Kev kho mob Endoscopic ntawm cov qog submucosal ntawm txoj hnyuv zom zaub mov: 3 lub ntsiab lus tseem ceeb tau muab sau ua ib tsab xov xwm

Cov qog nqaij hlav hauv qab plab (SMT) ntawm txoj hnyuv plab yog cov qhov txhab siab uas pib los ntawm cov leeg nqaij mucosa, submucosa, lossis muscularis propria, thiab kuj tseem yuav yog cov qhov txhab sab nraud. Nrog rau kev txhim kho ntawm cov thev naus laus zis kho mob, cov kev kho mob phais ib txwm muaj tau maj mam nkag mus rau lub sijhawm ntawm kev kho mob tsawg kawg nkaus, xws li lKev phais mob aparoscopic thiab kev phais mob robotic. Txawm li cas los xij, hauv kev kho mob, nws tuaj yeem pom tias "kev phais mob" tsis haum rau txhua tus neeg mob. Nyob rau xyoo tas los no, qhov tseem ceeb ntawm kev kho mob endoscopic tau maj mam tau txais kev saib xyuas. Cov ntawv tshiab tshaj plaws ntawm kev pom zoo ntawm cov kws tshaj lij Suav teb txog kev kuaj mob endoscopic thiab kev kho mob SMT tau raug tso tawm. Tsab xov xwm no yuav kawm luv luv txog cov kev paub tseem ceeb.

1. Tus cwj pwm kis kab mob SMTcov lus qhia

(1) Qhov tshwm sim ntawm SMT tsis sib npaug hauv ntau qhov ntawm txoj hnyuv zom zaub mov, thiab lub plab yog qhov chaw feem ntau rau SMT.

Qhov tshwm sim ntawm ntau yamCov feem ntawm txoj hnyuv zom zaub mov tsis sib npaug, nrog rau txoj hnyuv zom zaub mov sab saud feem ntau tshwm sim. Ntawm cov no, 2/3 tshwm sim hauv plab, ua raws li txoj hlab pas, duodenum, thiab hnyuv loj.

(2) Kev kuaj mob histopathologicall hom SMT yog cov nyuaj, tab sis feem ntau SMT yog cov qhov txhab zoo, thiab tsuas yog ob peb yam yog cov mob phem.

A.SMT tsis suav nrogn-neoplastic lesions xws li cov ntaub so ntswg pancreatic ectopic thiab neoplastic lesions.

B. Ntawm cov qog nqaij hlavs, gastrointestinal leiomyomas, lipomas, Brucella adenomas, granulosa cell tumors, schwannomas, thiab glomus tumors feem ntau yog benign, thiab tsawg dua 15% tuaj yeem tshwm sim ua cov ntaub so ntswg Kawm phem.

C. Cov hlab ntsha hauv plab hnyuvCov qog nqaij hlav (GIST) thiab cov qog nqaij hlav neuroendocrine (NET) hauv SMT yog cov qog nqaij hlav uas muaj qee yam peev xwm ua rau mob qog noj ntshav, tab sis qhov no nyob ntawm nws qhov loj me, qhov chaw thiab hom.

D. Qhov chaw ntawm SMT muaj feem cuam tshuamrau qhov kev faib tawm pathological: a. Leiomyomas yog ib hom pathological SMT hauv txoj hlab pas, suav txog 60% txog 80% ntawm cov esophageal SMTs, thiab feem ntau yuav tshwm sim hauv nruab nrab thiab qis dua ntawm txoj hlab pas; b. Cov hom pathological ntawm gastric SMT yog qhov nyuaj heev, nrog GIST, leiomyoma thiab ectopic pancreas yog qhov feem ntau. Ntawm cov gastric SMT, GIST feem ntau pom muaj nyob rau hauv fundus thiab lub cev ntawm lub plab, leiomyoma feem ntau nyob rau hauv cardia thiab sab saud ntawm lub cev, thiab ectopic pancreas thiab ectopic pancreas yog feem ntau. Lipomas feem ntau pom muaj nyob rau hauv gastric antrum; c. Lipomas thiab cysts feem ntau pom muaj nyob rau hauv descending thiab bulbous qhov chaw ntawm duodenum; d. Hauv SMT ntawm lub plab hnyuv qis, lipomas feem ntau pom muaj nyob rau hauv colon, thaum NETs feem ntau pom muaj nyob rau hauv rectum.

