Ukwelashwa kwe-Endoscopic kwamathumba angaphansi kwepheshana lokugaya: amaphuzu amakhulu ama-3 afingqiwe esihlokweni esisodwa.

Izimila ezingaphansi kwe-submucosal (SMT) zepheshana lamathumbu ziyizilonda eziphakeme ezivela ku-muscularis mucosa, i-submucosa, noma i-muscularis propria, futhi ingase ibe izilonda ezingaphandle kwesikhumba.Ngokuthuthuka kobuchwepheshe bezokwelapha, izinketho zokwelashwa kokuhlinzwa kwendabuko ziye zangena kancane kancane enkathini yokwelashwa okungavamisile, njengokuthi l.ukuhlinzwa kwe-aparoscopic nokuhlinzwa kwerobhothi.Kodwa-ke, ekusebenzeni komtholampilo, kungatholakala ukuthi "ukuhlinzwa" akufanelekile kuzo zonke iziguli.Eminyakeni yamuva, inani lokwelashwa kwe-endoscopic liye lathola ukunakwa kancane kancane.Inguqulo yakamuva yokuvumelana kochwepheshe baseShayina ekuxilongweni kwe-endoscopic kanye nokwelashwa kwe-SMT kukhishiwe.Lesi sihloko sizofunda kafushane ulwazi olufanele.

1.Isici sobhubhane lwe-SMTabagxekayo

(1) Isigameko se-SMI-T ayilingani ezingxenyeni ezihlukahlukene zomgudu wokugaya ukudla, futhi isisu siyindawo evamile ye-SMT.

Izehlakalo ezihlukahlukenes izingxenye zomgudu wokugaya ukudla azilingani, umgudu wokugaya ongaphezulu uvame kakhulu.Kulokhu, i-2/3 ivela esiswini, ilandelwa umphimbo, i-duodenum, nekholoni.

(2) I-histopathyl Izinhlobo ze-SMT ziyinkimbinkimbi, kodwa eziningi ze-SMT ziyizilonda eziyingozi, futhi zimbalwa kuphela eziyingozi.

I-A.SMT ihlanganisa noIzilonda ze-n-neoplastic ezifana nezicubu ze-ectopic pancreatic kanye nezilonda ze-neoplastic.

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

C.I-stroma yamathumbul izimila (GIST) kanye nezicubu ze-neuroendocrine (NET) ku-SMT amathumba anamandla athile amabi, kodwa lokhu kuncike kusayizi wawo, indawo kanye nohlobo.

D. Indawo ye-SMT ihlobenekusigaba se-pathological: a.I-leiomyomas iwuhlobo oluvamile lwe-SMT lwe-pathological ku-esophagus, olubalelwa ku-60% kuya ku-80% wama-SMT omphimbo, futhi maningi amathuba okuba zenzeke phakathi nezingxenye eziphansi zomphimbo;b.Izinhlobo ze-pathological SMT zesisu ziyinkimbinkimbi, nge-GIST, leiomyoI-ma kanye ne-ectopic pancreas yiyona evame kakhulu.Phakathi kwe-SMT yesisu, i-GIST ivame ukutholakala ku-fundus nasemzimbeni wesisu, i-leiomyoma ivamise ukuba senhliziyo nengxenye engaphezulu yomzimba, kanti amanyikwe e-ectopic nama-ectopic pancreas avame kakhulu.I-Lipomas ivame kakhulu ku-antrum yesisu;c.Ama-Lipomas nama-cyst avame kakhulu ezingxenyeni ezihlayo nezine-bulbous ze-duodenum;d.Ku-SMT yepheshana eliphansi lesisu, ama-lipomas agqama kukholoni, kuyilapho ama-NET egcwele ku-rectum.

(3) Sebenzisa i-CT ne-MRI ukuze ulinganise, uphathe, futhi uhlole izimila.Kuma-SMT okusolwa ukuthi angaba yingozi noma anamathumba amakhulu (obudeububanzi> 2 cm), i-CT ne-MRI iyanconywa.

Ezinye izindlela zokucabanga, ezihlanganisa i-CT ne-MRI, nazo zibaluleke kakhulu ekuxilongweni kwe-SMT.Bangabonisa ngokuqondile indawo yethumba, iphethini yokukhula, usayizi wesilonda, ukuma, ukuba khona noma ukungabikho kwe-lobule, ukuminyana, i-homogeneity, izinga lokuthuthuka, kanye ne-contour yomngcele, njll., futhi bangathola ukuthi kanye nezinga lokujiyaukuvuleka kodonga lwamathumbu.Okubaluleke kakhulu, lokhu kuhlolwa kwezithombe kungathola ukuthi kukhona yini ukuhlasela kwezakhiwo eziseduze zesilonda kanye nokuthi kukhona yini ukuqubuka kwe-metastasis ku-peritoneum ezungezile, ama-lymph nodes nezinye izitho.Ziyindlela eyinhloko yokukala emtholampilo, ukwelashwa kanye nokuhlolwa kwesibikezelo sezimila.

