Unyango lwe-Endoscopic ye-submucosal tumors ye-digestive tract: iingongoma ezi-3 eziphambili zishwankathelwe kwinqaku elinye.

I-Submucosal tumors (SMT) ye-gastrointestinal tract yizilonda eziphakamileyo ezivela kwi-muscularis mucosa, i-submucosa, okanye i-muscularis propria, kwaye inokuba yizilonda ezingaphandle.Ngophuhliso lwetekhnoloji yezonyango, ukhetho lotyando lwesintu luye lwangena ngokuthe ngcembe kwixesha lonyango olungephi, olufana ne-l.utyando lwe-aparoscopic kunye noqhaqho lwerobhothi.Nangona kunjalo, ekusebenzeni kweklinikhi, kunokufunyanwa ukuba "utyando" alufanelekanga zonke izigulane.Kwiminyaka yakutshanje, ixabiso lonyango lwe-endoscopic liye lafumana ingqalelo ngokuthe ngcembe.Ushicilelo lwamva nje lwemvumelwano yeengcali zaseTshayina malunga nokuxilongwa kwe-endoscopic kunye nonyango lwe-SMT lukhutshiwe.Eli nqaku liza kufunda ngokufutshane ulwazi olufanelekileyo.

I-1.SMT uphawu lobhubhaneabagxeki

(1) Ukwenzeka kweSMI-T ayilingani kwiindawo ezahlukeneyo zendlela yokwetyisa, kwaye isisu sesona sayithi sixhaphakileyo se-SMT.

Iziganeko ezahlukeneyos iindawo zokwetyisa azilingani, kunye nomjelo wokwetyisa ongaphezulu uxhaphake kakhulu.Kwezi, i-2/3 ivela esiswini, ilandelwa ngummizo, i-duodenum, kunye nekholoni.

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

A.SMT ibandakanya noizilonda ze-n-neoplastic ezifana ne-ectopic pancreatic tissue kunye nezilonda ze-neoplastic.

B.Phakathi kwe-neoplastic lesions, i-leiomyomas yesisu, i-lipomas, i-Brucella adenomas, i-granulosa cell tumors, i-schwannomas, kunye ne-glomus tumors ininzi i-benign, kwaye ngaphantsi kwe-15% inokuvela njengezicubu Funda ububi.

C.Istroma yamathumbul i-tumor (GIST) kunye ne-neuroendocrine tumors (NET) kwi-SMT ngamathumba anamandla athile anobungozi, kodwa oku kuxhomekeke kubukhulu bayo, indawo kunye nohlobo.

D. Indawo ye-SMT inxulumenekuhlelo lwezifo: a.I-Leiomyomas luhlobo oluqhelekileyo lwe-pathological ye-SMT kwi-esophagus, i-akhawunti ye-60% ukuya kwi-80% ye-SMTs ye-esophageal, kwaye inokwenzeka ukuba yenzeke kumbindi kunye namacandelo asezantsi e-esophagus;b.Iintlobo ze-pathological ze-SMT zesisu zintsokothile noko, zine-GIST, leiomyoma kunye ne-ectopic pancreas yeyona ixhaphakileyo.Phakathi kwe-SMT yesisu, i-GIST ixhaphake ngokufumaneka kwi-fundus kunye nomzimba wesisu, i-leiomyoma idla ngokufumaneka kwi-cardia nakwindawo engaphezulu yomzimba, kwaye i-ectopic pancreas kunye ne-ectopic pancreas zezona zixhaphakileyo.I-Lipomas ixhaphake kakhulu kwi-antrum yesisu;c.I-Lipomas kunye ne-cysts zixhaphake kakhulu kwiindawo ezihlayo kunye ne-bulbous ze-duodenum;d.Kwi-SMT yendlela esezantsi yesisu, i-lipomas ibaluleke kakhulu kwikholoni, ngelixa ii-NETs ziphambili kwi-rectum.

