内镜下"开窗术"治疗胃肠道脂肪瘤七例

我们收治的7例胃肠道脂肪瘤中男5例，女2例，年龄为48～65岁，平均年龄56．8岁。所有病人至少具有上腹痛、腹胀、便秘、腹泻中的一种症状而就诊。内镜检查显示：所有7例病变均为黏膜丘状隆起，黏膜表面光滑，呈淡黄色。肿块质地柔软，用活检钳探触可见随即出现的局部凹陷。超声内镜检查示：肿块都是高回音团块，质地均匀、边界清楚，位于黏膜下层，没有延续至固有肌层。诊断为胃肠道黏膜下良性病变，提示黏膜下脂肪瘤。其中胃1例，结肠6例。瘤体直径最大为2．0cm，最小为0．5cm，一般为0．5～1．0cm。根据胃镜和超声内镜检查诊断为：胃肠道平坦型脂肪瘤。     

微探头超声指导内镜黏膜下剥离术治疗上消化道黏膜下隆起性病变的价值

背景：微探头超声（MPS）能对上消化道黏膜下隆起性病变进行较准确的定位,并初步定性诊断,内镜黏膜下剥离术（ESD）可完整切除病变,目前MPS指导ESD治疗上消化道黏膜下隆起性病变的研究少见。目的：评价MPS指导ESD治疗上消化道黏膜下隆起性病变的价值。方法：对胃镜检查发现的89例上消化道黏膜下隆起性病变行MPS检查,比较两者的诊断准确率。然后采用ESD切除病变,分析手术情况。结果：上消化道黏膜下隆起性病变以平滑肌瘤和间质瘤为主,MPS对上消化道黏膜下隆起性病变的总体诊断准确率显著高于胃镜（83．1％对51．7％,P〈0．05）。82例病变位于黏膜肌层或黏膜下层,平均直径为12．6mm,平均手术时间28．2min,ESD完整切除率100％;5例病变位于固有肌层,平均直径为13．8mm,平均手术时间48．5min,ESD完整切除率71．4％,其余2例固有肌层病变因难以控制的出血和黏连而行外科手术。所有患者术后随访无病变残留和复发。结论：MPS可对上消化道黏膜下隆起性病变作出较准确的判断,应作为内镜下治疗的术前常规检查。MPS引导ESD治疗上消化道黏膜下隆起性病变安全、有效。     

小探头超声内镜对食管黏膜隆起性病变的诊断价值

对98例食管隆起性病变患者进行小探头超声内镜（MPS）检查。结果MPS诊断为间质细胞瘤40例、恶性间质细胞瘤5例、脂肪瘤6例、血管瘤3例、食管囊肿6例、息肉15例、食管静脉曲张11例、食管腔外压迫12例。其中38例在MPS检查后于内镜下切除病变。48例有手术或活检病理检查结果,其诊断与MPS诊断完全相符。MPS对食管黏膜隆起性病变具有较好的定位及定性诊断价值。     

高频超声小探头引导内镜下切除消化道表浅隆起性病变

目的 探讨经内镜高频超声小探头引导内镜下黏膜切除术治疗消化道表浅隆起性病变的安全性、可行性.方法 对普通内镜下发现的67例消化道表浅隆起性病变,经内镜活检钳道插入高频超声小探头进行检查,对其中39例显示病变来源于黏膜层、黏膜肌层及黏膜下层的病变行内镜下黏膜切除术.切除的病变送病理检查.结果 16例消化道息肉、2例异位胰腺、14例间质瘤、3例脂肪瘤,3例类癌,1例早期胃癌共39例病变内镜下完全切除.操作过程顺利,其中一例出现术后迟发性出血,给予内镜下成功止血,无其他严重并发症出现,病理符合率87.1%.结论 高频超声小探头检查可初步明确病变来源及层次,安全有效地指导消化道表浅隆起性病变黏膜切除术治疗.     

