Endoscopic kurapwa kwe submucosal tumors yegumbo rekudya: 3 pfungwa huru dzakapfupikiswa muchinyorwa chimwe.

Submucosal tumors (SMT) yedumbu remudumbu maronda akakwira anobva muscularis mucosa, submucosa, kana muscularis propria, uye anogona kunge ari extraluminal maronda.Nekuvandudzwa kwehunyanzvi hwekurapa, sarudzo dzechinyakare dzekuvhiya dzakapinda zvishoma nezvishoma munguva yekurapa kushoma, senge l.kuvhiyiwa kweparoscopic uye kuvhiyiwa kwerobhoti.Zvisinei, mukudzidzira kwekliniki, zvinogona kuwanikwa kuti "kuvhiyiwa" hakukodzeri varwere vose.Mumakore achangopfuura, kukosha kwe endoscopic kurapwa kwave kugamuchirwa zvishoma nezvishoma.Iyo yazvino vhezheni yeChinese nyanzvi yekubvumirana pane endoscopic kuongororwa uye kurapwa kweSMT yakaburitswa.Ichi chinyorwa chichadzidza muchidimbu ruzivo rwakakodzera.

1.SMT denda hunhurics

(1) Chiitiko cheSMT haina kuenzana muzvikamu zvakasiyana-siyana zveguyo, uye dumbu ndiro rinowanzozivikanwa nzvimbo ye SMT.

Kuitika kwakasiyanas zvikamu zvegumbo rekudya hazvina kuenzana, nepamusoro pegumbo rinonyanya kuwanda.Pakati peizvi, 2/3 inoitika mudumbu, ichiteverwa nesophagus, duodenum, uye colon.

(2) The histopathologicall marudzi eSMT akaoma, asi mazhinji eSMT ane maronda asina kunaka, uye mashoma chete akashata.

A.SMT inosanganisira kweten-neoplastic maronda akadai ectopic pancreatic tishu uye neoplastic maronda.

B.Pakati pezvironda zveplastics, gastrointestinal leiomyomas, lipomas, Brucella adenomas, granulosa cell tumors, schwannomas, uye glomus tumors kazhinji ane ngozi, uye isingasviki 15% inogona kuonekwa senyama Dzidza zvakaipa.

C.Gastrointestinal stromal tumors (GIST) uye neuroendocrine tumors (NET) muSMT mamota ane humwe huipi hunogona kuitika, asi izvi zvinoenderana nehukuru hwayo, nzvimbo uye rudzi.

D. Nzvimbo yeSMT ine hukamakune pathological classification: a.Leiomyomas inzira yakajairika yeSMT mugurokuro, inoverengera 60% kusvika 80% yesophageal SMTs, uye inowanzoitika pakati nepakati zvikamu zvegurokuro;b.The pathological types of gastric SMT yakaoma, ine GIST, leiomyoma uye ectopic pancreas ndiyo inonyanya kuzivikanwa.Pakati pegastric SMT, GIST inonyanya kuwanikwa mu fundus uye muviri wedumbu, leiomyoma inowanzowanikwa mu cardia nechepamusoro pemuviri, uye ectopic pancreas uye ectopic pancreas ndiyo yakawanda.Lipomas inowanzoonekwa mugastric antrum;c.Lipomas uye cysts zvinowanzoitika mukudzika uye bulbous zvikamu zve duodenum;d.MuSMT yepasi regumbo turakiti, lipomas ndiye akanyanya mukoloni, nepo maNETs ari akanyanya murectum.

(3) Shandisa CT uye MRI kugiredhi, kurapa, uye kuongorora mamota.Kune maSMTs anofungidzirwa kuti anogona kukuvadza kana kuve nemamota makuru (akarebadhayamita> 2 cm), CT uye MRI inokurudzirwa.