(3) Siv CT thiab MRI los ntsuas qib, kho, thiab soj ntsuam cov qog nqaij hlav. Rau cov SMTs uas xav tias yuav muaj mob qog nqaij hlav lossis muaj cov qog nqaij hlav loj (ntevYog tias koj muaj lub cheeb tsam uas loj dua 2 cm, ces yuav tsum tau siv CT thiab MRI.

Lwm cov txheej txheem thaij duab, suav nrog CT thiab MRI, kuj tseem ceeb heev rau kev kuaj mob SMT. Lawv tuaj yeem qhia qhov chaw ntawm qhov mob qog, tus qauv kev loj hlob, qhov loj me ntawm qhov mob, cov duab, muaj lossis tsis muaj lobulation, qhov ceev, homogeneity, qib kev txhim kho, thiab ciam teb contour, thiab lwm yam, thiab tuaj yeem nrhiav seb thiab qib ntawm tuabkev qhib ntawm phab ntsa plab hnyuv. Qhov tseem ceeb tshaj, cov kev kuaj duab no tuaj yeem ntes tau seb puas muaj kev nkag mus rau hauv cov qauv ntawm qhov mob thiab seb puas muaj metastasis hauv peritoneum, cov qog ntshav thiab lwm yam kabmob ib puag ncig. Lawv yog txoj hauv kev tseem ceeb rau kev ntsuas qib hauv kev kho mob, kev kho mob thiab kev kwv yees ntawm cov qog.

(4) Kev kuaj cov ntaub so ntswg tsis yog rov ua duaHaum rau cov SMTs benign uas tuaj yeem kuaj pom los ntawm kev siv endoscopy ua ke nrog EUS, xws li lipomas, cysts, thiab ectopic pancreas.

Rau cov qhov txhab uas xav tias yog mob qog nqaij hlav lossis thaum kev siv tshuab endoscopy ua ke nrog EUS tsis tuaj yeem soj ntsuam cov qhov txhab zoo lossis mob qog nqaij hlav, EUS-guided fine-needle aspiration/biopsy siv tau (endoscopic ultrasonography guided fine nKev kuaj mob eedle/biopsy, EUS-FNA/FNB), kev kuaj mob mucosal incision (mucosalincision-assisted biopsy, MIAB), thiab lwm yam. ua kev kuaj biopsy rau kev ntsuam xyuas kab mob ua ntej phais. Vim muaj kev txwv ntawm EUS-FNA thiab qhov cuam tshuam tom qab ntawd rau kev phais endoscopic, rau cov neeg uas tsim nyog rau kev phais endoscopic, ntawm qhov kev xav kom paub tseeb tias cov qog tuaj yeem raug phais tag nrho, cov chav tsev nrog cov thev naus laus zis kho mob endoscopic laus tuaj yeem kho tau los ntawm cov neeg paub dhau los. Tus kws kho mob endoscopist ua qhov kev phais endoscopic ncaj qha yam tsis tau txais kev kuaj mob ua ntej phais.

Txhua txoj kev tau txais cov qauv kuaj mob ua ntej phais mob yog kev nkag mus rau hauv lub cev thiab yuav ua rau lub qhov mucosa puas tsuaj lossis ua rau lo rau cov ntaub so ntswg submucosal, yog li ua rau muaj kev nyuaj ntawm kev phais mob thiab tej zaum yuav ua rau muaj kev pheej hmoo ntawm kev los ntshav, ua tiav.kev faib ua feem, thiab kev kis tus kab mob qog nqaij hlav. Yog li ntawd, kev kuaj nqaij ua ntej phais tsis tas yuav tsum muaj. Tsim nyog, tshwj xeeb tshaj yog rau SMTs uas tuaj yeem kuaj tau los ntawm kev siv endoscopy ua ke nrog EUS, xws li lipomas, cysts, thiab ectopic pancreas, tsis tas yuav kuaj cov nqaij.

