Ukwelashwa kwe-endoscopic kwama-tumoral sumors wephakethe lokugaya ukudla: Amaphuzu ama-3 amakhulu afingqiwe ku-athikili eyodwa

Ama-Sumors asenkulisa (i-SMT) yepheshana lesisu aphakanyisiwe izilonda eziphakanyisiwe ezivela kwi-muscularis mucosa, i-subrucosa, noma ama-musculalis propria, futhi angaba nezilonda ezingaphandle. Ngokuthuthukiswa kobuchwepheshe bezokwelapha, izinketho zokwelashwa kwendabuko zokuhlinzwa kancane kancane zingene enkathini yokwelashwa okuhlaselayo okuncane, njengokuthi lUkuhlinzwa kwe-Aparoscopic kanye nokuhlinzwa kwamarobhothi. Kodwa-ke, ekusebenzeni kwemitholampilo, kungatholakala ukuthi "ukuhlinzwa" akufanelekeli zonke iziguli. Eminyakeni yamuva, inani lokwelashwa kwe-endoscopic lithole kancane kancane. Uhlobo lwakamuva lwesivumelwano sesazi saseChinese ekuxilongeni kwe-endoscopic nokwelashwa kwe-SMT kukhishwe. Lo mbhalo uzofunda kafushane ulwazi olufanele.

1.Smt ubhubhane charateizicubu

(1) Izehlakalo zeSMU-T akalingani ezingxenyeni ezahlukahlukene zepheshana lokugaya ukudla, futhi isisu yindawo evame kakhulu ye-SMT.

Izehlakalo ze-variou variouIzingxenye zepheshana lokugaya ukudla azilingani, ngecala lokugaya ukudla elingaphezulu livame kakhulu. Kulezi, 2/3 zenzeke esiswini, kulandelwa yi-esophagus, i-duodenum nekholoni.

(2) I-histopathologicaIzinhlobo ze-SMT eziyinkimbinkimbi, kepha iningi le-SMT linezilonda ezilinganayo, futhi zimbalwa kuphela ezihlukunyezwa.

A.SMT kufaka chaIzilonda ze-N-Neoplastic ezifana nezicubu ze-pancreatic ze-ectopic kanye nezilonda ze-neoplastic.

B.Among lesiko le-neoplasticAma-leiomyomas ase-gastrointestinal, ama-lipomas, ama-bruculla adenomas, ama-tumors we-granulosa, ama-schwannosa, kanye nama-tumors we-glanus, futhi ngaphansi kwe-15% kungavela njengoba izicubu zibonakale zifundwa okubi.

C.Gastreststinal Stromal Ama-tumors (Gist) kanye nama-Neuroendocrine Tumors (Net) ku-SMT amathumbu anamandla athile abuhlungu, kepha lokhu kuya ngosayizi wawo, indawo nohlobo.

D.Indawo ye-SMT ihlobeneukuhlukaniswa kwe-pathological: a. I-Leiomomyomas uhlobo olujwayelekile lwe-SMT e-SMT e-esophagus, i-accounting ngo-60% kuya ku-80% we-esophageal SMTS, futhi maningi amathuba okuthi avele ezingxenyeni eziphakathi nendawo eziphansi ze-esophagus; b.Izinhlobo ze-pathological ze-SMT esiswini ziyinkimbinkimbi, nge-gist, i-leiomyoAma-pancreas we-ma kanye ne-ectopic abe evame kakhulu. Phakathi kwesisusi se-SMT, i-gist ivame ukutholakala kakhulu ku-fundus kanye nomzimba wesisu, i-leiomom ivame ukutholakala embonini nasengxenyeni engenhla yomzimba, nama-pancreas ama-ectopic kanye nama-pancreas ajwayelekile. Ama-lipomas ajwayelekile kakhulu ku-antrum yesisu; c. Ama-Lipomas nama-cysts ajwayelekile ngokwehla kanye nezingxenye ze-duodenum; d. Ku-SMT yepheshana lesisu elingaphansi, ama-lipomas ahamba phambili ekoloni, kanti amanetha ehamba phambili e-rectum.

(3) Sebenzisa i-CT ne-MRI ebangeni, ekwelapheni, kanye nokuhlola izimila. Kwi-SMTS okusolwa ukuthi ingabi yingozi noma inamasu amakhulu (ubudeUbubanzi> 2 cm), i-CT ne-MRI kunconyiwe.

