Unyango lwe-Endoscopic lwee-submucosal tumors zendlela yokugaya ukutya: amanqaku amathathu aphambili ashwankathelwe kwinqaku elinye

Ii-submucosal tumors (SMT) zendlela yokugaya ukutya zizilonda eziphakamileyo ezivela kwi-muscularis mucosa, i-submucosa, okanye i-muscularis propria, kwaye zisenokuba zizilonda ezingaphandle kolusu. Ngophuhliso lwetekhnoloji yezonyango, iindlela zonyango lwendabuko ziye zangena kancinci kancinci kwixesha lonyango olungenalo utyando, olufana ne-lUtyando lwe-aparoscopic kunye notyando lwerobhothi. Nangona kunjalo, kwindlela yokusebenza kwezonyango, kunokufunyanwa ukuba "utyando" alufanelekanga kubo bonke abaguli. Kwiminyaka yakutshanje, ixabiso lonyango lwe-endoscopic liye lafumana ingqalelo kancinci kancinci. Inguqulelo yamva nje yesivumelwano seengcali zaseTshayina malunga nokuxilongwa kwe-endoscopic kunye nonyango lwe-SMT ikhutshiwe. Eli nqaku liza kufunda ulwazi olufanelekileyo ngokufutshane.

1. Uphawu lobhubhane lwe-SMTubuhlanga

(1) Ukwanda kwe-SMI-T ayilingani kwiindawo ezahlukeneyo zendlela yokugaya ukutya, kwaye isisu sesona ndawo sixhaphakileyo se-SMT.

Ukwanda kweentlobo ezahlukeneyoIindawo zendlela yokugaya azilingani, kwaye indlela yokugaya ephezulu ixhaphake kakhulu. Kwezi, i-2/3 zenzeka esiswini, kulandele i-esophagus, i-duodenum, kunye ne-colon.

(2) I-histopathologicalaIintlobo ze-SMT zintsonkothile, kodwa uninzi lwe-SMT zizilonda ezingenabungozi, kwaye zimbalwa kuphela ezinobungozi.

I-A.SMT ibandakanya akukhoizilonda ze-n-neoplastic ezifana nezicubu ze-pancreatic ezingaphandle kwe-ectopic kunye nezilonda ze-neoplastic.

B.Phakathi kwesilonda se-neoplasticii-s, ii-leiomyomas zesisu, ii-lipomas, ii-Brucella adenomas, ii-granulosa cell tumors, ii-schwannomas, kunye nee-glomus tumors uninzi lwazo azinabungozi, kwaye ngaphantsi kwe-15% zinokubonakala njengezicwili Funda ububi.

C. I-stroma yesisuIi-tumor ze-l (GIST) kunye nee-neuroendocrine tumors (NET) kwi-SMT zii-tumor ezine-malignant ethile, kodwa oku kuxhomekeke kubukhulu bazo, indawo kunye nohlobo lwazo.

D. Indawo ye-SMT inxulumenekudidi lwe-pathological: a. IiLeiomyomas luhlobo oluqhelekileyo lwe-SMT oluyi-pathological kwi-esophagus, oluyi-60% ukuya kwi-80% yee-SMT ze-esophagus, kwaye lunokwenzeka kakhulu kwiindawo eziphakathi nezisezantsi ze-esophagus; b. Iintlobo ze-pathological ze-SMT zesisu ziyinkimbinkimbi, kunye ne-GIST, i-leiomyoI-ma kunye ne-ectopic pancreas zezona zixhaphakileyo. Phakathi kwe-SMT yesisu, i-GIST ixhaphake kakhulu kwi-fundus nasemzimbeni wesisu, i-leiomyoma idla ngokufumaneka kwi-cardia nakwinxalenye ephezulu yomzimba, kwaye i-ectopic pancreas kunye ne-ectopic pancreas zixhaphake kakhulu. Ii-Lipomas zixhaphake kakhulu kwi-gastric antrum; c. Ii-Lipomas kunye nee-cysts zixhaphake kakhulu kwiindawo ezihlayo nezine-bulbous ze-duodenum; d. Kwi-SMT yendlela esezantsi yesisu, ii-lipomas zixhaphake kakhulu kwi-colon, ngelixa ii-NETs zixhaphake kakhulu kwi-rectum.

