Ukwelashwa nge-endoscopic kwezimila ezingaphansi komucu wokugaya ukudla: amaphuzu amathathu amakhulu afingqiwe esihlokweni esisodwa

Ama-submucosal tumors (SMT) omgudu wokugaya ukudla yizilonda eziphakeme ezivela ku-muscularis mucosa, i-submucosa, noma i-muscularis propria, futhi zingase zibe yizilonda ezingaphandle kokukhanya. Ngokuthuthuka kobuchwepheshe bezokwelapha, izinketho zokwelapha zokuhlinzwa zendabuko ziye zangena kancane kancane enkathini yokwelashwa okungangenisi kakhulu, njenge-lukuhlinzwa kwe-aparoscopic kanye nokuhlinzwa kwerobhothi. Kodwa-ke, emtholampilo, kungatholakala ukuthi "ukuhlinzwa" akufaneleki kubo bonke iziguli. Eminyakeni yamuva nje, ukubaluleka kokwelashwa kwe-endoscopic kuye kwaqashelwa kancane kancane. Inguqulo yakamuva yokuvumelana kochwepheshe baseShayina mayelana nokuxilongwa kwe-endoscopic kanye nokwelashwa kwe-SMT ikhishwe. Lesi sihloko sizofunda kafushane ulwazi olufanele.

1. Isici sobhubhane lwe-SMTimithetho

(1) Ukwanda kwe-SMI-T ayilingani ezingxenyeni ezahlukene zomgudu wokugaya ukudla, futhi isisu siyindawo evame kakhulu ye-SMT.

Ukwanda kwezinhlobo ezahlukeneIzingxenye zomgudu wokugaya ukudla azilingani, kanti umgudu wokugaya ukudla ophezulu uvame kakhulu. Kulezi, okungu-2/3 kwenzeka esiswini, kulandele umphimbo, i-duodenum, kanye nekholoni.

(2) I-histopathologicalaIzinhlobo ze-SMT ziyinkimbinkimbi, kodwa iningi le-SMT liyizilonda ezingenabungozi, futhi zimbalwa kuphela ezinobungozi.

I-A.SMT ifaka phakathi chaizilonda ze-n-neoplastic ezifana nezicubu ze-pancreatic ectopic kanye nezilonda ze-neoplastic.

B. Phakathi kwesilonda se-neoplastics, ama-leiomyomas emathumbu, ama-lipomas, ama-Brucella adenomas, ama-granulosa cell tumors, ama-schwannomas, kanye nama-glomus tumors ngokuvamile ayingozi, futhi angaphansi kuka-15% angavela njengezicubu Funda ububi.

C. I-stroma yesisuIzimila ze-L (GIST) kanye nezimila ze-neuroendocrine (NET) ku-SMT ziyizimila ezinamandla athile okubulala, kodwa lokhu kuncike ngobukhulu bazo, indawo kanye nohlobo lwazo.

D. Indawo ye-SMT ihlobenengokwesigaba se-pathological: a. Ama-Leiomyoma awuhlobo oluvamile lwe-SMT oluyimbangela yesifo emqaleni, olubalelwa ku-60% kuya ku-80% wama-SMT omphimbo, futhi avame ukwenzeka ezingxenyeni eziphakathi nezingezansi zomphimbo; b. Izinhlobo ze-pathological ze-SMT yesisu ziyinkimbinkimbi kakhulu, nge-GIST, leiomyoI-ma kanye ne-ectopic pancreas yizona ezivame kakhulu. Phakathi kwe-SMT yesisu, i-GIST ivame kakhulu ukutholakala ku-fundus kanye nomzimba wesisu, i-leiomyoma ivame ukutholakala e-cardia nasengxenyeni engenhla yomzimba, kanti i-ectopic pancreas kanye ne-ectopic pancreas zivame kakhulu. Ama-Lipoma avame kakhulu ku-gastric antrum; c. Ama-Lipoma nama-cyst avame kakhulu ezingxenyeni ezihlayo nezinkulu ze-duodenum; d. Ku-SMT yendlela engezansi yesisu, ama-lipoma avame kakhulu ku-colon, kuyilapho ama-NET evame kakhulu ku-rectum.