Ezinye izindlela zokucabanga, kufaka phakathi i-CT ne-MRI, nazo zibaluleke kakhulu ekutholakaleni i-SMT. Bangakhombisa ngokuqondile indawo okwenzeka kwesimila, iphethini yokukhula, ubukhulu be-lesion, ukwakheka, ubukhona noma ukungabikho kokuqamba kwabantu, ukuthuthukiswa komngcele, njll., Futhi kungathola ukuthi ngabe ubukhulu bokuthiEning of the gametrointestinal wall.Ngakubaluleka, lezi zivivinyo zokucabanga zingathola ukuthi ngabe kukhona ukuhlaselwa kwezakhiwo eziseduzane ze-lesion nokuthi ngabe kukhona i-metastasis ePeritoneum, ama-lymph node nezinye izitho. Bayindlela esemqoka yokubalwa kwemitholampilo, ukwelashwa kanye nokuhlolwa kwe-degnoghosis of tumors.

(4) Isampula yezicubu alilona refoI-MMMEND For Benign SMTS engatholakala nge-endoscopy evamile ehlanganiswe ne-eus, njengama-lipomas, ama-cysts, kanye namanyikwe amanyikwe.

Ngezilonda ezisolwa ngokuba yingozi noma lapho i-endoscopy evamile ehlanganiswe ne-eus ingakwazi ukuhlola i-benign noma izilonda eziphathwayo, isifiso esihle se-FineE FineE FineE STRIOPSY (i-Endoscopic Ultrasonography iqondiswe kahle nI-Eedle Adrivered / Biopsy, EUS-FNA / FNB), i-mucosal incision biopsy (i-mucosalin-osizwe i-biopsy, njll. Yenza isampula ye-biopsy yokuhlolwa kwe-properative pathological ukuhlolwa. Ngenxa yokulinganiselwa kwe-EUS-FNA kanye nomthelela olandelayo ekuhlelweni kwe-endoscopic, kulabo abafanelekile ukuthola ukuhlinzwa kwe-endoscopic, kubuchwepheshe bokuvuthwa kwe-endoscopic kungalashwa ngokuphelele, i-endoscopic yokwelashwa e-endoscopist ingenza i-endoscopist yenza ukulungiswa kwe-endoscopic ngqo ngaphandle kokuthola ukuxilongwa kwe-endoscolopos ngqo.

Noma iyiphi indlela yokuthola ama-specimens we-pathological ngaphambi kokuhlinzwa ihlasele futhi izolimaza i-mucosa noma idala ukunamathela kwizicubu zomkhumbi, ngaleyo ndlela kwandise ubungozi bokuhlinzwa, amakhaisabelo, kanye nokusatshalaliswa kwesimila. Ngakho-ke, i-biopsy ye-preoperative ayidingeki. Kudingekile, ikakhulukazi ama-SMTS angatholakala nge-endoscopy ejwayelekile ehlanganiswe ne-eus, njengama-lipomas, ama-cysts, kanye nama-panplic adingekayo.

2.smt endoscopic takement

(1) Izimiso zokwelapha

Izilonda ezingenalo i-lymph node metastasis noma ingozi ephansi kakhulu ye-lymph node metastasis, ingavulwa kabusha ngokusebenzisa amasu e-endoscopic, futhi ube nengozi ephansi yensalela nokuphindaphindwayo kufanelekile ukusulwa kwe-endoscopic uma ukwelashwa kudingeka. Ukususwa okuphelele kwesimila kunciphisa isimila esele esele kanye nengozi yokuphindeka. Le khasiIsimiso sokuphathwa kwama-treem kufanele silandelwe ngesikhathi sokuvuselelwa kwe-endoscopic, kanye nobuqotho besimila se-tumor kufanele buqinisekiswe ngesikhathi sokuma kabusha.

(2) izinkomba

I.Vumani ngamanga amabi asolwa ngokuhlolwa okubangela noma ngokuqinisekiswa yi-biopsy pathology, ikakhulukazi lezo ezisolwa yi-GISt ngokuhlolwa kobubanzi besimila sobude be-≤2cm kanye nengozi ephansi yokuphindaphinda kanye ne-metastasis, futhi ngamathuba okuvuselelwa kabusha okuphelele, kungahle kuvulwe kabusha; Ngomhlambi onobubanzi obude bokusolwa okunobuso obusezingeni eliphansi> 2cm, uma i-lymph node noma i-lymph node noma i-endostasis ingahle ikhishwe ekuqinisekisweni kokuthi i-endoscopist ye-endoscopic eyunithi evuthiwe e-endoscopic technology. kabusha kabusha.