(4)Isampula yezicubu ayitholakaliihloselwe ama-SMT alungile angatholwa nge-endoscopy evamile ehlanganiswe ne-EUS, njengama-lipomas, ama-cysts, nama-ectopic pancreas.

Ngezilonda okusolwa ukuthi ziyingozi noma lapho i-endoscopy evamile ehlanganiswe ne-EUS ingakwazi ukuhlola izilonda ezimbi noma ezimbi, i-EUS-guided fine-needle aspiration/biopsy ingasetshenziswa(endoscopic ultrasonography guided fine ni-eedle aspiration/biopsy, EUS-FNA/FNB), i-mucosal incision biopsy(i-mucosalincision-assisted biopsy, MIAB), njll. yenza isampula ye-biopsy yokuhlolwa kokugula kwangaphambi kokuhlinzwa.Uma kubhekwa ukulinganiselwa kwe-EUS-FNA kanye nomthelela olandelayo ekukhishweni kwe-endoscopic, kulabo abafanelekela ukuhlinzwa kwe-endoscopic, ngesisekelo sokuqinisekisa ukuthi isimila singakhishwa ngokuphelele, amayunithi anobuchwepheshe bokwelapha be-endoscopic obuvuthiwe angelashwa abanolwazi. I-endoscopist yenza i-endoscopic resection ngqo ngaphandle kokuthola ukuxilongwa kwangaphambili kwe-pathological.

Noma iyiphi indlela yokuthola izibonelo ze-pathological ngaphambi kokuhlinzwa iyahlasela futhi izolimaza i-mucosa noma ibangele ukunamathela kwezicubu ze-submucosal, ngaleyo ndlela kwandise ubunzima bokuhlinzwa futhi ngokunokwenzeka kwandise izingozi zokopha, i-perfo.ration, kanye nokusabalalisa isimila.Ngakho-ke, i-biopsy yangaphambi kokuhlinzwa akudingekile.Kudingekile, ikakhulukazi kuma-SMTs angatholwa nge-endoscopy evamile ehlanganiswe ne-EUS, njengama-lipomas, ama-cysts, nama-ectopic pancreas, akukho sampula yezicubu ezidingekayo.

2.SMT endoscopic treatmentnt

(1)Izimiso zokwelapha

Izilonda ezingenayo i-lymph node metastasis noma ingozi ephansi kakhulu ye-lymph node metastasis, zingahlehliswa ngokuphelele kusetshenziswa amasu e-endoscopic, futhi zibe nengozi ephansi yokusala nokuphindaphinda zifaneleka ukukhishwa kwe-endoscopic uma ukwelashwa kudingekile.Ukususwa ngokuphelele kwesimila kunciphisa isimila esisele kanye nengozi yokuphindelela.IUmgomo wokwelashwa okungenamathumba kufanele ulandelwe ngesikhathi sokukhishwa kwe-endoscopic, futhi ubuqotho be-capsule yesimila kufanele kuqinisekiswe ngesikhathi sokukhishwa.

(2)Izinkomba

i.Amathumba anamandla amabi asolwa ngokuhlolwa ngaphambi kokuhlinzwa noma aqinisekiswa yi-biopsy pathology, ikakhulukazi lawo asolwa nge-GII-ST enokuhlolwa kwangaphambili kokusebenza kobude be-tumor ≤2cm kanye nengozi ephansi yokuphindaphinda kanye ne-metastasis, kanye nethuba lokukhishwa okuphelele, kungenziwa i-endoscopically resected;Izimila ezinobubanzi obude Nge-GIST okusolwa ukuthi inengozi ephansi engu-2cm, uma i-lymph node noma i-metastasis ekude ikhishiwe ekuhlolweni kwangaphambi kokuhlinzwa, ngesisekelo sokuqinisekisa ukuthi isimila singakhishwa ngokuphelele, ukuhlinzwa kwe-endoscopic kungenziwa ngodokotela abanolwazi iyunithi enobuchwepheshe bokwelapha be-endoscopic obuvuthiwe.ukukhishwa kabusha.

ii.Izimpawu (isb, ukopha, ukuvimbela) SMT.

iii.Iziguli okusolwa ukuthi izimila zazo azibi ngokuhlolwa ngaphambi kokuhlinzwa noma okuqinisekiswe yi-pathology, kodwa azikwazi ukulandelelwa njalo noma izimila zazo ezikhula ngesikhathi esifushane phakathi nenkathi yokulandelela futhi ezinesifiso esinamandla.e yokwelashwa kwe-endoscopic.