Dzimwe nzira dzekufungidzira, kusanganisira CT uye MRI, dzinewo kukosha kukuru kwekuongororwa kweSMT.Vanogona kuratidza zvakananga nzvimbo yekuitika kwebundu, chimiro chekukura, saizi yeronda, chimiro, kuvapo kana kusavapo kwe lobulation, density, homogeneity, dhigirii rekusimudzira, uye muganhu contour, nezvimwewo, uye vanogona kuwana kana uye dhigirii gobvu.ening of the gastrointestinal wall.Zvinonyanya kukosha, izvi zvinongororwa zvekufungidzira zvinogona kuona kana kune kupindira kwezvivako zviri pedyo zvechirwere uye kana kune metastasis munzvimbo yakapoteredza peritoneum, lymph nodes nedzimwe nhengo.Ndivo nzira huru yekiriniki giredhi, kurapwa uye prognosis ongororo yemamota.

(4) Tissue sampling haisi recozvakagadzirirwa maSMTs ane benign anogona kuongororwa neyakajairwa endoscopy yakasanganiswa neEUS, senge lipomas, cysts, uye ectopic pancreas.

Kune maronda anofungidzirwa kuti ane hutsinye kana kana endoscopy yakajairwa yakasanganiswa neEUS isingakwanise kuongorora maronda akashata kana akashata, EUS-inotungamirwa neinotungamira tsono aspiration / biopsy inogona kushandiswa (endoscopic ultrasonography inotungamirwa yakanaka n.eedle aspiration/biopsy, EUS-FNA/FNB), mucosal incision biopsy(mucosalincision-assisted biopsy, MIAB), zvichingodaro ita biopsy sampling yepreoperative pathological evaluation.Tichifunga nezve zvipimo zveEUS-FNA uye nemhedzisiro inozokonzeresa endoscopic resection, kune avo vanokodzera kuvhiyiwa endoscopic, pane fungidziro yekuona kuti bundu rinogona kubviswa zvachose, mayuniti ane yakakura endoscopic kurapwa tekinoroji anogona kurapwa nevane ruzivo. Iyo endoscopist inoita endoscopic resection zvakananga pasina kuwana preoperative pathological diagnosis.

Chero nzira yekuwana pathological specimens vasati vavhiyiwa invasive uye ichakuvadza mucosa kana kukonzera kunamatira kune submucosal tissue, nekudaro kuwedzera kuoma kwekuvhiyiwa uye zvichida kuwedzera njodzi dzekubuda ropa, perfo.ration, uye kuparadzirwa kwebundu.Nokudaro, preoperative biopsy haifaniri hazvo kudiwa.Zvinodikanwa, kunyanya kune maSMTs anogona kuongororwa neyakajairwa endoscopy yakasanganiswa neEUS, senge lipomas, cysts, uye ectopic pancreas, hapana sampling yetishu inodiwa.

2.SMT endoscopic kurapwant

(1)Mitemo yekurapa

Maronda asina lymph node metastasis kana ngozi yakaderera zvikuru ye lymph node metastasis, inogona kugadziriswa zvachose uchishandisa endoscopic maitiro, uye ine ngozi shoma yekusara uye kudzokorora inokodzera endoscopic resection kana kurapwa kuchidikanwa.Kubviswa zvachose kwebundu kunoderedza kusara kwebundu uye njodzi yekudzokazve.Themusimboti wekurapwa pasina bundu kunofanirwa kuteverwa panguva ye endoscopic resection, uye kuvimbika kwebundu capsule kunofanirwa kuve nechokwadi panguva yekubviswa.

(2)Zviratidzo

i. Tumors ane njodzi inogona kufungidzirwa ne preoperative bvunzo kana yakasimbiswa ne biopsy pathology, kunyanya avo vanofungidzirwa nezveGI.ST ine preoperative assessment yebundu kureba kwe ≤2cm uye njodzi yakaderera yekudzokorora uye metastasis, uye pamwe nekukwanisa kwekugadzirisa zvachose, inogona kugadziriswa endoscopically;Kumamota ane dhayamita refu Kune vanofungidzirwa kuti vane njodzi yakaderera GIST> 2cm, kana lymph node kana metastasis iri kure yakabviswa kubva pakuongororwa kusati kwaitwa, pachitariswa chekuona kuti bundu racho rinogona kubviswa zvachose, endoscopic surgery inogona kuitwa nevanoziva endoscopist mu. yuniti ine yakakura endoscopic kurapwa tekinoroji.resection.

ii.Symptomatic (semuenzaniso, kubuda ropa, kuvharidzira) SMT.

iii.Varwere vane mapundu anofungidzirwa kuti haana kunaka nekuongororwa kwepamberi kana kusimbiswa nehutachiona, asi haagone kuteverwa nguva nenguva kana kuti mamota anowedzera mukati menguva pfupi munguva yekutevera uye vane chido chakasimba.e endoscopic kurapwa.

