Endoscopic kev kho mob ntawm cov qog submucosal ntawm lub plab zom mov: 3 cov ntsiab lus tseem ceeb tau sau tseg hauv ib tsab xov xwm

Cov qog nqaij hlav submucosal (SMT) ntawm lub plab zom mov yog cov kab mob siab uas tshwm sim los ntawm cov nqaij mos mucosa, submucosa, los yog muscularis propria, thiab tej zaum kuj yog cov kab mob extraluminal.Nrog rau kev txhim kho cov cuab yeej kho mob, cov kev kho mob phais ib txwm tau maj mam nkag mus rau lub sijhawm ntawm kev kho mob tsawg kawg nkaus, xws li lKev phais aparoscopic thiab kev phais neeg hlau.Txawm li cas los xij, hauv kev kho mob, nws tuaj yeem pom tias "kev phais" tsis haum rau txhua tus neeg mob.Nyob rau hauv xyoo tas los no, tus nqi ntawm kev kho mob endoscopic tau maj mam tau txais kev mloog.Qhov tseeb version ntawm Suav cov kws tshaj lij pom zoo rau kev kuaj mob endoscopic thiab kev kho mob ntawm SMT tau raug tso tawm.Kab lus no yuav qhia luv luv txog cov kev paub uas cuam tshuam.

1.SMT tus cwj pwm kis mobristics

(1) Qhov tshwm sim ntawm SMT tsis sib xws hauv ntau qhov chaw ntawm lub plab zom mov, thiab lub plab yog qhov chaw tshaj plaws rau SMT.

Qhov xwm txheej ntawm various qhov chaw ntawm lub plab zom mov yog qhov tsis sib xws, nrog rau lub plab zom mov sab sauv ntau dua.Ntawm cov no, 2/3 tshwm sim hauv plab, ua raws li txoj hlab pas, duodenum, thiab txoj hnyuv.

(2) Histopathologyl hom SMT yog complex, tab sis feem ntau SMT yog benign lesions, thiab tsuas yog ob peb yog malignant.

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

B.Ntawm cov kab mob neoplastics, gastrointestinal leiomyomas, lipomas, Brucella adenomas, granulosa cell hlav, schwannomas, thiab glomus qog feem ntau benign, thiab tsawg dua 15% tuaj yeem tshwm sim raws li cov ntaub so ntswg kawm phem.

C. Gastrointestinal stromal qog nqaij hlav (GIST) thiab cov qog nqaij hlav neuroendocrine (NET) hauv SMT yog cov qog nqaij hlav uas muaj qee yam tsis zoo, tab sis qhov no nyob ntawm nws qhov loj me, qhov chaw thiab hom.

D.Qhov chaw ntawm SMT muaj feem cuam tshuamrau kev faib tawm pathological: a.Leiomyomas yog ib hom kab mob sib kis ntawm SMT hauv txoj hlab pas, suav txog 60% mus rau 80% ntawm cov hlab ntsha SMTs, thiab feem ntau yuav tshwm sim nyob rau hauv nruab nrab thiab qis ntu ntawm txoj hlab pas;b.Cov kab mob ntawm lub plab SMT yog qhov nyuaj, nrog GIST, leiomyoma thiab ectopic pancreas yog qhov ntau tshaj plaws.Ntawm cov plab hnyuv SMT, GIST feem ntau pom muaj nyob rau hauv lub plab thiab lub cev ntawm lub plab, leiomyoma feem ntau yog nyob rau hauv cardia thiab sab sauv ntawm lub cev, thiab ectopic pancreas thiab ectopic pancreas feem ntau.Lipomas muaj ntau dua nyob rau hauv lub plab antrum;c.Lipomas thiab cysts feem ntau tshwm sim nyob rau hauv cov nqes hav thiab bulbous qhov chaw ntawm lub duodenum;d.Hauv SMT ntawm lub plab zom mov, lipomas yog qhov tseem ceeb hauv txoj hnyuv, thaum NETs yog qhov tseem ceeb hauv qhov quav.

(3) Siv CT thiab MRI los ntsuas qib, kho, thiab ntsuas cov qog.Rau SMTs uas xav tias yuav ua rau mob qog noj ntshav lossis muaj qog nqaij hlav loj (ntevtxoj kab uas hla > 2 cm), CT thiab MRI raug pom zoo.