II. Izimpawu (isib. Ukopha, ukuvinjwa) i-SMT.

I-III.Tatients Okomsindo osolwa ukuthi abe senign ngokuhlolwa okubandlulule noma ukuqinisekiswa yi-pathology, kepha akunakulandelwa njalo noma amathumbu akhulisa isikhathi esifushane ngesikhathi sokulandela isikhathi futhi ane-desir eqinilee ekwelashweni kwe-endoscopic.

(3) Contraindications

Mina. Khomba izilonda ezinamiihlehliswe ama-lymph node noma amasayithi akude.

II. Kwamanye ama-SMT ane-lymph ecacilenodeNoma i-metastasis ekude, i-bulk biopsy iyadingeka ukuthola i-pathology, engabhekwa njengento ephikisayo.

III. Ngemuva kokucaciswa okuningiliziweUkuhlola, kunqunywa ukuthi isimo esijwayelekile simpofu futhi ukuhlinzwa kwe-endoscopic akunakwenzeka.

Izilonda ze-Benign ezifana ne-lipoma nama-pancreas ama-ectopic ngokuvamile azibangeli izimpawu ezinjengobuhlungu, ukopha kanye nokuvinjwa. Lapho sI-MT ibonakalisa njengokuguguleka, isilonda, noma inyuka ngokushesha ngesikhathi esifushane, kungenzeka ukuthi kukhuphuka isilonda esibi.

(4) Ukukhetha kwerevection method

I-Endoscopic Snare Revenetion: NgobaI-SMT Esezingeni eliphansi, iphuma emgodini njengoba kunqunywe yi-EPPoperative EUS kanye ne-CT Examents, futhi ingahle iphinde isetshenziswe ngokuphelele ngesinye isikhathi ngesigaxa, ukulungiswa kabusha kwe-endoscopic.

Izifundo ezifuywayo nezangaphandle zikuqinisekisile ukuthi kuphephile futhi kusebenza ngempumelelo ku-SMT e-SMT <2cm, ngengozi yokopha ngo-4% kuya ku-13% kanye nokugcotshwaingozi ye-2% kuya ku-70%.

Ukwembiwa kwe-endoscopic subvucosal, e-ENSE: Ama-SMTS ane-DIMETE ENDAWO LE-≥2 cm noma uma izivivinyo zokucabanga ezingabambisani ezifana ne-EUS ne-CT QinisekisaE-tumor ikhipha emgodini, i-ESE iyenzeka ngokusetha kabusha kwe-endoscopic sleeve kabusha ama-SMTs abucayi.

I-ESE ilandela imikhuba yobuchwepheshe yeUkuhlukaniswa kwe-endoscopic (i-ESD) kanye ne-endoscopic mucosal resection, futhi kuvame ukusebenzisa i-15 "Flip-top" yokuvuka okuzungeze isimila ukususa i-mucosa emboza i-SMT futhi iveze ngokuphelele isimila. , ukufeza inhloso yokulondolozwa kobuqotho besimila, kuthuthukisa ubuciko bokuhlinzwa, kanye nokunciphisa izinkinga ezingabambisanayo. Okwethumba ≤1.5 cm, isilinganiso esiphelele sokuvuselela ama-100% singatholakala.

Indawo yokuphumula ye-endoscopic ye-subbeCosalI-Ion, i-STER: Nge-SMT isuka kwi-Muscular Propria e-Esophagus, iHilum, i-curvature encane yomzimba wesisu, i-rectum, okulula ukusungula imigudu, futhi okulula ukusungula indlela yokwelashwa engu-3.5 cm.

I-STER ubuchwepheshe obusha obuthuthukisiwe ngokusekelwe e-Endoscopic esophageal SpnIncteromy (inkondlo) futhi isandiso sobuchwepheshe be-ESDnology. Izinga le-En Bloc Rection of Ster for SMT Ukwelashwa lifinyelela kuma-84.9% kuya ku-97.59%.

Isiphikiso esigcwele se-endoscopicI-ION, EFTR: Ingasetshenziselwa i-SMT lapho kunzima khona ukusungula umhubhe noma ububanzi obukhulu be-tumor ≥3.5 cm futhi ayilungele i-STER. Uma isimila siphuma ngaphansi kolwelwesi olunsomi noma lukhula ngaphandle kwengxenye ye-cavity, futhi isimila sitholakala sinamathela ngokuqinile kwisendlalelo se-serosa ngesikhathi sokuhlinzwa futhi asikwazi ukuhlukaniswa, singasetshenziswa. I-EFTR yenza ukwelashwa e-endoscopic.