2. Kev kho mob SMT endoscopicnt

(1) Cov ntsiab cai kho mob

Cov qhov txhab uas tsis muaj cov qog ntshav kis mus rau lwm qhov lossis muaj kev pheej hmoo tsawg heev ntawm cov qog ntshav kis mus rau lwm qhov, tuaj yeem phais tau tag nrho siv cov txheej txheem endoscopic, thiab muaj kev pheej hmoo tsawg ntawm cov seem thiab rov tshwm sim dua yog qhov tsim nyog rau kev phais endoscopic yog tias tsim nyog kho. Kev tshem tawm tag nrho ntawm cov qog ntshav txo cov qog ntshav seem thiab kev pheej hmoo ntawm kev rov tshwm sim dua. LubYuav tsum ua raws li txoj cai ntawm kev kho mob tsis muaj qog thaum lub sijhawm endoscopic resection, thiab yuav tsum xyuas kom meej tias lub capsule qog noj ntshav ruaj khov thaum lub sijhawm resection.

(2) Cov cim qhia

i. Cov qog nqaij hlav uas muaj peev xwm ua rau mob qog nqaij hlav uas xav tias yuav yog los ntawm kev kuaj mob ua ntej lossis lees paub los ntawm kev kuaj mob biopsy, tshwj xeeb tshaj yog cov uas xav tias muaj kab mob plab hnyuv.ST nrog kev ntsuam xyuas ua ntej ntawm qhov ntev ntawm qhov mob qog ntawm ≤2cm thiab muaj kev pheej hmoo tsawg ntawm kev rov tshwm sim thiab metastasis, thiab nrog rau qhov ua tau ntawm kev phais tag nrho, tuaj yeem raug phais endoscopically; rau cov qog nrog lub cheeb ntev Rau qhov xav tias muaj kev pheej hmoo tsawg GIST >2cm, yog tias cov qog ntshav lossis metastasis deb tau raug tshem tawm ntawm kev ntsuam xyuas ua ntej phais, ntawm lub hauv paus ntawm kev ua kom ntseeg tau tias qhov mob qog tuaj yeem raug phais tag nrho, kev phais endoscopic yuav ua tau los ntawm cov kws kho mob endoscopist uas muaj kev paub dhau los hauv chav tsev nrog cov thev naus laus zis kho endoscopic laus. resection.

ii. Muaj tsos mob (piv txwv li, los ntshav, txhaws) SMT.

iii. Cov neeg mob uas lawv cov qog nqaij hlav raug xav tias tsis muaj mob los ntawm kev kuaj ua ntej lossis tau lees paub los ntawm kev kuaj mob, tab sis tsis tuaj yeem raug saib xyuas tas li lossis lawv cov qog nqaij hlav loj hlob hauv lub sijhawm luv luv thaum lub sijhawm saib xyuas thiab cov neeg uas muaj lub siab xav ua kom zoo.e rau kev kho mob endoscopic.

(3) Cov Kev Txwv Tsis Pub Siv

i. Txheeb xyuas cov qhov txhab uas ua rau kuvsaj mus rau cov qog ntshav hauv lub qhov ncauj lossis cov chaw deb.

ii. Rau qee qhov SMT nrog cov lymph ntshiabnodelossis metastasis deb, yuav tsum tau kuaj ntau qhov biopsy kom tau txais pathology, uas tuaj yeem suav tias yog ib qho contraindication.

iii. Tom qab ua tiav kev phais ua ntejkev ntsuam xyuas, nws tau txiav txim siab tias tus mob dav dav tsis zoo thiab kev phais endoscopic tsis tuaj yeem ua tau.

Cov qhov txhab zoo li lipoma thiab ectopic pancreas feem ntau tsis ua rau muaj cov tsos mob xws li mob, los ntshav, thiab txhaws. Thaum SMT tshwm sim los ntawm kev lwj, mob qog, lossis nce sai sai hauv lub sijhawm luv luv, qhov ua tau tias nws yog qhov mob phem yuav nce ntxiv.

(4) Kev xaiv txoj kev txiav tawmd

Kev phais endoscopic rau cov hlab ntsha tawg: rauSMT uas tsis tob npaum li saum npoo av, tawm mus rau hauv qhov chaw raws li kev kuaj EUS thiab CT ua ntej phais, thiab tuaj yeem phais tag nrho ib zaug nrog lub snare, kev phais endoscopic snare siv tau.