Lwm txoj hauv kev ua duab, suav nrog CT thiab MRI, kuj tseem ceeb heev rau kev kuaj mob SMT.Lawv tuaj yeem tso ncaj qha qhov chaw ntawm cov qog tshwm sim, kev loj hlob tus qauv, qhov loj me, cov duab, muaj lossis tsis muaj lobulation, qhov ntom ntom, homogeneity, qib ntawm kev txhim kho, thiab ciam teb, thiab lwm yam, thiab tuaj yeem nrhiav seb puas thiab qib tuab.ening ntawm lub plab hnyuv phab ntsa.Qhov tseem ceeb tshaj, cov kev kuaj xyuas no tuaj yeem kuaj xyuas seb puas muaj kev cuam tshuam ntawm cov kab mob uas nyob ib sab thiab seb puas muaj metastasis nyob rau hauv ib puag ncig peritoneum, lymph nodes thiab lwm yam kabmob.Lawv yog cov txheej txheem tseem ceeb rau kev soj ntsuam grading, kev kho mob thiab prognosis kev soj ntsuam ntawm cov qog.

(4) Cov ntaub so ntswg sampling tsis yog recommended rau benign SMTs uas tuaj yeem kuaj tau los ntawm cov qauv endoscopy ua ke nrog EUS, xws li lipomas, cysts, thiab ectopic pancreas.

Rau cov kab mob uas xav tias yog malignant lossis thaum siv cov tshuaj endoscopy ua ke nrog EUS tsis tuaj yeem ntsuas qhov benign lossis malignant lesions, EUS-guided fine-needle aspiration/biopsy yuav siv tau (endoscopic ultrasonography coj zoo nedle aspiration/biopsy, EUS-FNA/FNB), mucosal incision biopsy (mucosalincision-assisted biopsy, MIAB), etc. ua biopsy sampling for preoperative pathological evaluation.Raws li cov kev txwv ntawm EUS-FNA thiab cov kev cuam tshuam tom qab ntawm endoscopic resection, rau cov neeg uas tsim nyog tau txais kev phais endoscopic, ntawm qhov chaw ntawm kev ua kom cov qog tuaj yeem raug kho kom tiav, chav nyob nrog cov cuab yeej siv kho mob endoscopic tuaj yeem kho tau los ntawm kev paub txog. Tus kws kho mob endoscopist ua endoscopic resection ncaj qha yam tsis tau txais kev kuaj mob ua ntej.

Txhua txoj kev tau txais cov kab mob pathological ua ntej kev phais yog qhov cuam tshuam thiab yuav ua rau cov mucosa puas los yog ua rau adhesion rau submucosal cov ntaub so ntswg, yog li ua rau qhov nyuaj ntawm kev phais thiab tej zaum yuav ua rau muaj kev pheej hmoo los ntshav, perforation, thiab qog dissemination.Yog li ntawd, preoperative biopsy tsis tas yuav tsum tau.Qhov tsim nyog, tshwj xeeb tshaj yog rau SMTs uas tuaj yeem kuaj pom los ntawm cov qauv endoscopy ua ke nrog EUS, xws li lipomas, cysts, thiab ectopic pancreas, tsis tas yuav tsum kuaj cov ntaub so ntswg.

2. SMT endoscopic kev kho mobnt

(1) Cov qauv kev kho mob

Cov kab mob uas tsis muaj lymph node metastasis lossis muaj kev pheej hmoo tsawg heev ntawm cov qog ntshav qog ntshav, tuaj yeem raug kho kom tiav siv cov txheej txheem endoscopic, thiab muaj kev pheej hmoo tsawg ntawm cov seem thiab rov ua dua yog tsim nyog rau endoscopic resection yog tias tsim nyog.Kev tshem tawm ua kom tiav ntawm cov qog ua kom txo qis cov qog seem thiab qhov kev pheej hmoo ntawm rov tshwm sim dua.CovLub hauv paus ntsiab lus ntawm kev kho cov qog tsis pub dawb yuav tsum tau ua raws li thaum lub sij hawm endoscopic resection, thiab kev ncaj ncees ntawm cov qog capsule yuav tsum tau xyuas kom meej thaum lub sij hawm resection.