Ukufunwa okufanelekile kwemveloIndawo ngemuva kwe-EFTR iyisihluthulelo sempumelelo ye-EFTR. Ukuze uhlole ngokunembile ubungozi bokuphindelela kwesimila futhi unciphise ubungozi bokusabalalisa isimila, akunconywa ukusika nokususa isibonakaliso se-tumor esivuthiwe ngesikhathi se-EFTR. Uma kudingekile ukususa isimila ngezicucu, ukugcotshwa kudinga ukulungiswa kuqala ukunciphisa ubungozi bokuthi ubungozi be-tumor siving futhi busakazeke. Izindlela ezithile ezithuthukayo zifaka phakathi i-suture ye-Metal Clip, Suture-Clip Suture Technique, "Indlela Yesikhwama Sezikhwama Sokuvalwa Kwezikulumo (ngaphezulu kwesiqeshana se-nylon, ngaphezulu kwesiqeshana se-NOSTerstit, ukubhekana nobunye ubuchwepheshe obusha ukubhekana nokopha, njll.

(5) Izinkinga ezisebenzayo

I-Intraperative Operative: Ukuphamba okubangela i-hemoglobin yesiguli ukwehla ngaphezulu kwama-20 g / l.
Ukuvikela ukopha okukhulu kwe-intraperative,Umjovo owenele we-subrucosal kufanele wenziwe ngesikhathi sokusebenza ukudalula imithambo yegazi emikhulu futhi wenze lula ama-electrocaagulation ukumisa ukopha. Ukuphanga okungenzeka kwe-Intraperative kungalashwa ngemimese ehlukahlukene ye -nisotion, ama-hercostatic forceps noma iziqeshana zensimbi, kanye ne-hemostasis yokuvimbela imithambo yegazi eveziwe ngesikhathi senqubo yokuhlaziya.

Ukuphuma kwe-postoperative: Ukubonakaliswa kokopha kwe-postoperative njengokuhlanza igazi, iMelena, noma igazi esihlalweni. Ezimweni ezinzima, ukushaqeka kwe-hemorrhagic kungenzeka. Kwenzeka kakhulu kungakapheli isonto eli-1 ngemuva kokuhlinzwa, kepha futhi kungenzeka futhi kumaviki ama-2 kuye kwangama-4 ngemuva kokuhlinzwa.

Ukuphuma kwe-postoperative kuvame ukuhlobeneIzici ezinjengokulawulwa kwengcindezi yegazi empofu yegazi kanye nokugqwala kwemithambo yegazi esele yi-gastric acid. Ngaphezu kwalokho, ukopha kwe-postoperative kuhlobene nendawo yalesi sifo, futhi kuvame kakhulu ku-antrum yesisu kanye ne-rectum ephansi.

Ukubambezeleka okubambezelekile: Imvamisa kubonakaliswa njengokubhekelwa esiswini, kukhulisa ubuhlungu besisu, izimpawu ze-peritonitis, umkhuhlane, nokuhlolwa kokulingisa kukhombisa ukuqongelela igesi noma ukuqongelela igesi okuqhathaniswa nakho ngaphambili.

Kuhlobene kakhulu nezici ezinjengokusetshenziselwa amanxeba ampofu, ukukhuphuka kwe-electrocauagation ngokweqile, ukusukuma kakhulu ukunyakaza, ukudla kakhulu, ukulawula amanxeba ampofu, nokuguguleka kwamanxeba nge-gastric acid. a. Uma isilonda sikhulu noma sijulile noma isilonda sine-FISIzinguquko ezinesiqiniseko, isikhathi sokuphumula sombhede kanye nesikhathi sokudla kufanelekile ngokufanelekile futhi isistimu yesisu kufanele kwenziwe ngemuva kokuhlinzwa (iziguli ngemuva kokuhlinzwa kwe-analtrointenalinal, b. Iziguli ezinesifo sikashukela kufanele zilawule ngokuqinile ushukela wegazi labo; Labo abanezinkinga ezincane kanye nezifo ezinamakhatheze nezifo zesisu kufanele zinikezwe ukwelashwa njengokudla, ukutheleleka, kanye nokucindezela kwe-acid; c. Kulabo abane-effision, ukuvalwa kwesifuba okuvaliwe kanye nokubhoboza isisu esiswini kungenziwa amashubhu kufanele kubekwe ukuze kugcinwe ukudonsa okubushelelezi; d. Uma ukutheleleka kungakwazi ukwenziwa kwasendaweni ngemuva kokwelashwa okulondoloziwe noma kuhlanganiswe nokutheleleka okukhulu kwe-thoracoabdominal, i-laparoscopy ye-laparoscopy kufanele yenziwe ngokushesha okukhulu, futhi ukulungiswa kokulungiswa kwesisu nangokulungiswa kwesisu kufanele kwenziwe.