(3)Sebenzisa i-CT kunye ne-MRI ukuze unike amanqaku, unyange, kwaye uvavanye iithumba. Kwi-SMTs ekurhanelwa ukuba zinokuba yingozi okanye zinethumba elikhulu (elide).ububanzi > 2 cm), i-CT kunye ne-MRI ziyacetyiswa.

Ezinye iindlela zokuthatha imifanekiso, kuquka i-CT kunye ne-MRI, nazo zibaluleke kakhulu ekuxilongweni kwe-SMT. Zingabonisa ngokuthe ngqo indawo yokwenzeka kwethumba, ipateni yokukhula, ubungakanani besilonda, imilo, ubukho okanye ukungabikho kwe-lobulation, ubuninzi, ukufana, ubungakanani bokukhula, kunye ne-contour yomda, njl.njl., kwaye zinokufumanisa ukuba kunye nobungakanani bobukhulu.ukuvaleka kodonga lwesisu. Okubaluleke ngakumbi, olu vavanyo lwemifanekiso lunokufumanisa ukuba kukho ukungenelela kwezakhiwo ezikufutshane zesilonda kwaye nokuba kukho ukusasazeka kwesifo kwi-peritoneum ejikelezileyo, ii-lymph nodes kunye nezinye izitho. Zezona ndlela ziphambili zokuvavanya, unyango kunye novavanyo lwesifo seethumba.

(4) Ukuthathwa kwesampuli yezicubu akuqondwayenzelwe ii-SMT ezingengobungozi ezinokuchongwa nge-endoscopy eqhelekileyo edityaniswe ne-EUS, ezifana nee-lipomas, ii-cysts, kunye ne-ectopic pancreas.

Kwizilonda ezirhanelwa ukuba ziyingozi okanye xa i-endoscopy eqhelekileyo edityaniswe ne-EUS ingenako ukuvavanya izilonda ezinobungozi okanye ezinobungozi, i-EUS-guided fine-needle aspiration/biopsy ingasetyenziswa (endoscopic ultrasonography guided fine ni-eedle aspiration/biopsy, i-EUS-FNA/FNB), i-mucosal incision biopsy (i-mucosalinciation-assisted biopsy, i-MIAB), njl. yenza isampuli ye-biopsy yovavanyo lwe-pathological ngaphambi kotyando. Ngenxa yemida ye-EUS-FNA kunye nempembelelo elandelayo ekususweni kwe-endoscopic, kwabo bafanelekileyo kutyando lwe-endoscopic, ngesiseko sokuqinisekisa ukuba ithumba linokususwa ngokupheleleyo, iiyunithi ezineteknoloji yonyango lwe-endoscopic evuthiweyo zinokunyangwa ngabantu abanamava. I-endoscopist yenza i-endoscopic resection ngokuthe ngqo ngaphandle kokufumana ukuxilongwa kwe-pathological ngaphambi kotyando.

Nayiphi na indlela yokufumana iisampulu zezifo ngaphambi kotyando iyahlasela kwaye iya konakalisa i-mucosa okanye ibangele ukunamathela kwizicubu ezingaphantsi kotyando, ngaloo ndlela yonyusa ubunzima botyando kwaye mhlawumbi yonyusa iingozi zokopha, ukusebenza kakuhle.umlinganiselo, kunye nokusasazwa kwethumba. Ke ngoko, i-biopsy yangaphambi kotyando ayiyomfuneko rhoqo. Akuyimfuneko, ingakumbi kwi-SMTs ezinokuchongwa nge-endoscopy eqhelekileyo edityaniswe ne-EUS, njenge-lipomas, i-cysts, kunye ne-ectopic pancreas, akukho mfuneko yokuthathwa kwesampuli yezicubu.