(3) Sebenzisa i-CT kunye ne-MRI kwibakala, ukunyanga, nokuvavanya izimila.Kwii-SMTs ekurhaneleka ukuba zinokuba yingozi okanye zinethumba elikhulu (elideububanzi> 2 cm), i-CT kunye ne-MRI ziyacetyiswa.

Ezinye iindlela zokucinga, kuquka i-CT kunye ne-MRI, nazo zibaluleke kakhulu ekuxilongweni kwe-SMT.Bangabonisa ngokuthe ngqo indawo yokwenzeka kwethumba, ipateni yokukhula, ubungakanani bomonakalo, imilo, ubukho okanye ukungabikho kwe-lobule, ingxinano, i-homogeneity, inqanaba lokuphucula, kunye ne-contour yomda, njl.Ukungena eludongeni lwesisu.Okubaluleke ngakumbi, olu vavanyo lwemifanekiso lunokubona ukuba kukho ukuhlaselwa kwezakhiwo ezikufutshane zesilonda kunye nokuba kukho i-metastasis kwi-peritoneum ejikelezileyo, i-lymph nodes kunye namanye amalungu.Ziyeyona ndlela iphambili yokuhlelwa kweklinikhi, unyango kunye novavanyo lwe-prognosis yamathumba.

(4)Iisampulu yezicubu ayifumaneki kwakhonazilungiselelwe ii-SMTs ezinobungozi ezinokufunyaniswa nge-endoscopy yesiqhelo edityaniswe ne-EUS, efana ne-lipomas, i-cysts, kunye ne-ectopic pancreas.

Kwizilonda ekurhanelwa ukuba ziyingozi okanye xa i-endoscopy yesiqhelo idityaniswe ne-EUS ayinako ukuvavanya izilonda ezinobungozi okanye ezinobungozi, i-EUS ekhokelwa yi-EUS-guided fine-needle aspiration/biopsy ingasetyenziswa(endoscopic ultrasonography guided fine ni-eedle aspiration/biopsy, EUS-FNA/FNB), i-mucosal incision biopsy(i-mucosalincision-assisted biopsy, i-MIAB), njl.njl. yenza isampulu ye-biopsy yovandlakanyo lwangaphambi kotyando lwezifo.Ngenxa yokusikelwa umda kwe-EUS-FNA kunye nempembelelo elandelayo kwi-endoscopic resection, kwabo bafanelekele utyando lwe-endoscopic, kwisiseko sokuqinisekisa ukuba ithumba linokuphinda lisuswe ngokupheleleyo, iiyunithi ezinobuchwephesha bonyango lwe-endoscopic oluqolileyo zinokunyangwa ngabanamava. I-endoscopist yenza i-endoscopic resection ngokuthe ngqo ngaphandle kokufumana ukuxilongwa kwangaphambili kwe-pathological.

Nayiphi na indlela yokufumana imizekelo ye-pathological ngaphambi kokuhlinzwa kwaye iya kulimaza i-mucosa okanye ibangele ukunamathela kwizicubu ze-submucosal, ngaloo ndlela yandisa ubunzima botyando kunye nokwandisa ingozi yokopha, i-perfo.iration, kunye nokusasazwa kwethumba.Ke ngoko, i-biopsy yangaphambi kotyando ayiyomfuneko.Okuyimfuneko, ngakumbi kwii-SMTs ezinokufunyaniswa nge-endoscopy yesiqhelo edityaniswe ne-EUS, efana ne-lipomas, i-cysts, kunye ne-ectopic pancreas, akukho sampuli yezicubu ezifunekayo.