(3)Contraindications

i.Ziva maronda andiinawoinonaka kune lymph nodes kana nzvimbo dziri kure.

ii.Kune imwe SMT ine lymph yakajekanodekana kure kure metastasis, bulk biopsy inodiwa kuwana pathology, iyo inogona kutorwa sehama contraindication.

iii.Pashure pezvakadzama preoperativekuongororwa, zvinotarirwa kuti mamiriro ezvinhu ose haana kunaka uye kuvhiyiwa kwe endoscopic hakugoneki.

Benign maronda akadai se lipoma uye ectopic pancreas kazhinji haakonzeri zviratidzo zvakaita sekurwadziwa, kubuda ropa, uye kuvharika.Apo SMT inoratidzira sekukurwa, chironda, kana kukurumidza kuwedzera munguva pfupi, mukana wekuti kuve kukuvadza kwakashata kunowedzera.

(4)Sarudzo yeresection method

Endoscopic snare resection: ForSMT iri pamusoro-soro, inobuda mugomba sezvakatemwa ne preoperative EUS uye CT bvunzo, uye inogona kudzokororwa zvachose panguva imwe chete nemusungo, endoscopic snare resection inogona kushandiswa.

Zvidzidzo zvemumba nekune dzimwe nyika zvakasimbisa kuti yakachengeteka uye inoshanda mune yepamusoro SMT <2cm, ine njodzi yekubuda ropa ye4% kusvika 13% uye perforation.njodzi ye2% kusvika 70%.

Endoscopic submucosal excavation,ESE : YeSMTs ine dhayamita refu ≥2 cm kana kana preoperative imaging bvunzo senge EUS uye CT inosimbisapabundu rinobuda mukati memhango, ESE inogoneka kune endoscopic sleeve resection yeakakosha SMTs.

ESE inotevera hunyanzvi maitiro eendoscopic submucosal dissection (ESD) uye endoscopic mucosal resection, uye nguva nenguva inoshandisa denderedzwa "flip-top" incision yakatenderedza bundu kubvisa mucosa inovhara SMT uye kunyatsoburitsa bundu racho., kuzadzisa chinangwa chekuchengetedza kutendeseka kwebundu, kuvandudza radicalness yekuvhiya, uye kuderedza intraoperative matambudziko.Pamamota ≤1.5 cm, chiyero chakakwana chekugadzirisa che100% chinogona kuwanikwa.

Submucosal Tunneling Endoscopic Resection, STER : Kune SMT inotangira muscularis propria mugurokuro, hilum, kushoma curvature yegastric body, gastric antrum uye rectum, zviri nyore kumisikidza tunnel, uye dhayamita rakachinjika ≤ 3.5 cm, STER inogona kudiwa nzira yekurapa.

STER tekinoroji nyowani yakagadziridzwa yakavakirwa peroral endoscopic esophageal sphincterotomy (POEM) uye ndeyekuwedzera kweESD tech.nology.Iyo en bloc resection rate yeSTER yeSMT kurapwa inosvika 84.9% kusvika 97.59%.

Endoscopic Yakazara-ukobvu Resection,EFTR :Inogona kushandiswa kuSMT uko kwakaoma kumisa mugero kana uko iyo yakanyanya kuchinjika dhayamita yebundu iri ≥3.5 cm uye haina kukodzera STER.Kana bundu racho richikwira pasi pepepuru membrane kana kukura kunze kwechikamu chegomba, uye bundu racho rinowanikwa rakanyatso kuomerera kune serosa layer panguva yekuvhiyiwa uye risingakwanisi kupatsanurwa, rinogona kushandiswa.EFTR inoita endoscopic treatment.