2. Unyango lwe-SMT endoscopynt

(1) Imigaqo yonyango

Izilonda ezingenayo i-lymph node metastasis okanye umngcipheko ophantsi kakhulu we-lymph node metastasis, zinokususwa ngokupheleleyo kusetyenziswa iindlela ze-endoscopic, kwaye zinomngcipheko ophantsi wokushiyeka kunye nokubuyela umva zifanelekile ekususweni kwe-endoscopic resection ukuba unyango luyimfuneko. Ukususwa ngokupheleleyo kwethumba kunciphisa i-tumor eseleyo kunye nomngcipheko wokubuyela umva.Umgaqo wonyango olungenaso isimila kufuneka ulandelwe ngexesha lokususwa kwe-endoscopic, kwaye ukuthembeka kwekhaphu yesimila kufuneka kuqinisekiswe ngexesha lokususwa kwesisu.

(2)Iimpawu

i.Iithumba ezinobungozi oburhanelekayo ngokuhlolwa ngaphambi kotyando okanye eziqinisekiswe yi-biopsy pathology, ingakumbi ezo zirhanelekayo kwi-GII-ST enovavanyo lwangaphambi kotyando lobude bethumba obuyi-≤2cm kunye nomngcipheko ophantsi wokuphinda ubuye kunye nokukhula kweseli, kunye nokuba kunokwenzeka ukuba isuswe ngokupheleleyo, inokusikwa nge-endoscopically; kwiithumba ezinobubanzi obude. Kwi-GIST ekrokrelwayo enomngcipheko ophantsi >2cm, ukuba i-lymph node okanye i-metastasis ekude ayifakwanga kuvavanyo lwangaphambi kotyando, ngesiseko sokuqinisekisa ukuba ithumba linokususwa ngokupheleleyo, utyando lwe-endoscopic lunokwenziwa ziingcali ze-endoscopist ezinamava kwiyunithi eneteknoloji yonyango lwe-endoscopic evuthiweyo.

ii. Iimpawu (umz., ukopha, ukuvaleka) i-SMT.

iii.Izigulane ezirhanelwa ukuba iithumba zazo azinabungozi ngokuhlolwa ngaphambi kotyando okanye ziqinisekiswe yi-pathology, kodwa azinakulandelwa rhoqo okanye iithumba zazo zikhula ngexesha elifutshane ngexesha lokulandelela kwaye zinomnqweno onamandlae yonyango lwe-endoscopic.

(3) Izithintelo

i. Chonga izilonda ezindibangelazifakwe kwi-lymph nodes okanye kwiindawo ezikude.

ii. Kwabanye abantu abane-SMT ecacileyonodeokanye i-metastasis ekude, i-bulk biopsy iyafuneka ukuze kufunyanwe isifo, nto leyo enokuthathwa njengento echaseneyo.

iii. Emva kotyando oluneenkcukachaEmva kovavanyo, kufumaniseke ukuba imeko iyonke ayintle kwaye utyando lwe-endoscopic alunakwenzeka.

Izilonda ezingentle ezifana ne-lipoma kunye ne-pancreas ectopic azibangeli zimpawu ezifana neentlungu, ukopha, kunye nokuvaleka.I-MT ibonakala njengokukhukuliseka, isilonda, okanye ukwanda ngokukhawuleza kwixesha elifutshane, amathuba okuba ibe sisilonda esibi ayanda.

(4) Ukukhetha indlela yokususa utyandod

Ukususwa kwe-Endoscopic snare: Nge-Endoscopic Snare resection:I-SMT engacacanga kangako, ephumayo ingene emngxunyeni njengoko kumiselwe luvavanyo lwe-EUS kunye ne-CT ngaphambi kotyando, kwaye inokusikwa ngokupheleleyo ngaxeshanye nge-snare, i-endoscopic snare resection ingasetyenziswa.

Izifundo zasekhaya nezangaphandle ziqinisekisile ukuba ikhuselekile kwaye isebenza kakuhle kwi-SMT engaphezulu kwe-<2cm, enomngcipheko wokopha we-4% ukuya kwi-13% kunye nokugqobhokaumngcipheko we-2% ukuya kwi-70%.