(3) Sebenzisa i-CT ne-MRI ukuze uhlole, welaphe, futhi uhlole izimila. Kuma-SMT okusolwa ukuthi angaba yingozi noma anezimila ezinkulu (ezinde).ububanzi > 2 cm), i-CT kanye ne-MRI kuyanconywa.

Ezinye izindlela zokuthwebula izithombe, okuhlanganisa i-CT ne-MRI, nazo zibaluleke kakhulu ekuxilongweni kwe-SMT. Zingabonisa ngqo indawo lapho kuvela khona isimila, iphethini yokukhula, usayizi wesilonda, ukuma, ukuba khona noma ukungabikho kwe-lobulation, ubuningi, ukulingana, izinga lokuthuthukiswa, kanye nomngcele, njll., futhi zingathola ukuthi ngabe kanye nezinga lokujiya.ukuvaleka kodonga lwesisu. Okubaluleke kakhulu, lokhu kuhlolwa kwezithombe kungabona ukuthi kukhona yini ukuhlasela kwezakhiwo eziseduze zesilonda nokuthi ngabe kukhona yini ukusabalala kwezicubu ezungeze i-peritoneum, ama-lymph node kanye nezinye izitho zomzimba. Ziyindlela eyinhloko yokulinganisa emtholampilo, ukwelashwa kanye nokuhlola ukubikezela kwezimila.

(4) Ukusampula izicubu akubukelwa phansiKwenzelwe ama-SMT angengozi angatholakala nge-endoscopy evamile ehlanganiswe ne-EUS, njenge-lipomas, ama-cysts, kanye ne-ectopic pancreas.

Uma kwenzeka izilonda ezisolwa ukuthi ziyingozi noma uma i-endoscopy evamile ehlanganiswe ne-EUS ingakwazi ukuhlola izilonda ezingengozi noma eziyingozi, i-EUS-guided fine-needle aspiration/biopsy ingasetshenziswa (i-endoscopic ultrasonography guided fine nukufuthwa kwe-eedle/i-biopsy, i-EUS-FNA/FNB), i-mucosal incision biopsy (i-mucosalincision-assisted biopsy, i-MIAB), njll. yenza amasampula e-biopsy ukuze kuhlolwe i-pathological ngaphambi kokuhlinzwa. Ngenxa yemikhawulo ye-EUS-FNA kanye nomthelela olandelayo ekususweni kwe-endoscopic, kulabo abafanelekile ukuhlinzwa kwe-endoscopic, ngesisekelo sokuqinisekisa ukuthi isimila singasuswa ngokuphelele, amayunithi anobuchwepheshe bokwelashwa kwe-endoscopic obuvuthiwe angelashwa onolwazi. I-endoscopist yenza i-endoscopic resection ngqo ngaphandle kokuthola ukuxilongwa kwe-pathological ngaphambi kokuhlinzwa.

Noma iyiphi indlela yokuthola amasampula e-pathological ngaphambi kokuhlinzwa iyahlasela futhi izolimaza i-mucosa noma ibangele ukunamathela ezicutshini ze-submucosal, ngaleyo ndlela kwandisa ubunzima bokuhlinzwa futhi mhlawumbe kwandise izingozi zokopha, ukusebenza kahle.ukulinganisela, kanye nokusabalala kwesimila. Ngakho-ke, i-biopsy yangaphambi kokuhlinzwa ayidingeki ngempela. Kuyadingeka, ikakhulukazi kuma-SMT angatholakala nge-endoscopy evamile ehlanganiswe ne-EUS, njenge-lipomas, ama-cyst, kanye ne-ectopic pancreas, akudingeki ukuthatha isampula yezicubu.

