儿童和青少年卵巢肿瘤的临床病理特点和治疗

目的研究儿童和青少年卵巢肿瘤的临床病理特点及其治疗方法和预后。方法回顾性分析1995年11月至2003年11月间收治的儿童和青少年卵巢肿瘤34例的临床表现、血清肿瘤标志物、病理类型、治疗方式和预后以及上述参数之间的关系。结果主要症状为腹部肿块(61．8％)和腹痛(29．4％)；34例中良性肿瘤22例，恶性肿瘤11例，交界性肿瘤1例；良性肿瘤预后好，仅1例复发；恶性肿瘤11例复发5例，复发病例挽救治疗成功3例；肿瘤标记物阳性7例(63．6％)，术后化疗后转阴性6例均无复发。结论儿童和青少年腹块和腹痛者应排除卵巢肿瘤的可能；良性肿瘤的治疗以保留生育的肿瘤切除或附件切除为主，生殖细胞恶性肿瘤可采取保留生育的手术切除 术后化疗的方法治疗；肿瘤标记物检测对诊断和病情监测有重要意义。     

Primary Leiomyosarcoma of the Liver: Diagnostic Efficacy of Endoscopic Retrograde Cholangiopancreatography

Abstract: A small primary leiomyosarcoma of the liver detected in a 58-year-old man is presented in this paper. In addition to the findings obtained by gray scale ultrasonogruphy and computed tomography, the possible diagnosis of this very rare tumor was suggested by endoscopic retrograde cholangiopancreatography (ERCP). The characteristic findings of leiomyosarcoma of the liver obtained by ERCP were skipping strictures at the intrahepatic bile ducts. The ERCP findings and diagnosis were verified bv pathological studies of the resected material. This appears to be the first report discussing the usefulness of ERCP in vnaking a diagnosis of primary leiomyosarcoma of the liver.     

Gastric Wall Structure Using a 30 MHz Endoscopic Ultrasound Probe,Focusing upon Delineation of the Muscularis Mucosae

Background: The normal gastric wall has been reported to appear to be a five‐layered structure. The structure of the gastric wall using a 30 MHz endoscopic ultrasound probe and especially the identification of the muscularis mucosae (MM), has not been analyzed clearly. Methods: In a basic study, 11 sections of normal gastric wall with 26 horizontally inserted nylon sutures were immersed in water. The sections were scanned and the findings correlated using standard histology. In a clinical study, 15 early gastric cancers were examined by a 30 MHz endoscopic ultrasound probe. Results: In a basic study, layers deeper than the lower part of the submucosa could not be seen using ultrasonography. The first to fourth layers represented the mucosal layer except the MM, the fifth layer (high‐echo layer) represented the boundary echo and a part of the MM, while the sixth layer (low‐echo layer) represented the rest of the MM. The muscularis mucosae was seen clearly in all samples. In a clinical study the layers deeper than the submucosal layer could not be seen and the MM was visible in 87% of cases. The depth of invasion was estimated accurately in 90% of mucosal cancers and in 80% of submucosal cancers. Conclusion: A 30 MHz endoscopic ultrasound probe, which cannot image the entire gastric wall, can visualize the MM and may help to confirm the structure of gastric wall layers and improve the ability to determine the depth of invasion in gastric cancer.     

ENDOSCOPIC NECROSECTOMY UNDER DIRECT VISION AFTER ENDOSCOPIC ULTRASOUND‐GUIDED CYSTGASTROSTOMY FOR ORGANIZED PANCREATIC NECROSIS

A 56‐year‐old man was referred for an enlarging pancreatic pseudocyst that developed after severe acute pancreatitis with gallstones. Abdominal ultrasound showed a huge cystic lesion with a large amount of solid high echoic components. Arterial phase contrast‐enhanced computed tomography scan revealed arteries across the cystic cavity. Stents were placed after endoscopic ultrasound‐guided cystgastrostomy; however, the stents were obstructed by necrotic debris, and secondary infection of the pseudocyst occurred. Therefore, the cystgastrostomy was dilated by a dilation balloon, and a forward‐viewing endoscope was inserted into the cystic cavity. Many vessels and a large amount of necrotic debris existed in the cavity. Under direct vision, all necrotic debris was safely removed using a retrieval net and forceps. One year after this procedure, there was no recurrence. Our case indicates that peripancreatic fat necrosis can cause exposure of vessels across/along the cystic cavity, and blind necrosectomy should be avoided.     

RARE GASTRIC CALCIFYING FIBROUS PSEUDOTUMOR REMOVED BY ENDOSCOPIC SUBMUCOSAL DISSECTION

We report a case of a calcifying fibrous pseudotumor of the stomach that we resected using endoscopic submucosal dissection (ESD). A 61‐year‐old male with a gastric submucosal tumor was admitted to our hospital for treatment. By upper gastrointestinal tract endoscopy, a smooth‐surfaced submucosal tumor measuring 2 cm in diameter was observed in the anterior wall of the middle body of the stomach. By endoscopic ultrasonography, a mass was observed in the stomach submucosa; the mass had a well‐defined boundary. Internally, the mass was heterogeneous and hypoechoic; high spots were scattered throughout the mass. Continuity between the mass and the muscularis mucosae and muscularis propria was not observed. Strongly suspecting that this mass was a gastrointestinal stromal tumor arising from the stomach, we resected the mass by ESD for total biopsy. Histopathologically, the mass consisted of proliferation of eosinophilic collagen fibers with plasma cell infiltration and lymphoid follicle proliferation. Calcification was also observed in some parts of the mass. Thus, the mass was identified as calcifying fibrous pseudotumor. Calcifying fibrous pseudotumor of the stomach is extremely rare and its histogenesis remains unclear; however, its morphology became distinct by comparing endoscopic/radiological and histopathological findings.     