Ukwembiwa kwe-submucosal ye-Endoscopic, ESE: Kwi-SMTs ezinobubanzi obude obuyi-≥2 cm okanye ukuba uvavanyo lomfanekiso wangaphambi kotyando olufana ne-EUS kunye ne-CT luqinisekisa okuxa ithumba liphuma lingene emngxunyeni, i-ESE inokwenzeka ekususweni kwe-endoscopic sleeve ye-SMTs ebalulekileyo.

I-ESE ilandela imikhwa yobugcisaukuqhaqha i-endoscopic submucosal dissection (ESD) kunye nokuqhaqha i-endoscopic mucosal resection, kwaye kusetyenziswa rhoqo i-“flip-top” incision ejikeleze i-tumor ukususa i-mucosa egqume i-SMT kwaye iveze ngokupheleleyo i-tumor. , ukufezekisa injongo yokugcina ukuthembeka kwe-tumor, ukuphucula ubukhali botyando, kunye nokunciphisa iingxaki zangaphakathi kotyando. Kwii-tumor ≤1.5 cm, izinga elipheleleyo lokususwa kwe-100% linokuphunyezwa.

I-Endoscopic Resect ye-Submucosal Tunnelingi-ion, i-STER: Kwi-SMT evela kwi-muscularis propria kwi-esophagus, i-hilum, ukugoba okuncinci komzimba wesisu, i-gastric antrum kunye ne-rectum, okulula ukuseka ii-tunnels, kwaye ububanzi obunqamlezileyo buyi-≤ 3.5 cm, i-STER inokuba yindlela yonyango ekhethwayo.

I-STER yiteknoloji entsha ephuhliswe ngokusekelwe kwi-peroral endoscopic esophageal sphincterotomy (POEM) kwaye lulwandiso lwe-ESD techI-en bloc resection rate ye-STER yonyango lwe-SMT ifikelela kwi-84.9% ukuya kwi-97.59%.

I-Endoscopic Full-density Resecti-ion, EFTR:Ingasetyenziselwa i-SMT apho kunzima ukuseka umngxuma okanye apho ububanzi obukhulu obunqamlezileyo bethumba buyi-≥3.5 cm kwaye ayifanelekanga kwi-STER. Ukuba ithumba liphuma phantsi kwe-membrane emfusa okanye likhula ngaphandle kwenxalenye yomngxuma, kwaye ithumba lifunyenwe linamathele ngokuqinileyo kumaleko we-serosa ngexesha lotyando kwaye alinakwahlulwa, lingasetyenziswa. I-EFTR yenza unyango lwe-endoscopic.

Ukugquma okufanelekileyo kwemboboIndawo emva kwe-EFTR yeyona nto iphambili kwimpumelelo ye-EFTR. Ukuze kuvavanywe ngokuchanekileyo umngcipheko wokuphinda kwethumba kwaye kuncitshiswe umngcipheko wokusasazwa kwethumba, akukhuthazwa ukuba kunqunyulwe kwaye kususwe isampuli yethumba esusiweyo ngexesha le-EFTR. Ukuba kuyimfuneko ukususa ithumba libe ziingceba, imbobo kufuneka ilungiswe kuqala ukuze kuncitshiswe umngcipheko wokuhlwayela imbewu yethumba kunye nokusasazeka kwalo. Ezinye iindlela zokuthungela ziquka: i-metal clip suture, i-suction-clip suture, indlela ye-omental patch suture, indlela ye-"purse bag suture" yentambo ye-nylon edityaniswe ne-metal clip, inkqubo yokuvala i-rake metal clip (over the scope clip, OTSC) i-OverStitch suture kunye nezinye iindlela ezintsha zokulungisa ukwenzakala kwamathumbu kunye nokujongana nokopha, njl.