Izinkinga ezihlobene negesi: kufaka phakathi i-subcutaI-neous emphysema, pneumomediastinum, pneumothorax kanye ne-pneumoperponeoneum.

I-Intraperate Operaterative Emphhema (ekhonjiswe njenge-emphysema ebusweni, entanyeni, edongeni lesifuba, kanye ne-scrotum) kanye ne-media cumophyema (sUkuhlelela kwe-epiglottis kungatholakala ngesikhathi se-gastroscopy) ngokuvamile akudingi ukwelashwa okukhethekile, futhi i-emphysema ngokuvamile izoxazululeka ngokwayo.

I-Pneumothorax enamandla yenzeka dUkuhlinzwa Ukuhlinzwa [Ingcindezi Yomoya Idlula 20 MMHG ngesikhathi sokuhlinzwa

.i-inage.

Ezigulini ezinama-pneumoperitoneum asobala ngesikhathi sokusebenza, sebenzisa inaliti ye-pneumopperitoneum yokubhoboza iphuzu le-McfarlandEsiswini esingezansi esifanele ukuze uhlehlise umoya, bese ushiya inalithi yokubhoboza endaweni kuze kube sekupheleni kokuhlinzwa, bese uyisusa ngemuva kokuqinisekisa ukuthi ayikho igesi esobala ekhishwayo.

I-Fistula yesisu: Uketshezi lokugaya ukudla okubangelwa ukuhlinzwa kwe-endoscopic kugeleza esifubeni noma emgodini wesisu ngokuvuza.
I-Esophageal Medialinal Fistulas kanye ne-esophagothothoracic fistulas bavame. Lapho nje kwenzeka i-fistula, yenza amanzi avaliwe esifubeni esikhungweniemanzini abushelelezi futhi anikeze ukwesekwa okwenele okunempilo. Uma kunesidingo, iziqeshana zensimbi kanye namadivayisi ahlukahlukene okuvala angasetshenziswa, noma isembozo esigcwele singaphinde sisebenze. Iziqu kanye nezinye izindlela zisetshenziselwa ukuvimbafistula. Amacala abucayi adinga ukungenelela okusheshayo okucindezelayo.

3.Potposurationate Management (Fokukodwa)

(1) Izilonda ze-benign:Pathology sAma-UgGes athi ama-ligline afana ne-lipoma ne-leiomomyoma akudingi ukulandela okujwayelekile.

(2) I-SMT ngaphandle kobubiOkungaba Umuntu Okufanele:Isibonelo, amanetha we-Ructal 2cm, kanye ne-medical- kanye nobungozi obukhulu, ukugabha okuphelele kufanele kwenziwe kanye nokwelashwa okwengeziwe (ukuhlinzwa, i-chemoraditherapy, ukwelashwa okuhlosiwe) kufanele kubhekwe ngokuqinile. phatha). Ukwakhiwa kwecebo kufanele kususelwe ekubonisaneni okuningi kwe-multidisciplinary nakumuntu ngamunye.

(3) I-SMT evumayo ebilayoIsibonelo, i-gist enobungozi obuphansi idinga ukuhlolwa yi-eus noma ukucabanga njalo ezinyangeni ezi-6 kuye kwezingu-12 ngemuva kokwelashwa, bese iphathwa ngokwemiyalo yemitholampilo.

(4) I-SMT enamandla aphakathi nangobuhlungu aphezulu:Uma i-postoperative pathology iqinisekisa uhlobo lwe-gastric net, inetha emibalabala enobude> 2cm, kanye ne-gist enobungozi obukhulu, ukuhlinzwa okuphezulu kufanele kwenziwe kanye nokwelashwa okwengeziwe noma ukwelashwa okuhlosiwe) kufanele kubhekwe ngokuqinile. phatha). Ukwakhiwa kwecebo kufanele kususelwe ku[Mayelana nathi 0118.docx] Ukubonisana okuningiliziwe kanyekanye.