Suturing yakakodzera ye perforationsaiti mushure meEFTR ndiyo kiyi yekubudirira kweEFTR.Kuti unyatsoongorora njodzi yekudzokororwa kwebundu uye kuderedza njodzi yekuparadzira bundu, hazvikurudzirwe kucheka uye kubvisa iyo yakadzoserwa bundu specimen panguva yeEFTR.Kana zvichidikanwa kubvisa bundu muzvidimbu, iyo perforation inoda kutanga yagadziriswa kuderedza njodzi yekumera kwebundu uye kupararira.Dzimwe nzira dzekugezera dzinosanganisira: metal clip suture, suction-clip suture, omental patch suture technique, "purse bag suture" nzira yenaironi tambo yakasanganiswa nesimbi clip, rake metal clip closure system (pamusoro pe scope clip, OTSC) OverStitch suture nezvimwe. matekinoroji matsva ekugadzirisa kukuvara kwemudumbu uye kubata nekubuda ropa, nezvimwe.

(5)Postoperative complications

Kubuda ropa muropa: Kubuda ropa kunoita kuti hemoglobin yemurwere iderere neinopfuura 20 g/L.
Kudzivirira kubuda kweropa kwakanyanya,zvakakwana submucosal jekiseni anofanira kuitwa panguva oparesheni kufumura hombe tsinga uye kufambisa electrocoagulation kumisa kubuda ropa.Kubuda ropa kwemukati mekushanda kunogona kurapwa nemapanga akasiyana-siyana ekucheka, hemostatic forceps kana simbi clips, uye kudzivirira hemostasis yemidziyo yeropa yakafumurwa inowanikwa panguva yekutsemura.

Kubuda ropa mushure mekushanda: Kubuda ropa mushure mekushanda kunoratidza seropa rekurutsa, melena, kana ropa muchituru.Muzviitiko zvakanyanya, hemorrhagic shock inogona kuitika.Inowanzoitika mukati mevhiki ye1 mushure mekuvhiyiwa, asi inogonawo kuitika 2 kusvika kumavhiki e4 mushure mekuvhiyiwa.

Kubuda ropa mushure mekushanda kunowanzoenderana nezvinhu zvakadai sekushaya simba kwemashure ekuvhiyiwa kweropa uye kuora kwetsinga dzeropa dzakasara negastric acid.Mukuwedzera, kubuda ropa mushure mekushanda kunobatanawo nenzvimbo yechirwere, uye inowanzoonekwa mugastric antrum uye pasi rectum.

Kunonoka kutumbuka: Kunowanzo ratidza seabdominal distension, kuwedzera kurwadza kwemudumbu, zviratidzo zve peritonitis, fivha, uye kuongorora kwekufungidzira kunoratidza kuunganidzwa kwegasi kana kuwedzera kuunganidzwa kwegasi zvichienzaniswa nekare.

Zvinonyanya kuenderana nezvinhu zvakaita sekushaikwa kwemaronda, kuwandisa kwe electrocoagulation, kumuka nekukurumidza kuti ufambe-famba, kudya nzeve yakawandisa, kutadza kutonga shuga muropa, uye kukukurwa kwemaronda negastric acid.a.Kana ronda rakakura kana rakadzika kana ronda riine fischokwadi-sekuchinja, nguva yekuzorora pamubhedha uye nguva yekutsanya inofanira kuwedzerwa zvakakodzera uye kuora kwepamuviri kunofanira kuitwa mushure mekuvhiyiwa (varwere mushure mekuvhiyiwa kwepazasi kwepamuviri kunofanira kuva nemarara emvura);b.Varwere vane chirwere cheshuga vanofanira kunyatsodzora shuga yavo yeropa;avo vane tumabhonzo diki uye hunyoro hwechipfuva nedumbu vanofanira kupihwa marapirwo akadai sekutsanya, anti-infection, uye kudzvanywa kweasidhi;c.Kune avo vane effusion, yakavharwa chipfuva drainage uye abdominal puncture inogona kuitwa Machubhu anofanirwa kuiswa kuti achengetedze mvura yakatsetseka;d.Kana hutachiona husingakwanisi kuwanikwa mushure mekurapa kwekuchengetedza kana kusanganiswa nehutachiona hwe thoracoabdominal, kuvhiyiwa laparoscopy kunofanira kuitwa nokukurumidza sezvinobvira, uye kugadziriswa kweperforation uye kubuda kwedumbu kunofanira kuitwa.