2.SMT unyango endoscopicnt

(1) Imigaqo yonyango

Izilonda ezingenayo i-lymph node metastasis okanye umngcipheko ophantsi kakhulu we-lymph node metastasis, unokutshatyalaliswa ngokupheleleyo usebenzisa iindlela ze-endoscopic, kwaye unomngcipheko ophantsi wokushiyeka kunye nokuphindaphinda zifanelekile ukutshatyalaliswa kwe-endoscopic ukuba unyango luyimfuneko.Ukususwa ngokupheleleyo kwe-tumor kunciphisa i-tumor eseleyo kunye nomngcipheko wokuphindaphinda.IUmgaqo wonyango olungenayo i-tumor kufuneka ulandelwe ngexesha lokutshatyalaliswa kwe-endoscopic, kwaye ukunyaniseka kwe-tumor capsule kufuneka kuqinisekiswe ngexesha lokutshatyalaliswa.

(2)Imiqondiso

i.Iithumba ezinokuthi zirhanelwe luvavanyo lwangaphambili okanye ziqinisekiswe yi-biopsy pathology, ngakumbi abo barhanelwa nge-GI.I-ST kunye novavanyo lwangaphambili lwe-tumor ubude be-≤2cm kunye nomngcipheko ophantsi wokuphindaphinda kunye ne-metastasis, kunye nokwenzeka kokutshatyalaliswa okupheleleyo, kunokukhutshwa ngokukhawuleza;kwi-tumor enobude obude Kwi-GIST ekrokrelekayo ephantsi ye-2cm, ukuba i-lymph node okanye i-metastasis ekude ayibandakanywanga kuvavanyo lwangaphambi kokuhlinzwa, kwisiseko sokuqinisekisa ukuba i-tumor inokukhutshwa ngokupheleleyo, utyando lwe-endoscopic lunokwenziwa ngoogqirha be-endoscopists abanamava. iyunithi enobuchwepheshe bonyango lwe-endoscopic obudala.uqhaqho.

ii.Iimpawu (umzekelo, ukopha, ukuthintela) SMT.

iii.Izigulana ezinethumba ekurhanelwa ukuba zilungile ngovavanyo lwangaphambi kokuhlinzwa okanye ziqinisekiswa yi-pathology, kodwa azikwazi ukulandelwa rhoqo okanye amathumba azo anda ngexesha elifutshane ngexesha lokulandela kwaye anomnqweno onamandla.e yonyango lwe-endoscopic.

(3)Izinto ezichaseneyo

i.Chonga izilonda endinazoincasa kwii-lymph nodes okanye kwiindawo ezikude.

ii.Kwi-SMT ethile ene-lymph ecacileyonodeokanye i-metastasis ekude, i-biopsy eninzi iyafuneka ukufumana i-pathology, enokuthi ithathwe njengento echaseneyo.

iii.Emva koqhaqho oluneenkcukachaUvavanyo, kuchongwa ukuba imeko jikelele ayilunganga kwaye utyando lwe-endoscopic alunakwenzeka.

Izilonda ezinobungozi ezifana ne-lipoma kunye ne-ectopic pancreas ngokubanzi azibangeli iimpawu ezinjengeentlungu, ukopha, kunye nokuphazamiseka.Xa uSI-MT ibonakalisa ukuguguleka, isilonda, okanye ukunyuka ngokukhawuleza ngexesha elifutshane, ukuba kunokwenzeka ukuba kube yinto enobungozi yokwandisa.

(4)Ukhetho lwendlela yokususwad

I-Endoscopic snare resection: KubaI-SMT engaphezulu, iqhubela kwi-cavity njengoko inqunywe yi-EUS yangaphambili kunye neemviwo ze-CT, kwaye inokuthi ikhutshwe ngokupheleleyo ngexesha elinye kunye nomgibe, i-endoscopic snare resection ingasetyenziswa.

Izifundo zasekhaya kunye nezangaphandle ziqinisekisile ukuba zikhuselekile kwaye zisebenza kwi-SMT engaphezulu <2cm, kunye nomngcipheko wokuphuma kwegazi kwi-4% ukuya kwi-13% kunye ne-perforation.umngcipheko we-2% ukuya kwi-70%.