Cov kev tshawb fawb hauv tsev thiab txawv teb chaws tau lees paub tias nws muaj kev nyab xeeb thiab ua tau zoo hauv superficial SMT <2cm, nrog rau kev pheej hmoo ntawm kev los ntshav ntawm 4% txog 13% thiab qhov perforationkev pheej hmoo ntawm 2% txog 70%.

Kev khawb hauv qab ntawm lub qhov ncauj los ntawm kev siv lub koob yees duab endoscopic, ESE: Rau cov SMTs uas muaj txoj kab uas hla ntev ≥2 cm lossis yog tias kev kuaj duab ua ntej kev phais xws li EUS thiab CT lees paub qhov ntawdThaum lub qog tawm mus rau hauv qhov khoob, ESE ua tau rau kev phais endoscopic ntawm cov SMTs tseem ceeb.

ESE ua raws li cov kev coj ua ntawm kev siv tshuabkev phais mob endoscopic submucosal dissection (ESD) thiab endoscopic mucosal resection, thiab siv ib qho kev phais puag ncig "flip-top" ncig lub qog kom tshem tawm cov mucosa uas npog SMT thiab qhia tag nrho lub qog. , kom ua tiav lub hom phiaj ntawm kev khaws cia qhov kev ncaj ncees ntawm lub qog, txhim kho qhov radicalness ntawm kev phais, thiab txo cov teeb meem intraoperative. Rau cov qog ≤1.5 cm, tus nqi phais tiav ntawm 100% tuaj yeem ua tiav.

Kev phais Endoscopic Submucosal Tunnelingion, STER: Rau SMT uas pib los ntawm cov leeg nqaij propria hauv txoj hlab pas, hilum, qhov nkhaus me dua ntawm lub cev plab, gastric antrum thiab rectum, uas yooj yim tsim cov qhov av, thiab qhov transverse diameter yog ≤ 3.5 cm, STER tuaj yeem yog txoj kev kho mob zoo tshaj plaws.

STER yog ib txoj kev siv tshuab tshiab uas tsim los ntawm kev siv peroral endoscopic esophageal sphincterotomy (POEM) thiab yog ib qho kev txuas ntxiv ntawm ESD tech.kev kawm. Tus nqi txiav tawm ntawm STER rau kev kho SMT nce mus txog 84.9% txog 97.59%.

Endoscopic Full-thickness Resection,EFTR: Nws siv tau rau SMT qhov twg nyuaj rau tsim kom muaj qhov av lossis qhov twg qhov siab tshaj plaws ntawm lub qog yog ≥3.5 cm thiab tsis haum rau STER. Yog tias lub qog tawm hauv qab daim nyias nyias ntshav lossis loj hlob sab nraud ntawm qhov chaw, thiab pom tias lub qog lo rau ntawm txheej serosa thaum phais thiab tsis tuaj yeem sib cais, nws siv tau. EFTR ua kev kho mob endoscopic.

Kev xaws kom raug ntawm qhov perforationQhov chaw tom qab EFTR yog qhov tseem ceeb rau kev vam meej ntawm EFTR. Yuav kom ntsuas tau qhov kev pheej hmoo ntawm kev rov qab mob qog thiab txo qhov kev pheej hmoo ntawm kev kis tus kab mob, nws tsis pom zoo kom txiav thiab tshem tawm cov qauv qog uas raug txiav thaum lub sijhawm EFTR. Yog tias nws tsim nyog tshem tawm cov qog ua tej daim, qhov perforation yuav tsum tau kho ua ntej kom txo qhov kev pheej hmoo ntawm kev cog qoob loo thiab kis mus rau lwm qhov. Qee txoj kev xaws suav nrog: cov xov hlau clip, suction-clip xaws, omental patch xaws, "purse bag suture" txoj kev siv txoj hlua nylon ua ke nrog cov xov hlau, rake metal clip kaw system (dhau lub scope clip, OTSC) OverStitch xaws thiab lwm yam thev naus laus zis tshiab los kho cov kev raug mob plab hnyuv thiab kev kho cov ntshav, thiab lwm yam.