(2) Cov lus qhia

i. Cov qog nqaij hlav uas muaj peev xwm xav tau los ntawm kev kuaj xyuas ua ntej lossis lees paub los ntawm kev kuaj ntshav biopsy, tshwj xeeb tshaj yog cov uas xav tias muaj GI.ST nrog rau kev soj ntsuam ua ntej ntawm cov qog ntev ntawm ≤2cm thiab tsis tshua muaj kev pheej hmoo ntawm kev rov ua dua thiab metastasis, thiab nrog rau qhov ua tiav ntawm qhov kev txiav txim siab tiav, tuaj yeem kho endoscopically;rau cov qog nqaij hlav nrog txoj kab ntev ntev Rau qhov xav tias tsis tshua muaj kev pheej hmoo GIST> 2cm, yog tias cov qog ntshav qab zib lossis cov metastasis nyob deb tau raug tshem tawm los ntawm kev ntsuam xyuas ua ntej, ntawm qhov chaw ua haujlwm kom ntseeg tau tias cov qog tuaj yeem raug kho kom tiav, kev phais endoscopic yuav ua tau los ntawm cov kws paub txog endoscopists hauv chav tsev nrog paub tab endoscopic kho tshuab.kev txiav txim.

ii.Cov tsos mob (piv txwv li, los ntshav, thaiv) SMT.

iii. Cov neeg mob uas cov qog xav tias tsis zoo los ntawm kev kuaj mob ua ntej lossis paub tseeb los ntawm pathology, tab sis tsis tuaj yeem ua raws li niaj zaus lossis nws cov qog loj zuj zus nyob rau lub sijhawm luv luv thaum lub sijhawm ua raws thiab cov uas muaj lub siab xav.e rau kev kho mob endoscopic.

(3) Contraindications

i.Txheeb xyuas cov kab mob uas muaj kuvtastasized rau cov qog ntshav los yog qhov chaw nyob deb.

ii.Rau qee qhov SMT nrog cov kua dej ntshiabnodelos yog nyob deb metastasis, bulk biopsy yuav tsum tau txais pathology, uas tuaj yeem suav tau tias yog ib tus txheeb ze contraindication.

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

Cov kab mob zoo xws li lipoma thiab ectopic pancreas feem ntau tsis ua rau cov tsos mob xws li mob, los ntshav, thiab kev cuam tshuam.Thaum SMT manifests li yaig, rwj, los yog sai heev nyob rau hauv ib lub sij hawm luv luv ntawm lub sij hawm, muaj peev xwm ntawm nws yog ib tug malignant lesion nce.

(4) Kev xaiv ntawm cov txheej txheem resectiond

Endoscopic snare resection: RauSMT uas yog ib qho tseem ceeb, protrudes rau hauv kab noj hniav raws li tau txiav txim los ntawm preoperative EUS thiab CT kuaj, thiab yuav tsum tau tag nrho resected nyob rau hauv ib lub sij hawm nrog ib tug snare, endoscopic snare resection yuav siv tau.

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

Endoscopic submucosal excavation, ESE: Rau SMTs nrog txoj kab uas hla ntev ≥2 cm lossis yog tias kev kuaj xyuas ua ntej xws li EUS thiab CT paub meej thntawm cov qog protrudes rau hauv kab noj hniav, ESE muaj peev xwm rau endoscopic tes tsho resection ntawm tseem ceeb SMTs.

ESE ua raws li kev coj ua ntawmendoscopic submucosal dissection (ESD) thiab endoscopic mucosal resection, thiab niaj zaus siv ib ncig "flip-top" incision nyob ib ncig ntawm cov qog kom tshem tawm cov mucosa npog lub SMT thiab tag nrho nthuav cov qog., kom ua tiav lub hom phiaj ntawm kev khaws cia cov qog nqaij hlav, txhim kho radicalness ntawm kev phais, thiab txo qis cov teeb meem intraoperative.Rau cov qog ≤1.5 cm, qhov kev txiav txim tiav ntawm 100% tuaj yeem ua tiav.

Submucosal Tunneling Endoscopic Resection, STER : Rau SMT originating los ntawm cov muscularis propria nyob rau hauv txoj hlab pas, hilum, tsawg curvature ntawm lub gastric lub cev, gastric antrum thiab lub qhov quav, uas yog ib qho yooj yim rau tsim tunnels, thiab transverse txoj kab uas hla yog ≤ 3.5 cm, STER tuaj yeem yog qhov nyiam. txoj kev kho mob.

STER yog ib lub tshuab tshiab tsim los ntawm peroral endoscopic esophageal sphincterotomy (POEM) thiab yog qhov txuas ntxiv ntawm ESD technco.Qhov en bloc resection tus nqi ntawm STER rau SMT kev kho mob nce mus txog 84.9% rau 97.59%.