Endoscopic submucosal excavation,ESE : Kwii-SMTs ezinobude obude ≥2 cm okanye ukuba iimviwo zokucinga kwangaphambili ezifana ne-EUS kunye ne-CT ziqinisekisakwithumba liphumela kumngxuma, i-ESE inokwenzeka kwi-endoscopic sleeve resection yee-SMTs ezibalulekileyo.

I-ESE ilandela imikhwa yobugcisa yei-endoscopic submucosal dissection (ESD) kunye ne-endoscopic mucosal resection, kwaye ngokuqhelekileyo isebenzisa i-circular "flip-top" incision malunga ne-tumor ukususa i-mucosa egubungela i-SMT kwaye iveze ngokupheleleyo i-tumor., ukufezekisa injongo yokugcina ingqibelelo ye-tumor, ukuphucula i-radicalness yotyando, kunye nokunciphisa iingxaki ze-intraoperative.Kwi-tumor ≤1.5 cm, umlinganiselo opheleleyo wokutshatyalaliswa kwe-100% unokufumaneka.

I-Submucosal Tunneling Endoscopic Resection, STER : Kwi-SMT evela kwi-muscularis propria kwi-esophagus, i-hilum, i-curvature encinci ye-gastric body, i-antrum ye-gastric kunye ne-rectum, ekulula ukuseka i-tunnels, kunye ne-diameter enqamlezayo ≤ 3.5 cm, i-STER ingakhethwa indlela yonyango.

I-STER bubuchwepheshe obutsha obuphuhliswe ngokusekelwe kwi-peroral endoscopic esophageal sphincterotomy (POEM) kwaye kukwandiswa kobuchwepheshe be-ESD.inzululwazi.Izinga le-en bloc resection ye-STER yonyango lwe-SMT ifikelela kwi-84.9% ukuya kwi-97.59%.

I-Endoscopic Ubutyebe obupheleleyo Resection,EFTR :Ingasetyenziselwa i-SMT apho kunzima ukuseka itonela okanye apho ubuninzi obunqamlezileyo be-tumor ≥3.5 cm kwaye ayifanelekanga kwi-STER.Ukuba i-tumor iphuma phantsi kwe-membrane emfusa okanye ikhule ngaphandle kwendawo yomgodi, kwaye i-tumor ifunyenwe ibambelele ngokuqinileyo kwi-serosa layer ngexesha lotyando kwaye ayinakuhlukaniswa, inokusetyenziswa.I-EFTR yenza unyango lwe-endoscopic.

I-suturing efanelekileyo yokubhobozaindawo emva kwe-EFTR ngundoqo kwimpumelelo ye-EFTR.Ukuze uhlolisise ngokuchanekileyo umngcipheko wokuphindaphinda kwe-tumor kunye nokunciphisa umngcipheko wokusasazwa kwe-tumor, akukhuthazwa ukusika kunye nokususa i-specimen ye-tumor ehlaziyiweyo ngexesha le-EFTR.Ukuba kuyimfuneko ukususa i-tumor ibe ngamaqhekeza, i-perforation kufuneka ilungiswe kuqala ukunciphisa umngcipheko we-tumor imbewu kunye nokusasazeka.Ezinye iindlela zokuthunga zibandakanya: ikliphu yentsimbi yekliphu, i-suction-clip suture, i-omental patch suture technique, i-"purse bag suture" indlela yentambo yenayiloni edityaniswe nekliphu yesinyithi, inkqubo yokuvala ikliphu yesinyithi (ngaphaya kwekliphu yobubanzi, OTSC) I-OverStitch suture kunye nezinye. itekhnoloji entsha yokulungisa ukulimala kwesisu kunye nokujongana nokopha, njl.