2. Ukwelashwa kwe-endoscopic kwe-SMTnt

(1) Izimiso zokwelapha

Izilonda ezingenayo i-lymph node metastasis noma ingozi ephansi kakhulu ye-lymph node metastasis, zingasuswa ngokuphelele kusetshenziswa amasu e-endoscopic, futhi zinomngcipheko ophansi wokusala kanye nokuphinda zivele zilungele ukususwa kwe-endoscopic uma kudingeka ukwelashwa. Ukususwa okuphelele kwesimila kunciphisa isimila esisele kanye nengozi yokuphinda zivele.Isimiso sokwelashwa okungenazo izimila kufanele silandelwe ngesikhathi sokususwa kwe-endoscopic, futhi ubuqotho be-capsule yesimila kufanele buqinisekiswe ngesikhathi sokususwa kwezicubu.

(2) Izinkomba

i. Izimila ezinobungozi obungasolwa ngokuhlolwa kwangaphambi kokuhlinzwa noma eziqinisekiswe yi-biopsy pathology, ikakhulukazi lezo ezisolwa nge-GII-ST enokuhlolwa kwangaphambi kokuhlinzwa kobude besimila esingu-≤2cm kanye nengozi ephansi yokuphinda sibuye futhi sidlule ku-metastasis, kanye nethuba lokususwa ngokuphelele, ingasuswa ngokuhlinzwa nge-endoscopically; kuma-tumors anobubanzi obude. Uma kusolwa ukuthi unengozi ephansi >2cm, uma i-lymph node noma i-metastasis ekude ingafakwanga ekuhlolweni kwangaphambi kokuhlinzwa, ngesisekelo sokuqinisekisa ukuthi isimila singasuswa ngokuphelele, ukuhlinzwa kwe-endoscopic kungenziwa ochwepheshe be-endoscopist abanolwazi eyunithi enobuchwepheshe bokwelapha i-endoscopic obuvuthiwe.

ii. Izimpawu (isib. ukopha, ukuvaleka) i-SMT.

iii. Iziguli okusolakala ukuthi izimila zazo azinangozi ngokuhlolwa kwangaphambi kokuhlinzwa noma okuqinisekiswa yisifo, kodwa azikwazi ukulandelwa njalo noma izimila zazo ezikhula phakathi nesikhathi esifushane ngesikhathi sokulandelela futhi ezinesifiso esinamandlaukwelashwa nge-endoscopic.

(3) Izimo zokuphikisana

i. Thola izilonda ezingibangelakufakwe ama-lymph node noma ezindaweni ezikude.

ii. Kwabanye abantu abane-SMT ecacilenodenoma i-metastasis ekude, i-bulk biopsy iyadingeka ukuze kutholakale i-pathology, okungabhekwa njengokungavumelani okuhlobene.

iii. Ngemva kokuhlinzwa okuningiliziweUma kuhlolwa, kutholakala ukuthi isimo esijwayelekile asisihle futhi ukuhlinzwa kwe-endoscopic akunakwenzeka.

Izilonda ezingemnandi njenge-lipoma kanye ne-pancreas ectopic ngokuvamile azibangeli izimpawu ezifana nobuhlungu, ukuphuma kwegazi, kanye nokuvaleka.I-MT ibonakala njengokuguguleka, isilonda, noma ukwanda ngokushesha esikhathini esifushane, amathuba okuba yisifo esibi ayanda.

(4) Ukukhetha indlela yokususa ukuhlinzwad

Ukususwa kwesihibe se-Endoscopic: UkuzeI-SMT engabonakali kakhulu, ephuma ingena emgodini njengoba kunqunywe ukuhlolwa kwe-EUS kanye ne-CT ngaphambi kokuhlinzwa, futhi ingasuswa ngokuphelele ngesikhathi esisodwa nge-snare, ingasetshenziswa ukususwa kwe-snare nge-endoscopic.

Izifundo zasekhaya nezakwamanye amazwe ziqinisekisile ukuthi iphephile futhi isebenza kahle ku-SMT engaphezulu kwe-<2cm, enengozi yokopha engu-4% kuya ku-13% kanye nokubhobokaingozi engu-2% kuya ku-70%.