(5)Iingxaki emva kotyando

Ukopha ngexesha lotyando: Ukopha okubangela ukuba i-hemoglobin yesigulana yehle ngaphezulu kwe-20 g/L.
Ukuthintela ukopha okukhulu ngexesha lotyando,Kufuneka kwenziwe inaliti eyaneleyo ye-submucosal ngexesha lotyando ukuze kuvezwe imithambo yegazi emikhulu kwaye kube lula ukugaya igazi nge-electrocoagulation ukuze kumiswe ukopha. Ukopha ngexesha lotyando kunokuphathwa ngeemela ezahlukeneyo zokusikwa, ii-hemostatic forceps okanye ii-metal clips, kunye ne-hemostasis yokuthintela imithambo yegazi evezwe ngexesha lenkqubo yokusikwa.

Ukopha emva kotyando: Ukopha emva kotyando kubonakala njengokuhlanza igazi, i-melena, okanye igazi elisesitulweni. Kwiimeko ezinzima, ukopha okubangelwa kukwaphuka kwegazi kunokwenzeka. Oku kwenzeka kakhulu kwiveki e-1 emva kotyando, kodwa kunokubakho kwiiveki ezi-2 ukuya kwezi-4 emva kotyando.

Ukopha emva kotyando kudla ngokunxulunyaniswaizinto ezifana nokulawula uxinzelelo lwegazi oluphantsi emva kotyando kunye nokugqwala kwemithambo yegazi eseleyo yi-asidi yesisu. Ukongeza, ukopha emva kotyando kukwanxulumene nendawo esikuyo isifo, kwaye kuxhaphake kakhulu kwi-gastric antrum nakwi-low rectum.

Ukugqobhoka okulibazisekileyo: Kudla ngokubonakala njengokudumba kwesisu, iintlungu zesisu eziya zisiba mandundu, iimpawu ze-peritonitis, umkhuhlane, kwaye ukuvavanywa komfanekiso kubonisa ukuqokelelwa kwegesi okanye ukwanda kokuqokelelwa kwegesi xa kuthelekiswa nangaphambili.

Ixhaphake kakhulu zizinto ezifana nokungathungwa kakuhle kwamanxeba, umbane ogqithisileyo wokugabha igazi, ukuvuka kwangethuba kakhulu ukuba ungahambi, ukutya kakhulu, ukulawula iswekile egazini, kunye nokuguguleka kwamanxeba yi-asidi yesisu. a. Ukuba inxeba likhulu okanye linzulu okanye inxeba line-fisUtshintsho olufana noluqinisekileyo, ixesha lokuphumla ebhedini kunye nexesha lokuzila ukutya kufuneka landiswe ngokufanelekileyo kwaye ukuthomalalisa isisu kufuneka kwenziwe emva kotyando (abaguli emva kotyando olusezantsi lwesisu kufuneka bakhuphe amanzi amdaka emqolo); b. Abaguli abanesifo seswekile kufuneka balawule ngokungqongqo iswekile yabo egazini; abo banemingxuma emincinci kunye nosulelo oluncinci lwesifuba kunye nesisu kufuneka banikwe unyango olufana nokuzila ukutya, ukulwa nosulelo, kunye nokunciphisa i-asidi; c. Kwabo bane-emission, ukukhupha amanzi esifubeni okuvaliweyo kunye nokubhoboza isisu kunokwenziwa. Iityhubhu kufuneka zibekwe ukuze kugcinwe ukukhupha amanzi okugudileyo; d. Ukuba usulelo alunakufumaneka kwindawo ethile emva konyango olugcinwe okanye ludityaniswe nosulelo olukhulu lwe-thoracoabdominal, kufuneka kwenziwe i-laparoscopy yotyando ngokukhawuleza, kwaye kufuneka kulungiswe ukukhupha amanzi amdaka kunye nokukhupha amanzi esiswini.

Iingxaki ezinxulumene negesi: Kubandakanya i-subcutai-neous emphysema, i-pneumomediastinum, i-pneumothorax kunye ne-pneumoperitoneum.