腔镜胆总管切开术与内镜联合腹腔镜治疗胆总管结石的临床分析

目的对腹腔镜胆总管切开术与内镜联合腹腔镜治疗胆囊结石合并胆总管结石的疗效进行比较和评价。方法回顾性分析2002年7月至2007年7月，20例行腹腔镜胆囊切除、胆总管探查（LCD组），15例行腹腔镜胆囊切除联合内镜乳头括约肌切开取石术（EST＋LC组）患者的手术及术后情况。结果LCD组近期并发症发生率低于EST＋LC组（20％ vs 5％，P〈0．05），LCD组平均住院日和平均住院费用均明显低于EST＋LC组（P〈0．05），手术成功率两组差异无统计学意义（P〉0．05）。结论腹腔镜胆总管切开术是治疗胆囊结石并胆总管结石疗效肯定的微创手术。     

TRANSGASTRIC TRANSHEPATIC ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE: HISTOLOGICAL ASSESSMENT OF ITS SINUS TRACT IN AN AUTOPSY CASE

Endosonography‐guided biliary drainage (ESBD) is gaining attention as a promising drainage technique for obstructive jaundice. However, histological changes resulting from ESBD have not been well understood. We had an opportunity to histologically investigate the influence of ESBD, established between the left hepatic duct and the stomach, on the relevant organs in an autopsy case with bile duct cancer extending from the pancreatic head to the hepatic hilum with duodenal invasion. Localized fibrous connective tissues were present around and along the sinus tract, including the connection between the surfaces of the left lobe of the liver and the gastric serosa, without hemorrhage, inflammatory changes, or cancer invasion. The inside of the ESBD stent was slightly stenotic at the intramural portion of the stomach due to proliferation of granulation tissue. No bile stasis or abscess was observed in the left lobe. These results are quite suggestive of the high safety and efficacy of ESBD with adequate performance.     

国产聚四氟乙烯胆道支架的研制与临床应用

目的:研制适合内镜下应用的国产聚四氟乙烯(Teflon)胆道支架,并验证其临床疗效.方法:研制9F Teflon胆道支架.选取80例恶性肝外胆管梗阻患者,随机分为两组各40例:实验组应用自行研制的国产9F Teflon支架,对照组采用进口8.5F Teflon支架.结果:操作后两组发热的发生率分别为22.2％和24.0％,高淀粉酶血症发生率分别为27.8％和27.3％,退黄总有效率为81.0％和87.0％,均无统计学差异.经1.5～15个月随访发现,两组支架的平均通畅期均为6个月,患者的平均存活期均为7个月.结论:国产9F胆道Teflon支架操作性能良好,主要疗效指标已达到国外同类产品的水平.     

ENDOSCOPIC COAGULATION THERAPY IS USEFUL FOR IMPROVING ENCEPHALOPATHY IN CIRRHOTIC PATIENTS WITH GASTRIC ANTRAL VASCULAR ECTASIA

Background: Gastric antral vascular ectasia (GAVE) is an uncommon but treatable cause of chronic gastrointestinal bleeding often associated with severe cirrhosis. Efficacy of endoscopic treatment is well known; however, long‐term outcome after endoscopic treatment is not clear. Methods: We studied 16 cases of GAVE patients with liver cirrhosis that were endoscopically treated using heater probe unit or argon plasma coagulator. Endoscopic finding of GAVE and clinical finding of hepatic encephalopathy in particular was evaluated after endoscopic therapy. Results: After endoscopic ablation therapy, mucosal vascular lesion of GAVE and rebleeding occurred in four patients during follow up; however, re‐treatment was effective and long‐term hemostasis was achieved. Moreover, a case report herein revealed the effectiveness of endoscopic therapy on hepatic encephalopathy of GAVE patients with cirrhosis. In the follow‐up study of 13 patients of GAVE with cirrhosis that suffered from encephalopathy, the coma level of nine patients was improved after endoscopic therapy. Conclusion: Endoscopic treatment, such as heater probe coagulation and argon plasma coagulation therapy, are effective and useful for long‐term follow up. Also, the beneficial effect of endoscopic therapy on hepatic encephalopathy for GAVE with cirrhosis encourages us to find and treat the mucosal lesion intensively to improve the quality of life of such patients.     

OBLIQUE‐VIEWING ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATED PROCEDURES IN POST‐BILLROTH II GASTRECTOMY PATIENTS

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures have been reported to be difficult to perform in patients with Billroth II gastrectomy. We evaluated the feasibility of using an oblique‐viewing endoscope equipped with a cannula deflector for these procedures in such patients. Patients and Methods: Twenty‐four patients with Billroth II gastrectomy were enrolled in the present study and underwent ERCP, endoscopic sphincterotomy, endoscopic nasobiliary drainage, expandable metal stent placement or tube stent placement. All procedures were performed with an oblique‐viewing endoscope equipped with a cannula deflector. Results: In all patients, afferent loops were entered. Reaching the papilla of Vater was achieved in 22 (91.7%) patients, in whom all planned procedures were accomplished. One patient experienced acute pancreatitis, hemorrhage from the papilla of Vater after sphincterotomy, and intestinal perforation. Conclusions: We believe an oblique‐viewing endoscope equipped with a cannula deflector to be useful in performing ERCP and associated procedures in many patients with Billroth II gastrectomy. However, one should be aware of major complications, such as perforation, that may occur.