Ukumbiwa kwe-submucosal ye-Endoscopic, ESE: Kuma-SMT anobubanzi obude obungu-≥2 cm noma uma ukuhlolwa kwezithombe zangaphambi kokuhlinzwa njenge-EUS ne-CT kuqinisekisa ukuthilapho isimila siphuma singene emgodini, i-ESE iyasebenza ekususweni kwesigxobo se-endoscopic se-SMTs ebalulekile.

I-ESE ilandela imikhuba yobuchwepheshe yeukuhlukaniswa kwe-endoscopic submucosal (ESD) kanye nokususwa kwe-endoscopic mucosal, futhi njalo kusetshenziswa ukusika okujikelezayo okuzungeze isimila ukuze kususwe i-mucosa emboze i-SMT futhi kuvezwe ngokuphelele isimila. , ukufeza injongo yokugcina ubuqotho besimila, ukuthuthukisa ukuqina kokuhlinzwa, kanye nokunciphisa izinkinga zangaphakathi kokuhlinzwa. Kuma-tumors ≤1.5 cm, izinga lokususwa eliphelele elingu-100% lingafinyelelwa.

I-Submucosal Tunneling Endoscopic Resecti-ion, i-STER: Nge-SMT evela ku-muscularis propria ku-esophagus, i-hilum, ukugoba okuncane komzimba wesisu, i-gastric antrum kanye ne-rectum, okulula ukusungula imigudu, kanti ububanzi obuphambene bungu-≤ 3.5 cm, i-STER ingaba yindlela yokwelapha ekhethwayo.

I-STER ubuchwepheshe obusha obuthuthukiswe ngokusekelwe ku-peroral endoscopic esophageal sphincterotomy (POEM) futhi buyisandiso se-ESD techI-nology. Izinga lokususwa kwe-en bloc kwe-STER yokwelashwa kwe-SMT lifinyelela ku-84.9% kuya ku-97.59%.

I-Endoscopic Full-ubukhulu Resecti-ion, i-EFTR:Ingasetshenziswa kwi-SMT lapho kunzima ukusungula umhubhe noma lapho ububanzi obukhulu obuphambeneyo besimila bungu-≥3.5 cm futhi bungafaneleki kwi-STER. Uma isimila siphuma ngaphansi kolwelwesi olunsomi noma sikhula ngaphandle kwengxenye yomgodi, futhi isimila sitholakale sinamathele ngokuqinile kungqimba lwe-serosa ngesikhathi sokuhlinzwa futhi singenakuhlukaniswa, singasetshenziswa. I-EFTR yenza ukwelashwa kwe-endoscopic.

Ukuthungwa okufanele kwemboboIndawo ngemuva kwe-EFTR iyisihluthulelo sempumelelo ye-EFTR. Ukuze kuhlolwe ngokunembile ingozi yokuphinda kube nesimila futhi kuncishiswe ingozi yokusabalala kwesimila, akukhuthazwa ukusika nokususa isampula yesimila esisusiwe ngesikhathi se-EFTR. Uma kudingeka ukususa isimila sibe yizicucu, ukubhoboka kudinga ukulungiswa kuqala ukuze kuncishiswe ingozi yokutshala nokusabalala kwesimila. Ezinye izindlela zokuthunga zifaka: i-metal clip suture, i-suction-clip suture, indlela ye-omental patch suture, indlela ye-"purse bag suture" yentambo ye-nylon ehlanganiswe ne-metal clip, uhlelo lokuvala i-rake metal clip (over the scope clip, OTSC) i-OverStitch suture kanye nobunye ubuchwepheshe obusha bokulungisa ukulimala kwamathumbu kanye nokubhekana nokopha, njll.

(5) Izinkinga zangemva kokuhlinzwa

Ukopha ngesikhathi sokuhlinzwa: Ukopha okubangela ukuthi i-hemoglobin yesiguli yehle ngaphezu kuka-20 g/L.
Ukuvimbela ukopha okukhulu ngesikhathi sokuhlinzwa,Kufanele kwenziwe umjovo owanele we-submucosal ngesikhathi sokuhlinzwa ukuze kuvezwe imithambo yegazi emikhulu futhi kube lula ukugaya igazi ngogesi ukuze kumiswe ukopha. Ukopha ngesikhathi sokuhlinzwa kungelashwa ngemimese ehlukahlukene yokusika, ama-hemostatic forceps noma ama-metal clips, kanye ne-hemostasis yokuvimbela yemithambo yegazi eveziwe etholakala ngesikhathi senqubo yokuhlukaniswa.