I-Intraoperative subcutaneous emphysema (eboniswa njenge-emphysema ebusweni, entanyeni, eludongeni lwesifuba, nakwi-scrotum) kunye ne-mediastinal pneumophysema (sukuvela kwe-epiglottis kunokufumaneka ngexesha le-gastroscopy) akusoloko kufuna unyango olukhethekileyo, kwaye i-emphysema ngokubanzi iya kuziphelela yodwa.

I-pneumothorax enzima iyenzeka dutyando lokuqhuba [uxinzelelo lomoya ludlula i-20 mmHg ngexesha lotyando

(1mmHg=0.133kPa), iSpO2<90%, iqinisekiswe yiX-ray yesifuba esisecaleni kwebhedi], utyando lunokuqhubeka emva kokuba isifuba sivaliwe.ukungabi neminyaka.

Kwizigulane ezine-pneumoperitoneum ecacileyo ngexesha lotyando, sebenzisa inaliti ye-pneumoperitoneum ukugqobhoza indawo yaseMcFarlandkwisisu esisezantsi ngasekunene ukuze umoya uphume, uze ushiye inaliti yokubhoboza endaweni yayo de kube sekupheleni kotyando, uze uyisuse emva kokuqinisekisa ukuba akukho gesi icacileyo ikhutshwayo.

I-fistula yesisu: Ulwelo lokugaya olubangelwa lutyando lwe-endoscopic lungena esifubeni okanye esiswini ngokuvuza.
I-Esophageal mediastinal fistulas kunye ne-esophagothoracic fistulas ziqhelekile. Nje ukuba i-fistula ivele, khupha amanzi esifubeni avaliweyo ukuze ugcinekwimibhobho yamanzi egudileyo kwaye inike inkxaso eyaneleyo yesondlo. Ukuba kuyimfuneko, iikliphu zesinyithi kunye nezixhobo ezahlukeneyo zokuvala zingasetyenziswa, okanye isigqubuthelo esipheleleyo singaphinda sisetyenziswe. Iistenti kunye nezinye iindlela zisetyenziselwa ukuvimbaI-fistula. Iimeko ezinzima zifuna utyando olukhawulezileyo.

3. Ulawulo emva kotyando (fukulandelwa)

(1) Izilonda ezingenobungozi:Izifoicebisa ukuba izilonda ezingengozini ezifana ne-lipoma kunye ne-leiomyoma azidingi ukulandelelana rhoqo okunyanzelekileyo.

(2) I-SMT engenalo ulwaphulo-mthethoamandla eembovane:Umzekelo, ii-NET ze-rectal eziyi-2cm, kunye ne-GIST enomngcipheko ophakathi nophezulu, kufuneka kwenziwe i-staging epheleleyo kwaye unyango olongezelelweyo (utyando, i-chemotherapy radiotherapy, unyango olujoliswe kuyo) kufuneka luqwalaselwe kakhulu. Ukwakhiwa kwesicwangciso kufuneka kusekelwe kwingxoxo eyahlukeneyo kwaye kumntu ngamnye.

(3) I-SMT enokubakho kancinci:Umzekelo, i-GIST enobungozi obuphantsi kufuneka ihlolwe yi-EUS okanye i-imaging rhoqo emva kweenyanga ezi-6 ukuya kwezi-12 emva konyango, ize inyangwe ngokwemiyalelo yeklinikhi.

(4) I-SMT enesifo esiphakathi nesiphezulu esibangela umhlaza:Ukuba isifo se-postoperative siqinisekisa uhlobo lwesithathu lwe-NET yesisu, i-colorectal NET enobude obungaphezulu kwe-2cm, kunye ne-GIST enomngcipheko ophakathi nophezulu, kufuneka kwenziwe i-staging epheleleyo kwaye unyango olongezelelweyo (utyando, i-chemotherapy radiotherapy, unyango olujoliswe kuyo) kufuneka luqwalaselwe kakhulu. Ukwakhiwa kwesicwangciso kufuneka kusekelwe kwi[malunga nathi 0118.docx]ukubonisana ngamacandelo amaninzi kwaye ngokomntu ngamnye.