(5)Iingxaki zasemva kotyando

Ukopha emithanjeni: Ukopha okubangela ukuba i<em>hemoglobin yomguli yehle ngaphezu kwama-20 g/L.
Ukuthintela ukopha okukhulu kwi-intraoperative,Isitofu esaneleyo se-submucosal kufuneka senziwe ngexesha lotyando ukuze kuvezwe imithambo yegazi emikhulu kwaye kuququzelele i-electrocoagulation yokuyeka ukopha.Ukopha kwi-intraoperative kunokunyangwa ngeemela ezahlukeneyo zokusika, i-hemostatic forceps okanye iikliphu zetsimbi, kunye ne-protection hemostasis yemithambo yegazi ebonakalayo efunyenwe ngexesha lenkqubo yokuqhawula.

Ukopha emva kokuhlinzwa: Ukopha kwasemva kokuhlinzwa kubonakala njengokugabha igazi, i-melena, okanye igazi kwisitulo.Kwiimeko ezinzima, ukothuka ukopha kungenzeka.Iyenzeka kakhulu kwiveki ye-1 emva kokuhlinzwa, kodwa inokuthi yenzeke kwiiveki ezi-2 ukuya kwezi-4 emva kokuhlinzwa.

Ukuphuma kwegazi emva kokuhlinzwa kudla ngokunxulumeneizinto ezifana nokulawulwa kakubi koxinzelelo lwegazi lwasemva kokuhlinzwa kunye nokubola kwemithambo yegazi eshiyekileyo nge-asidi yesisu.Ukongezelela, ukuphuma kwegazi emva kokuhlinzwa kuhambelana nendawo yesi sifo, kwaye ixhaphake kakhulu kwi-antrum yesisu kunye ne-rectum ephantsi.

Ukugqobhoza okulibazisekayo: Ngokuqhelekileyo kubonakala njengokuphazamiseka kwesisu, intlungu yesisu esibuhlungu, iimpawu ze-peritonitis, umkhuhlane, kunye nokuhlolwa kwemifanekiso kubonisa ukuqokelela kwegesi okanye ukunyuka kwegesi xa kuthelekiswa nangaphambili.

Ubukhulu becala inxulumene nezinto ezifana nokungaqhubi kakuhle kwamanxeba, i-electrocoagulation egqithisileyo, ukuvuka kwangethuba ukuba uhambe, ukutya kakhulu indlebe, ukulawulwa kakubi kweswekile yegazi, kunye nokukhukuliseka kwamanxeba yiasidi yesisu.a.Ukuba inxeba likhulu okanye linzulu okanye inxeba linemifinyautshintsho oluqinisekileyo, ixesha lokuphumla kwebhedi kunye nexesha lokuzila kufuneka landiswe ngokufanelekileyo kwaye ukuchithwa kwesisu kufuneka kwenziwe emva kokuhlinzwa (izigulane emva kokuhlinzwa okuncinci kwesisu kufuneka zibe ne-anal drainage);b.Abaguli abanesifo seswekile kufuneka balawule ngokungqongqo iswekile yegazi;abo banemingxuma emincinci kunye nosulelo oluncinci lwe-thoracic kunye nesisu kufuneka banikwe unyango olufana nokuzila ukudla, ukuchasana nokutheleleka, kunye nokunciphisa i-asidi;c.Kwabo bane-effusion, ukukhupha isifuba esivaliweyo kunye nokuhlatywa kwesisu kunokwenziwa.d.Ukuba usulelo alukwazi ukufakwa kwindawo emva konyango olulondolozayo okanye ludibaniswe nesifo esinzima se-thoracoabdominal, i-laparoscopy yokuhlinzwa kufuneka yenziwe ngokukhawuleza, kwaye ukulungiswa kwe-perforation kunye nokuphuma kwesisu kufuneka kwenziwe.

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

I-Intraoperative subcutaneous emphysema (eboniswe njenge-emphysema ebusweni, entanyeni, kudonga lwesifuba, kunye nesingxobo) kunye ne-mediastinal pneumophysema (s)Ukuphila kwe-epiglottis kunokufumaneka ngexesha le-gastroscopy) ngokuqhelekileyo ayifuni unyango olukhethekileyo, kwaye i-emphysema iya kuzisombulula ngokwayo.