(3)Izimo ezingasetshenziswa

i.Khomba izilonda enginazoi-tastasized kuma-lymph nodes noma izindawo ezikude.

ii.Kwamanye ama-SMT ane-lymph ecacilenodenoma i-metastasis ekude, i-biopsy yenqwaba iyadingeka ukuze kutholwe i-pathology, engathathwa njengokuphikisana okuhlobene.

iii.Ngemuva kokuhlinzwa okuningiliziweukuhlolwa, kunqunywa ukuthi isimo esijwayelekile sibi futhi ukuhlinzwa kwe-endoscopic akunakwenzeka.

Izilonda ezingezinhle ezifana ne-lipoma nama-ectopic pancreas ngokuvamile azibangeli izimpawu ezinjengobuhlungu, ukopha, nokuvinjelwa.Lapho u-SI-MT ibonakalisa ukuguguleka, isilonda, noma ukwanda ngokushesha ngesikhathi esifushane, amathuba okuba isilonda esibi siyanda.

(4) Ukukhetha indlela yokuhlinzad

Ukukhishwa kwe-Endoscopic snare: ForI-SMT ekha phezulu, ephumela emgodini njengoba kunqunywe ukuhlolwa kwangaphambi kokuhlinzwa kwe-EUS kanye ne-CT, futhi ingakhishwa ngokuphelele ngesikhathi esisodwa ngogibe, ukususwa kogibe lwe-endoscopic kungasetshenziswa.

Izifundo zasekhaya nezangaphandle ziye zaqinisekisa ukuthi iphephile futhi iyasebenza ku-SMT engaphandle <2cm, enengozi yokopha ye-4% kuya ku-13% kanye nokubhobozwa.ingozi 2% kuya 70%.

I-Endoscopic submucosal excavation,ESE : Okwama-SMT anobubanzi obude ≥2 cm noma uma ukuhlolwa kwe-imaging ngaphambi kokuhlinzwa okufana ne-EUS ne-CT kuqinisekisaesimila siphumela emgodini, i-ESE ingenzeka ekukhishweni komkhono we-endoscopic wama-SMT abucayi.

I-ESE ilandela imikhuba yobuchwepheshe yei-endoscopic submucosal dissection (ESD) kanye ne-endoscopic mucosal resection, futhi ngokuvamile isebenzisa isiyingi "flip-top" ukusikwa ezungeze isimila ukuze kukhishwe ulwelwesi olumboze i-SMT futhi luveze ngokugcwele isimila., ukufeza inhloso yokugcina ubuqotho bethumba, ukuthuthukisa ukuqina kokuhlinzwa, nokunciphisa izinkinga ze-intraoperative.Ngama-tumors ≤1.5 cm, izinga lokukhishwa okuphelele kwe-100% lingafinyelelwa.

I-Submucosal Tunneling Endoscopic Resection, STER : Kwe-SMT evela ku-muscularis propria kumphimbo, i-hilum, ukugoba okuncane komzimba wesisu, i-gastric antrum ne-rectum, okulula ukumisa imigudu, futhi ububanzi obuguquguqukayo bungu-≤ 3.5 cm, i-STER ingakhethwa indlela yokwelapha.

I-STER ubuchwepheshe obusha obuthuthukisiwe obusekelwe ku-peroral endoscopic esophageal sphincterotomy (POEM) futhi iyisandiso se-ESD tech.i-nology.Izinga lokukhishwa kabusha kwe-en bloc le-STER yokwelashwa kwe-SMT lifinyelela ku-84.9% kuya ku-97.59%.

I-Endoscopic Full-thickness Resection,EFTR :Ingasetshenziselwa i-SMT lapho kunzima khona ukusungula umhubhe noma lapho ubukhulu bobubanzi obuguquguqukayo bethumba bungu-≥3.5 cm futhi aliyifanele i-STER.Uma isimila siphumela ngaphansi kolwelwesi olunsomi noma sikhule ngaphandle kwengxenye yomgodi, futhi isimila sitholakala sinamathela ngokuqinile kungqimba lwe-serose phakathi nokuhlinzwa futhi asikwazi ukuhlukaniswa, singasetshenziswa.I-EFTR yenza ukwelashwa kwe-endoscopic.