Ukopha ngemva kokuhlinzwa: Ukopha ngemva kokuhlinzwa kubonakala njengokuhlanza igazi, i-melena, noma igazi esitulweni. Ezimweni ezimbi kakhulu, ukushaqeka kwegazi kungase kwenzeke. Ngokuvamile kwenzeka phakathi nesonto elilodwa ngemva kokuhlinzwa, kodwa futhi kungenzeka emavikini amabili kuya kwamane ngemva kokuhlinzwa.

Ukopha ngemva kokuhlinzwa kuvame ukuhlotshaniswaizici ezifana nokulawulwa kabi komfutho wegazi ngemva kokuhlinzwa kanye nokugqwala kwemithambo yegazi esele yi-asidi yesisu. Ngaphezu kwalokho, ukopha ngemva kokuhlinzwa kuhlobene nendawo yesifo, futhi kuvame kakhulu entunjeni yesisu kanye nase-rectum ephansi.

Ukubhoboka okubambezelekile: Ngokuvamile kubonakala njengokuvuvuka kwesisu, ubuhlungu besisu obuqhubeka buba bubi, izimpawu ze-peritonitis, umkhuhlane, kanye nokuhlolwa kwesithombe kukhombisa ukuqongelela kwegesi noma ukuqongelela kwegesi okwandayo uma kuqhathaniswa nokwangaphambilini.

Kuhlobene kakhulu nezici ezifana nokugoba kabi kwamanxeba, ugesi omningi ojiyile, ukuvuka kusenesikhathi kakhulu ukuze ungahambi, ukudla kakhulu, ukulawula ushukela egazini okungekuhle, kanye nokuguguleka kwamanxeba yi-asidi yesisu. a. Uma inxeba likhulu noma lijulile noma inxeba line-fisIzinguquko eziqinisekile, isikhathi sokuphumula embhedeni kanye nesikhathi sokuzila ukudla kufanele sandiswe ngokufanele futhi ukuncishiswa kwamathumbu kufanele kwenziwe ngemva kokuhlinzwa (iziguli ngemuva kokuhlinzwa komgudu wokugaya ukudla okuphansi kufanele zikhiphe amanzi emseleni wendunu); b. Iziguli ezinesifo sikashukela kufanele zilawule ushukela wazo wegazi ngokuqinile; labo abanezimbobo ezincane kanye nokutheleleka okuncane kwesifuba nesisu kufanele banikezwe ukwelashwa okufana nokuzila ukudla, ukulwa nokutheleleka, kanye nokunciphisa i-asidi; c. Kulabo abane-ejensi, ukukhishwa kwamanzi esifubeni okuvaliwe kanye nokubhoboza kwesisu kungenziwa Amapayipi kufanele abekwe ukuze kugcinwe ukukhishwa kwamanzi kubushelelezi; d. Uma ukutheleleka kungenakutholakala endaweni ethile ngemva kokwelashwa okulondolozayo noma kuhlanganiswe nokutheleleka okukhulu kwe-thoracoabdominal, i-laparoscopy yokuhlinzwa kufanele yenziwe ngokushesha okukhulu, futhi ukulungiswa kokukhishwa kwamanzi kanye nokukhishwa kwamanzi esiswini kufanele kwenziwe.

Izinkinga ezihlobene negesi: Kubandakanya i-subcutai-neous emphysema, i-pneumomediastinum, i-pneumothorax kanye ne-pneumoperitoneum.

I-Intraoperative subcutaneous emphysema (ekhonjiswa njenge-emphysema ebusweni, entanyeni, odongeni lwesifuba, kanye nasesikhumbeni) kanye ne-mediastinal pneumophysema (s)ukuvela kwe-epiglottis kungatholakala ngesikhathi se-gastoscopy) ngokuvamile akudingi ukwelashwa okukhethekile, futhi i-emphysema ngokuvamile izozixazulula yodwa.