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

Intraoperative subcutaneous emphysema (inoratidzwa seemphysema kumeso, mutsipa, chipfuva, uye scrotum) uye mediastinal pneumophysema (s.epiglottis inogona kuwanikwa panguva yegastroscopy) kazhinji haidi kurapwa kwakakosha, uye emphysema inozozvigadzirisa yega.

Yakanyanya pneumothorax inoitika dkuvhiyiwa weti [kumanikidzwa kwemhepo kunodarika 20 mmHg panguva yekuvhiyiwa

(1mmHg = 0.133kPa), SpO2 <90%, yakasimbiswa nekukurumidzira pamubhedha wechipfuva X-ray], kuvhiyiwa kunogona kuenderera mberi mushure mekuvharwa kwechipfuva.inage.

Kune varwere vane pneumoperitoneum iri pachena panguva yekuvhiya, shandisa pneumoperitoneum tsono kubaya nzvimbo yeMcFarland.mudumbu rezasi rekurudyi kuti musvibise mhepo, wosiya tsono yekubaya iri panzvimbo kusvika pakupera kwekuvhiya, wozoibvisa mushure mekusimbisa kuti hapana gasi rinobuda.

Gastrointestinal fistula: Digestive fluid inokonzerwa nekuvhiyiwa kwe endoscopic inoyerera ichipinda muchipfuva kana mudumbu kuburikidza nekubuda.
Esophageal mediastinal fistulas uye esophagothoracic fistulas zvinowanzoitika.Kana fistula yangoitika, ita mvura yechipfuva yakavharwa kune maintamumvura yakatsetseka uye inopa rubatsiro rwakakwana rwekudya kunovaka muviri.Kana zvichidikanwa, zvimedu zvesimbi uye zvakasiyana-siyana zvekuvhara zvinogona kushandiswa, kana chifukidziro chakazara chinogona kushandiswazve.Stents nedzimwe nzira dzinoshandiswa kuvharafistula.Mhosva dzakakomba dzinoda kupindira kwekuvhiya nokukurumidza.

3.Postoperative management (fkupera)

(1) Maronda akanaka:Pathology sinokurudzira kuti maronda asina kunaka akadai se lipoma uye leiomyoma haadi zvinosungirwa kugara uchitevera.

(2) SMT isina kushatisamasvosve anogona:Semuyenzaniso, rectal NETs 2cm, uye yepakati-uye nepamusoro-njodzi GIST, danho rakakwana rinofanira kuitwa uye mamwe marapirwo (kuvhiya, chemoradiotherapy, kurapa kwakanangwa) kunofanirwa kutariswa zvakanyanya.kubata).Kuumbwa kwechirongwa kunofanirwa kuve kwakavakirwa pakubvunzana kwakasiyana-siyana uye pamunhu.

(3) Yakaderera yakashata inogona SMT:Semuenzaniso, GIST ine ngozi shoma inoda kuongororwa neEUS kana kufungidzira mwedzi mitanhatu kusvika kumiviri yega yega mushure mekurapwa, uyezve kurapwa maererano nemirairo yekiriniki.

(4) SMT ine yepakati uye yakakwirira yakashata inogona:Kana postoperative pathology ichisimbisa mhando ye3 gastric NET, colorectal NET ine kureba> 2cm, uye yepakati-nengozi yeGIST, danho rakakwana rinofanira kuitwa uye mamwe marapirwo (kuvhiya, chemoradiotherapy, kurapa kwakanangwa) kunofanirwa kutariswa zvakanyanya.kubata).Kuumbwa kwechirongwa kunofanirwa kuve kwakavakirwa[ about us 0118.docx] multidisciplinary consultation and on a individual basis.