I-suturing efanele ye-perforationindawo ngemva kwe-EFTR iwukhiye wempumelelo ye-EFTR.Ukuze kuhlolwe ngokunembile ingozi yokuphindaphinda kwe-tumor futhi kuncishiswe ingozi yokusabalalisa isimila, akunconywa ukusika nokukhipha isampula ye-tumor ekhishwe ngesikhathi se-EFTR.Uma kudingekile ukususa isimila sibe yizicucu, ukubhoboza kudinga ukulungiswa kuqala ukuze kuncishiswe ingozi yokukhula kwesimila nokusabalala.Ezinye izindlela zokuthunga zihlanganisa: i-metal clip suture, i-suction-clip suture, i-omental patch suture technique, indlela ye-"purse bag suture" yentambo enayiloni ehlanganiswe nesiqeshana sensimbi, i-rake metal clip closure system (phezu kwesiqeshana se-scope, i-OTSC) i-OverStitch suture nokunye. ubuchwepheshe obusha bokulungisa ukulimala kwamathumbu kanye nokubhekana nokopha, njll.

(5)Izinkinga zangemva kokuhlinzwa

Ukopha ngokuhlinza: Ukopha okwenza i-hemoglobin yesiguli yehle ngaphezu kuka-20 g/L.
Ukuvimbela ukopha okukhulu kwe-intraoperative,Umjovo we-submucosal owanele kufanele wenziwe ngesikhathi sokuhlinzwa ukuze kuvezwe imithambo yegazi emikhulu futhi kusize i-electrocoagulation ukuze kumiswe ukopha.Ukopha ngaphakathi ngokuhlinza kungelashwa ngemimese ehlukene yokusika, amandla e-hemostatic noma iziqeshana zensimbi, kanye nokuvimbela ukopha kwemithambo yegazi eveziwe etholakala phakathi nenqubo yokuhlinza.

Ukopha kwangemva kokuhlinzwa: Ukopha kwangemva kokuhlinzwa kubonakala njengokuhlanza igazi, i-melena, noma igazi esitulweni.Ezimweni ezimbi kakhulu, ukushaqeka kwe-hemorrhagic kungenzeka.Kwenzeka kakhulu phakathi kweviki elingu-1 ngemva kokuhlinzwa, kodwa kungenzeka futhi emavikini ama-2 kuya kwangu-4 ngemva kokuhlinzwa.

Ukopha kwangemva kokuhlinzwa kuvame ukuhlobeneizici ezifana nokulawulwa kabi komfutho wegazi wangemva kokuhlinzwa kanye nokugqwala kwemithambo yegazi esele nge-asidi yesisu.Ngaphezu kwalokho, ukuphuma kwegazi ngemuva kokuhlinzwa kuhlobene nendawo yesifo, futhi kuvame kakhulu ku-antrum yesisu kanye ne-rectum ephansi.

Ukulibaziseka kokubhobozwa: Ngokuvamile kubonakala njengokuvuvukala kwesisu, ubuhlungu besisu obuyandayo, izimpawu ze-peritonitis, imfiva, nokuhlolwa kwesithombe kukhombisa ukunqwabelana kwegesi noma ukunqwabelana kwegesi okukhulayo uma kuqhathaniswa nangaphambili.

Ihlobene kakhulu nezici ezinjengokungenwa kahle kwezilonda, ukubola kwe-electrocoagulation, ukuvuka ekuseni kakhulu ukuhambahamba, ukudla indlebe kakhulu, ukulawula ushukela wegazi okungekuhle, nokuguguleka kwezilonda nge-asidi yesisu.a.Uma inxeba likhulu noma lijulile noma inxeba linemifishiizinguquko eziqinisekile, isikhathi sokuphumula kombhede kanye nesikhathi sokuzila kufanele sinwetshwe ngokufanelekile futhi ukuchithwa kwamathumbu emathunjini kufanele kwenziwe ngemva kokuhlinzwa (iziguli ngemva kokuhlinzwa okuphansi kwe-gastrointestinal tract kufanele zibe ne-anal drainage);b.Iziguli ezinesifo sikashukela kufanele zilawule ngokuqinile ushukela wazo;labo abanezimbobo ezincane kanye nezifo ezincane ze-thoracic kanye nesisu kufanele banikezwe ukwelashwa okufana nokuzila ukudla, ukulwa nokutheleleka, nokucindezelwa kwe-asidi;c.Kulabo abane-effusion, i-drainage yesifuba evaliwe kanye nokubhobozwa kwesisu kungenziwa Amashubhu kufanele abekwe ukuze kugcinwe amanzi abushelelezi;d.Uma ukutheleleka kungenakutholakala endaweni ngemuva kokwelashwa okulondolozayo noma kuhlanganiswe nokutheleleka okukhulu kwe-thoracoabdominal, i-laparoscopy yokuhlinzwa kufanele yenziwe ngokushesha ngangokunokwenzeka, futhi ukulungiswa kwe-perforation kanye nokukhipha isisu kufanele kwenziwe.