(5) Cov teeb meem tom qab phais

Kev los ntshav thaum lub sijhawm phais: Kev los ntshav uas ua rau tus neeg mob cov hemoglobin poob qis dua 20 g/L.
Yuav kom tiv thaiv tau kev los ntshav ntau heev thaum phais,Yuav tsum tau txhaj tshuaj submucosal txaus thaum lub sijhawm phais kom pom cov hlab ntsha loj dua thiab pab txhawb kev siv hluav taws xob los tiv thaiv kev los ntshav. Kev los ntshav thaum phais tuaj yeem kho tau los ntawm ntau yam riam txiav, cov forceps hemostatic lossis cov hlau clips, thiab kev tiv thaiv hemostasis ntawm cov hlab ntsha uas pom thaum lub sijhawm phais.

Kev Los Ntshav Tom Qab Phais: Kev los ntshav tom qab phais qhia tau tias yog ntuav ntshav, melena, lossis ntshav hauv cov quav. Hauv cov mob hnyav, yuav muaj kev poob siab los ntshav. Feem ntau nws tshwm sim hauv 1 lub lis piam tom qab phais, tab sis kuj tuaj yeem tshwm sim 2 txog 4 lub lis piam tom qab phais.

Kev los ntshav tom qab phais feem ntau yog txuam nrogcov yam xws li kev tswj ntshav siab tom qab phais tsis zoo thiab kev xeb ntawm cov hlab ntsha seem los ntawm cov kua qaub hauv plab. Tsis tas li ntawd, kev los ntshav tom qab phais kuj tseem cuam tshuam nrog qhov chaw ntawm tus kab mob, thiab feem ntau tshwm sim hauv lub plab antrum thiab qhov quav qis.

Kev tho qhov qeeb: Feem ntau pom tau tias yog mob plab loj zuj zus, mob plab zuj zus tuaj, cov cim qhia tias mob peritonitis, kub taub hau, thiab kev kuaj duab qhia tias muaj roj ntau lossis muaj roj ntau dua piv rau yav dhau los.

Feem ntau nws muaj feem cuam tshuam nrog cov yam xws li kev xaws cov qhov txhab tsis zoo, kev siv hluav taws xob ntau dhau, sawv ntxov dhau los txav mus los, noj zaub mov ntau dhau, tswj cov ntshav qab zib tsis zoo, thiab cov kua qaub hauv plab zom cov qhov txhab. a. Yog tias qhov txhab loj lossis tob lossis qhov txhab muaj qhov txhab me me.Yog tias muaj kev hloov pauv zoo li no, lub sijhawm pw thiab lub sijhawm yoo mov yuav tsum ntev dua thiab yuav tsum ua kom lub plab zom mov tsis txhob nruj tom qab phais (cov neeg mob tom qab phais plab zom mov qis dua yuav tsum tau tso dej tawm ntawm qhov quav); b. Cov neeg mob ntshav qab zib yuav tsum tswj lawv cov ntshav qab zib kom nruj; cov neeg uas muaj qhov me me thiab muaj kab mob hauv siab thiab plab me me yuav tsum tau txais kev kho mob xws li yoo mov, tiv thaiv kab mob, thiab txo cov kua qaub; c. Rau cov neeg uas muaj kua qaub, yuav tsum tau tso dej tawm hauv lub hauv siab thiab tho qhov plab. Yuav tsum tau muab cov raj tso rau kom cov dej ntws zoo; d. Yog tias qhov kab mob tsis tuaj yeem nyob hauv thaj chaw tom qab kev kho mob ceev lossis ua ke nrog kev kis kab mob hauv siab hnyav, yuav tsum tau phais laparoscopy sai li sai tau, thiab yuav tsum tau kho qhov thiab tso dej tawm hauv plab.

Cov teeb meem ntsig txog roj: suav nrog subcutaneousmob ntsws (neous emphysema), mob ntsws (pneumomediastinum), mob ntsws (pneumothorax), thiab mob ntsws (pneumoperitoneum).