Endoscopic Full-thickness Resection, EFTR: Nws tuaj yeem siv rau SMT qhov twg nws nyuaj rau tsim ib lub qhov los yog qhov twg qhov siab tshaj plaws txoj kab uas hla ntawm cov qog yog ≥3.5 cm thiab tsis haum rau STER.Yog hais tias cov qog protrudes nyob rau hauv cov ntshav daim nyias nyias los yog loj hlob sab nraum ib feem ntawm cov kab noj hniav, thiab cov qog tau pom tias yuav nruj nreem rau hauv serosa txheej thaum phais thiab tsis tuaj yeem sib cais, nws tuaj yeem siv tau.EFTR ua kev kho mob endoscopic.

Perforation ntawm lub perforationsite tom qab EFTR yog tus yuam sij rau kev ua tiav ntawm EFTR.Txhawm rau txhawm rau ntsuas qhov kev pheej hmoo ntawm cov qog rov ua dua thiab txo qhov kev pheej hmoo ntawm kev nthuav tawm cov qog, nws tsis pom zoo kom txiav thiab tshem tawm cov qog nqaij hlav rov qab thaum EFTR.Yog tias tsim nyog tshem tawm cov qog hauv daim, lub perforation yuav tsum tau kho ua ntej kom txo tau qhov kev pheej hmoo ntawm qog hlav thiab kis.Qee txoj kev suturing muaj xws li: hlau clip suture, suction-clip suture, omental patch suture txheej txheem, "purse bag suture" txoj kev ntawm nylon hlua ua ke nrog hlau clip, rake hlau clip kaw system (tshaj qhov clip, OTSC) OverStitch suture thiab lwm yam. cov thev naus laus zis tshiab los kho cov kev raug mob plab hnyuv thiab cuam tshuam los ntshav, thiab lwm yam.

(5) Cov teeb meem tom qab phais

Intraoperative los ntshav: los ntshav uas ua rau tus neeg mob lub hemoglobin poob ntau tshaj 20 g / L.
Txhawm rau tiv thaiv cov ntshav los ntawm intraoperative loj,Kev txhaj tshuaj submucosal txaus yuav tsum tau ua thaum lub sijhawm ua haujlwm kom nthuav tawm cov hlab ntsha loj dua thiab ua kom cov electrocoagulation kom tsis txhob los ntshav.Intraoperative los ntshav tuaj yeem kho nrog ntau yam riam, hemostatic forceps lossis hlau clips, thiab tiv thaiv hemostasis ntawm cov hlab ntsha raug pom thaum lub sij hawm txiav.

Postoperative los ntshav: Postoperative los ntshav manifests raws li ntuav ntshav, melena, los yog ntshav nyob rau hauv cov quav.Hauv cov xwm txheej hnyav, hemorrhagic shock yuav tshwm sim.Nws feem ntau tshwm sim hauv 1 lub lis piam tom qab kev phais, tab sis kuj tuaj yeem tshwm sim 2 mus rau 4 lub lis piam tom qab kev phais.

Postoperative los ntshav feem ntau muaj feem xyuam nrogyam xws li kev tswj ntshav qab zib tsis zoo thiab kev txhim kho ntawm cov hlab ntsha seem los ntawm gastric acid.Tsis tas li ntawd, cov ntshav tom qab phais kuj muaj feem xyuam rau qhov chaw ntawm tus kab mob, thiab feem ntau tshwm sim hauv lub plab antrum thiab qis qhov quav.

ncua perforation: Feem ntau tshwm sim raws li mob plab, mob plab zuj zus, cov tsos mob ntawm peritonitis, kub taub hau, thiab kev tshuaj ntsuam xyuas qhia tau tias muaj roj tsub zuj zuj lossis nce roj ntxiv piv nrog ua ntej.

Nws feem ntau cuam tshuam nrog cov yam ntxwv xws li kev ua tsis zoo ntawm cov qhov txhab, ntau dhau ntawm electrocoagulation, sawv ntxov mus ncig, noj earl dhau lawm, tswj ntshav qab zib tsis zoo, thiab yaig ntawm qhov txhab los ntawm gastric acid.a.Yog lub qhov txhab loj los yog tob los yog lub qhov txhab muaj fisCov kev hloov pauv zoo li qub, lub sijhawm pw tsaug zog thiab lub sijhawm yoo mov yuav tsum tau txuas ntxiv kom tsim nyog thiab lub plab zom mov yuav tsum tau ua tom qab kev phais (cov neeg mob tom qab phais plab hnyuv yuav tsum muaj qhov tso dej ntawm qhov quav);b.Cov neeg mob ntshav qab zib yuav tsum nruj tswj hwm lawv cov ntshav qab zib;cov neeg uas muaj me me perforations thiab me me thoracic thiab plab kab mob yuav tsum tau muab kev kho mob xws li yoo mov, tiv thaiv kab mob, thiab acid suppressing;c.Rau cov neeg uas muaj effusion, kaw lub hauv siab kua dej thiab lub plab ntswj tuaj yeem ua tau Tubes yuav tsum tau muab tso rau kom tswj tau cov kua dej du;d.Yog tias tus kab mob tsis tuaj yeem nyob hauv cheeb tsam tom qab kev kho mob los yog ua ke nrog cov kab mob thoracoabdominal hnyav, kev phais laparoscopy yuav tsum tau ua sai li sai tau, thiab kho perforation thiab tso zis hauv plab yuav tsum tau ua.