I-pneumothorax emandla yenzeka dutyando lokuchama [uxinzelelo lomoya lodlula ama-20 mmHg ngexesha lotyando

(1mmHg=0.133kPa), SpO2<90%, engqinwe ngeX-ray yebhedi engxamisekileyo, utyando lunokuhlala luqhutyekwa emva kokuvaleka kwesifubaukuguga.

Kwizigulane ezine-pneumoperitoneum ebonakalayo ngexesha lotyando, sebenzisa inaliti yepneumoperitoneum ukugqobhoza indawo yeMcFarland.emazantsi esisu ekunene ukuze deflate umoya, kwaye ushiye inaliti yokugqobhoza endaweni de kuphele utyando, uze uyisuse emva kokuqinisekisa ukuba akukho rhasi ecacileyo ekhutshwayo.

I<em>gastrointestinal fistula: Ulwelo lokwetyisa olubangelwa lutyando lwe-endoscopic luqukuqela lungene esifubeni okanye kumgodi wesisu ngokuvuza.
I-Esophageal mediastinal fistulas kunye ne-esophagothoracic fistula zixhaphakile.Nje ukuba kubekho i-fistula, yenza amanzi avaliweyo esifuba kwi-mantakwimijelo egudileyo kwaye ibonelele ngenkxaso yesondlo eyaneleyo.Ukuba kuyimfuneko, iikliphu zetsimbi kunye nezixhobo ezahlukeneyo zokuvala zingasetyenziswa, okanye isigqubuthelo esipheleleyo sinokuphinda sisetyenziswe.Stents kunye nezinye iindlela zisetyenziselwa ukubhlokai-fistula.Iimeko ezinzima zifuna ungenelelo olukhawulezileyo lotyando.

3.Ulawulo lwasemva kotyando (fukuphumla)

(1) Izilonda ezinobungozi:I-Pathology siphakamisa ukuba izilonda ezinobungozi ezifana ne-lipoma kunye ne-leiomyoma ayifuni ukulandelwa rhoqo okunyanzelekileyo.

(2) I-SMT ngaphandle kokuhlambalazaamandla embovane:Ngokomzekelo, i-NETs ye-rectal 2cm, kunye ne-GIST ephakathi kunye ne-high-risk, i-staging epheleleyo kufuneka yenziwe kwaye unyango olongezelelweyo (utyando, i-chemoradiotherapy, unyango olujoliswe kuyo) kufuneka luthathelwe ingqalelo ngamandla.phatha).Ukuqulunqwa kwesicwangciso kufuneka kusekelwe kudliwano-ndlebe lweenkqubo ezininzi kunye nomntu ngamnye.

(3) I-SMT enobungozi obuphantsi:Umzekelo, umngcipheko ophantsi we-GIST kufuneka uvavanywe yi-EUS okanye ucinge rhoqo emva kweenyanga ezi-6 ukuya kwezili-12 emva konyango, emva koko unyangwe ngokwemiyalelo yekliniki.

(4) I-SMT enesakhono esiyingozi esiphakathi nesiphezulu:Ukuba i-postoperative pathology iqinisekisa uhlobo lwe-3 ye-NET ye-gastric, i-NET ye-colorectal enobude> 2cm, kunye ne-GIST ephakathi kunye ne-high-risk, i-staging epheleleyo kufuneka yenziwe kwaye unyango olongezelelweyo (utyando, i-chemoradiotherapy, unyango olujoliswe kuyo) kufuneka luqwalaselwe ngamandla.phatha).Ukuqulunqwa kwesicwangciso kufuneka kusekelwe[malunga nathi 0118.docx]uthethwano lweenkqubo ezininzi kwaye ngokomntu ngamnye.