Mob ntsws o (emphysema) thaum lub sijhawm phais mob (qhia tias yog mob ntsws o ntawm lub ntsej muag, caj dab, phab ntsa hauv siab, thiab lub hnab zis) thiab mob ntsws o hauv lub ntsws (mediastinal pneumophysema) (sqhov o ntawm lub epiglottis tuaj yeem pom thaum lub sijhawm gastroscopy) feem ntau tsis tas yuav kho tshwj xeeb, thiab qhov mob emphysema feem ntau yuav ploj mus ntawm nws tus kheej.

Muaj mob ntsws hnyav heev tshwm sim dthaum lub sijhawm phais [lub siab ntawm txoj hlab pa tshaj 20 mmHg thaum lub sijhawm phais]

(1mmHg = 0.133kPa), SpO2 <90%, lees paub los ntawm kev thaij duab xoo hluav taws xob thaum muaj xwm txheej ceev ntawm lub txaj], feem ntau kev phais mob tuaj yeem txuas ntxiv mus tom qab kaw lub hauv siab.hnub nyoog.

Rau cov neeg mob uas pom tseeb tias muaj mob pneumoperitoneum thaum lub sijhawm phais, siv koob pneumoperitoneum los tho qhov McFarland point.nyob rau hauv lub plab sab xis kom tso cua tawm, thiab cia lub koob txhaj tshuaj nyob rau hauv qhov chaw kom txog thaum kawg ntawm kev phais, thiab tom qab ntawd tshem nws tawm tom qab paub tseeb tias tsis muaj roj pom tseeb tawm.

Qhov fistula ntawm txoj hnyuv: Cov kua dej hauv plab uas tshwm sim los ntawm kev phais endoscopic ntws mus rau hauv lub hauv siab lossis lub plab los ntawm qhov xau.
Cov qhov txhab ntawm txoj hlab pas thiab cov qhov txhab ntawm txoj hlab pas feem ntau pom muaj. Thaum muaj qhov txhab, ua kom cov kua hauv siab ntws tawm kom tsis txhob ntws ntau dhau.hauv kev ntws dej kom du thiab muab kev txhawb nqa kev noj haus kom txaus. Yog tias tsim nyog, cov hlau clips thiab ntau yam khoom siv kaw tuaj yeem siv tau, lossis tag nrho cov npog tuaj yeem rov ua dua tshiab. Stents thiab lwm txoj hauv kev siv los thaiv qhovqhov quav. Cov mob hnyav yuav tsum tau phais sai sai.

3. Kev tswj hwm tom qab phais (follow-up)

(1) Cov qhov txhab tsis muaj teeb meem:Kev mob nkeegqhia tau hais tias cov qog nqaij hlav zoo li lipoma thiab leiomyoma tsis tas yuav tsum tau saib xyuas tas li.

(2) SMT tsis muaj kev phemmuaj peev xwm ntawm cov ntsaum:Piv txwv li, rectal NETs 2cm, thiab nruab nrab- thiab siab-risk GIST, tiav staging yuav tsum tau ua thiab ntxiv kev kho mob (phais, chemoradiotherapy, targeted therapy) yuav tsum tau xav txog. Kev tsim cov phiaj xwm yuav tsum yog raws li kev sab laj ntau yam thiab ntawm tus kheej.

(3) SMT muaj peev xwm ua rau mob qog noj ntshav tsawg:Piv txwv li, GIST uas muaj kev pheej hmoo tsawg yuav tsum tau soj ntsuam los ntawm EUS lossis kev thaij duab txhua 6 txog 12 lub hlis tom qab kev kho mob, thiab tom qab ntawd kho raws li cov lus qhia kho mob.

(4) SMT nrog rau qhov nruab nrab thiab siab malignant peev xwm:Yog tias kev mob tom qab phais mob lees paub hom 3 gastric NET, colorectal NET nrog qhov ntev >2cm, thiab nruab nrab-thiab siab-phem GIST, yuav tsum tau ua tiav kev ntsuas theem thiab kev kho mob ntxiv (phais, chemoradiotherapy, targeted therapy) yuav tsum tau xav txog. Kev tsim cov phiaj xwm yuav tsum raws li[txog peb 0118.docx] kev sab laj ntau yam thiab ntawm tus kheej.