlandmudumbu repazasi rerudyi kuti mweya udzike, uye siya tsono yekuboorwa iri panzvimbo yayo kusvika pakupera kwekuvhiyiwa, wobva waibvisa mushure mekusimbisa kuti hapana gasi riri pachena riri kuburitswa.

Fistula yemudumbu: Mvura inobuda mudumbu inokonzerwa nekuvhiyiwa kwe endoscopic inoyerera ichipinda muchipfuva kana mudumbu kuburikidza nekubuda kwemvura.
Zvirwere zveEsophageal mediastinal fistulas uye esophagothoracic fistulas zvakajairika. Kana fistula yangoitika, bvisa mvura muchipfuva kuti uchengetedzemunzvimbo dzakatsetseka dzemvura uye dzinopa rutsigiro rwakakwana rwezvekudya. Kana zvichidikanwa, zvipikiri zvesimbi nezvimwe zvakasiyana-siyana zvekuvhara zvinogona kushandiswa, kana kuti chifukidziro chose chinogona kudzokororwa. Mastenti nedzimwe nzira dzinoshandiswa kudzivirirafistula. Nyaya dzakakomba dzinoda kuvhiyiwa nekukurumidza.

3. Kutarisirwa mushure mekuvhiyiwa (f)kuomerera)

(1) Maronda asina kunaka:Zvirwere zvepfungwazvinoratidza kuti maronda asina njodzi akadai se lipoma ne leiomyoma haadi kuteverwa nguva nenguva.

(2) SMT isina mhosva yekukuvadzakugona kwesvosve:Semuenzaniso, maNET erectal 2cm, uye GIST ine njodzi yepakati nepamusana, kurongwa kwakazara kwematanho ekurapa kunofanirwa kuitwa uye mamwe marapirwo (kuvhiyiwa, chemotherapy, kurapwa kwakanangana) anofanira kufungwa zvakanyanya. Kuumbwa kwechirongwa kunofanirwa kunge kwakavakirwa pakubvunzana kwemarudzi akawanda uye pamunhu mumwe nemumwe.

(3) SMT ine mukana mudiki wekenza:Semuenzaniso, GIST ine njodzi shoma inofanira kuongororwa neEUS kana kufungidzira mwedzi 6 kusvika 12 yega yega mushure mekurapwa, uye yozorapwa zvichienderana nemirayiridzo yekiriniki.

(4) SMT ine mukana wepakati nepakati uye wakakwira wekenza:Kana chirwere chemudumbu mushure mekuvhiyiwa chikaratidza kuti chirwere chemudumbu cherudzi rwechitatu chine NET, NET yemudumbu ine hurefu hwe>2cm, uye GIST ine njodzi yepakati nepakati, kuvhiyiwa kwacho kunofanira kuitwa uye mamwe marapirwo (kuvhiyiwa, chemotherapy, kurapwa kwakanangana) anofanira kufungwa nezvawo. Kugadzirwa kwechirongwa kunofanira kunge kwakavakirwa pa:[nezvedu 0118.docx]kubvunzana kwevadzidzi vane hunyanzvi hwakasiyana-siyana uye pamunhu mumwe nemumwe.