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

I-intraoperative subcutaneous emphysema (ekhonjiswe njenge-emphysema ebusweni, entanyeni, odongeni lwesifuba, nescrotum) kanye ne-mediastinal pneumophysema (sUkuphila kahle kwe-epiglottis kungatholakala ngesikhathi se-gastroscopy) ngokuvamile akudingi ukwelashwa okukhethekile, futhi i-emphysema izozixazulula ngokwayo.

I-pneumothorax enzima yenzeka dukuhlinzwa komchamo [umfutho womoya wedlula ama-20 mmHg phakathi nokuhlinzwa

(1mmHg=0.133kPa), i-SpO2<90%, iqinisekiswe i-X-ray yesifuba esiphuthumayo eceleni kombhede], ukuhlinzwa kungaqhutshekwa ngemva kokuvaleka kwesifubainage.

Ezigulini ezine-pneumoperitoneum esobala ngesikhathi sokuhlinzwa, sebenzisa inaliti ye-pneumoperitoneum ukubhoboza iphuzu le-McFarland.kwesokudla esingezansi kwesisu ukuze unciphise umoya, futhi ushiye inaliti yokubhoboza endaweni kuze kube sekupheleni kokusebenza, bese uyisusa ngemva kokuqinisekisa ukuthi akukho gesi esobala ekhishwayo.

I-Gastrointestinal fistula: Uketshezi lokugaya okubangelwa ukuhlinzwa kwe-endoscopic lugelezela esifubeni noma emgodini wesisu ngokuvuza.
I-Esophageal mediastinal fistulas kanye ne-esophagothoracic fistulas zivamile.Uma kwenzeka i-fistula, khipha amanzi esifuba ku-mantaku-drainage ebushelelezi futhi inikeze ukwesekwa okwanele okunomsoco.Uma kunesidingo, iziqeshana zensimbi nezinye izinto zokuvala ezihlukahlukene zingasetshenziswa, noma isembozo esigcwele singagaywa kabusha.Ama-stents nezinye izindlela zisetshenziselwa ukuvimbai-fistula.Izimo ezinzima zidinga ukungenelela okusheshayo kokuhlinzwa.

3. Ukuphathwa kwangemuva kokuhlinzwa (fukukhuphuka)

(1) Izilonda ezinhle:I-Pathology siphakamisa ukuthi izilonda ezinobungozi ezifana ne-lipoma ne-leiomyoma azidingi ukulandelwa okujwayelekile okuphoqelekile.

(2) I-SMT ngaphandle kobubiamandla entuthwane:Isibonelo, ama-rectal NETs angu-2cm, kanye ne-GIST enobungozi obuphakathi nendawo, kufanele kwenziwe isiteji esiphelele futhi ukwelashwa okwengeziwe (ukuhlinzwa, i-chemoradiotherapy, ukwelashwa okuhlosiwe) kufanele kucatshangelwe ngokuqinile.phatha).Ukwakhiwa kwalolu hlelo kufanele kusekelwe ekubonisaneni kwezinhlaka eziningi kanye nomuntu ngamunye.

(3) I-SMT enamandla ayingozi ephansi:Isibonelo, i-GIST enengcuphe ephansi idinga ukuhlolwa yi-EUS noma ukuthwebula izithombe njalo ngemva kwezinyanga eziyisi-6 kuya kweziyi-12 ngemva kokwelashwa, bese iphathwa ngokwemiyalelo yomtholampilo.

(4) I-SMT enamandla ayingozi aphakathi nendawo naphezulu:Uma i-postoperative pathology iqinisekisa uhlobo lwe-3 ye-gastric NET, i-colorectal NET enobude > 2cm, kanye ne-GIST enobungozi obuphakathi nendawo, kufanele kwenziwe isiteji esiphelele futhi ukwelashwa okwengeziwe (ukuhlinzwa, i-chemoradiotherapy, ukwelashwa okuhlosiwe) kufanele kucatshangelwe ngokuqinile.phatha).Ukwakhiwa kohlelo kufanele kusekelwe[mayelana nathi 0118.docx]i-multidisciplinary consultation kanye nomuntu ngamunye.