I-pneumothorax enzima iyenzeka dukuhlinzwa kokuphefumula [umfutho womoya udlula u-20 mmHg ngesikhathi sokuhlinzwa

(1mmHg=0.133kPa), i-SpO2<90%, okuqinisekiswe yi-X-ray yesifuba esiseceleni kombhede], ukuhlinzwa kungaqhubeka ngemva kokuhlinzwa kwesifuba okuvaliwe.ukungabi neminyaka.

Ezigulini ezine-pneumoperitoneum esobala ngesikhathi sokuhlinzwa, sebenzisa inalithi ye-pneumoperitoneum ukubhoboza iphuzu laseMcFarlandesiswini esingezansi kwesokudla ukuze ukhiphe umoya, bese ushiya inaliti yokubhoboza endaweni yayo kuze kube sekupheleni kokuhlinzwa, bese uyisusa ngemva kokuqinisekisa ukuthi akukho gesi ecacile ekhishwayo.

I-fistula yesisu: Uketshezi lokugaya olubangelwa ukuhlinzwa kwe-endoscopic lugeleza luye esifubeni noma emgodini wesisu ngokuvuza.
Ama-fistula ase-Esophageal mediastinal kanye nama-fistula ase-esophagothoracic avamile. Uma i-fistula isivele, khipha amanzi esifubeni ukuze ulondolozeekukhipheni amanzi okushelelayo futhi kuhlinzekwe ngokusekelwa okwanele kokudla okunomsoco. Uma kudingeka, iziqeshana zensimbi namadivayisi ahlukahlukene okuvala zingasetshenziswa, noma isembozo esigcwele singaphinde sisetshenziswe. Ama-stents nezinye izindlela zisetshenziswa ukuvimbaI-fistula. Amacala amakhulu adinga ukuhlinzwa okusheshayo.

3. Ukuphathwa ngemva kokuhlinzwa (f)ukulandelwa)

(1) Izilonda ezingembi:I-Pathologykusikisela ukuthi izilonda ezingenabungozi njenge-lipoma ne-leiomyoma azidingi ukulandelwa okuvamile okuphoqelekile.

(2) I-SMT engenalo unya olubiamandla ezintuthwane:Isibonelo, ama-NET e-rectal angu-2cm, kanye ne-GIST enobungozi obuphakathi nendawo kanye nephezulu, kufanele kwenziwe isigaba esiphelele futhi kufanele kucatshangelwe kakhulu ukwelashwa okwengeziwe (ukuhlinzwa, ukwelashwa ngamakhemikhali, ukwelashwa okuqondisiwe). Ukwakhiwa kohlelo kufanele kusekelwe ekubonisaneni okuhlukahlukene kanye nomuntu ngamunye.

(3) I-SMT engaba nomthelela ophansi ebulalayo:Isibonelo, i-GIST enobungozi obuphansi idinga ukuhlolwa yi-EUS noma nge-imaging njalo ezinyangeni eziyi-6 kuya kweziyi-12 ngemuva kokwelashwa, bese yelashwa ngokwemiyalelo yezokwelapha.

(4) I-SMT enamandla okubulala amagciwane aphakathi nendawo kanye naphezulu:Uma i-pathology yangemva kokuhlinzwa iqinisekisa uhlobo lwesithathu lwe-NET yesisu, i-NET ye-colorectal enobude obungaphezulu kuka-2cm, kanye ne-GIST enobungozi obuphakathi nendawo kanye nobukhulu, kufanele kwenziwe isigaba esiphelele futhi ukwelashwa okwengeziwe (ukuhlinzwa, ukwelashwa ngamakhemikhali, ukwelashwa okuqondiwe) kufanele kucatshangelwe kakhulu. Ukwakhiwa kohlelo kufanele kusekelwe ku[mayelana nathi 0118.docx] ukubonisana ngemikhakha eminingi kanye nomuntu ngamunye.