Cov teeb meem ntawm roj: suav nrog subcutaneous emphysema, pneumomediastinum, pneumothorax thiab pneumoperitoneum.

Intraoperative subcutaneous emphysema (xws li emphysema ntawm lub ntsej muag, caj dab, hauv siab phab ntsa, thiab scrotum) thiab mediastinal pneumophysema (s.Kev noj qab haus huv ntawm epiglottis tuaj yeem pom thaum lub sij hawm gastroscopy) feem ntau tsis tas yuav kho tshwj xeeb, thiab emphysema feem ntau yuav daws nws tus kheej.

Mob pneumothorax tshwm sim during phais [airway siab tshaj 20 mmHg thaum phais

(1mmHg = 0.133kPa), SpO2 <90%, paub tseeb tias thaum muaj xwm txheej ceev hauv txaj hauv siab X-ray], kev phais feem ntau tuaj yeem txuas ntxiv tom qab kaw lub hauv siab dratsis muaj hnub.

Rau cov neeg mob uas pom tseeb pneumoperitoneum thaum lub sijhawm ua haujlwm, siv lub koob pneumoperitoneum txhawm rau txhawm rau McFarland point.nyob rau hauv txoj cai qis lub plab kom deflate cov huab cua, thiab tawm hauv lub puncture koob nyob rau hauv qhov chaw mus txog rau thaum xaus ntawm lub lag luam, thiab ces tshem tawm nws tom qab paub meej tias tsis muaj cov pa pom tseeb tawm.

Gastrointestinal fistula: Cov kua dej digestive tshwm sim los ntawm kev phais endoscopic ntws mus rau hauv lub hauv siab los yog lub plab kab noj hniav los ntawm kev xau.
Esophageal mediastinal fistulas thiab esophagothoracic fistulas muaj ntau.Thaum muaj fistula tshwm sim, ua lub hauv siab kaw rau maintanyob rau hauv cov kua dej du thiab muab cov khoom noj khoom haus 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.Stents thiab lwm txoj kev yog siv los thaiv covfistula.Cov mob hnyav yuav tsum tau txais kev phais sai.

3.Postoperative Management (follow-up)

(1) Cov kab mob zoo:Pathology suggests tias cov kab mob benign xws li lipoma thiab leiomyoma tsis tas yuav tsum tau soj ntsuam tas li.

(2) SMT tsis muaj malignAnt muaj peev xwm:Piv txwv li, qhov quav NETs 2cm, thiab nruab nrab- thiab muaj kev pheej hmoo siab GIST, ua tiav qhov kev ua tiav yuav tsum tau ua thiab kev kho mob ntxiv (kev phais, chemoradiotherapy, kev kho mob) yuav tsum tau xav txog.kho).Kev tsim cov phiaj xwm yuav tsum ua raws li kev sib tham ntau yam kev qhuab qhia thiab ntawm tus kheej.

(3) Tsawg malignant muaj peev xwm SMT:Piv txwv li, GIST uas pheej hmoo tsawg yuav tsum tau soj ntsuam los ntawm EUS los yog ntsuas txhua 6 mus rau 12 lub hlis tom qab kev kho mob, thiab tom qab ntawd kho raws li kev kho mob cov lus qhia.

(4) SMT nrog nruab nrab thiab siab malignant peev xwm:Yog hais tias postoperative pathology paub meej tias hom 3 gastric NET, colorectal NET nrog ib tug ntev> 2cm, thiab nruab nrab- thiab high-risk GIST, ua kom tiav staging yuav tsum tau ua thiab cov kev kho mob ntxiv (kev phais, chemoradiotherapy, tsom txoj kev kho) yuav tsum tau xav txog.kho).Kev tsim cov phiaj xwm yuav tsum ua raws li[txog peb 0118.docx] kev sib tham ntau yam thiab ntawm tus kheej.