内镜超声在消化道黏膜下肿瘤诊断与治疗中的价值

目的 评价内镜超声在消化道黏膜下肿瘤的诊断及治疗中的价值.方法 对内镜检查中怀疑黏膜下肿瘤者进行内镜超声检查,根据黏膜下肿瘤的起源层次及性质决定治疗方案,内镜治疗包括内镜下黏膜切除术、黏膜剥离-肿瘤摘除术、高频电切术及硬化治疗.结果 73例良性间质瘤起源于黏膜肌层,7例直肠类癌位于黏膜固有层;脂肪瘤13例、异位胰腺17例、胃底静脉曲张5例、囊肿6例起源于黏膜下层;95例良性间质瘤及21例恶性间质瘤起源于固有肌层,1例类癌侵及固有肌层.61例源于黏膜肌层及8例源于固有肌层的良性间质瘤、8例脂肪瘤、8例异位胰腺及7例类癌经内镜切除,4例囊肿行内镜下穿刺治疗;33例源于固有肌层的良性间质瘤、18例恶性间质瘤、2例脂肪瘤、2例异位胰腺及1例类癌经手术切除.病理符合率为97.97%.结论 超声内镜能够对消化道黏膜下肿瘤进行起源和定性诊断,对黏膜下肿瘤治疗方案的选择具有重要的指导意义.     

小探头超声内镜在食管黏膜下病变患者的应用价值

常规内镜及活检可使许多消化道黏膜的表浅病变得到明确的诊断,但对黏膜深层及黏膜下的病变,多难达到满意结果。小探头超声可直接通过内镜活检孔道进行超声扫描,无需更换内镜,患者痛苦小,易于接受。为评价小探头超声内镜（miniprobe sonography,MPS）对食管黏膜下病变患者的诊断和治疗中的临床应用价值,现总结我院内镜确诊的223例食管黏膜下病变患者检查及治疗情况,报道如下。     

43例食管黏膜下隆起性病变的临床、内镜及病理分析

目的探讨食管黏膜下隆起性病变的临床,内镜及病理特点。方法对43例食管隆起性病变患者均采用FUJIONEG-450型胃镜,OlympusUM-2R超声微探头检查及治疗。超声频率为7.5MHz～12MHz,高频电发生器为ERBE-200型。结果常规内镜发现隆起性病变位于食管上段5例,中段22例,下段16例。超声内镜提示间叶源性肿瘤40例,脂肪瘤3例。病灶位于黏膜肌层25例,黏膜下层18例。所有隆起性病变高频电切除后行"全瘤"活检。病理结果显示平滑肌瘤29例,间质瘤8例,脂肪瘤3例,神经纤维瘤2例,神经鞘瘤1例。43例患者半年至一年复查均痊愈,无复发。结论在超声引导下对小于2cm的食管黏膜下隆起性病变行高频电切除术,是安全有效的内镜微创技术。     

消化道黏膜下肿物的内镜及超声内镜下特点分析

目的探讨消化道黏膜下肿物的内镜及超声内镜下特点。方法对153例消化道黏膜下肿物进行内镜及超声内镜检查,最终经病理学及免疫组化明确诊断。结果确诊消化道平滑肌瘤51例、胃肠道间质瘤37例、脂肪瘤30例、类癌21例、异位胰腺7例、神经鞘瘤3例、错构瘤3例和血管球瘤1例。超声内镜对平滑肌瘤、间质瘤、脂肪瘤、类癌、异位胰腺、神经鞘瘤、错构瘤和血管球瘤的诊断符合率分别为92%、92%、100%、71%、71%、0、0和100%,其总诊断符合率为86%,明显高于内镜总诊断符合率(70%)。结论超声内镜可明确消化道黏膜下肿物的大小、起源、回声、生长方式,对消化道黏膜下肿物的诊断及鉴别诊断有重要作用。     

微探头超声内镜指导内镜下剥离联合圈套结扎治疗上消化道固有肌层肿瘤的初探

目的探讨微探头超声内镜指导内镜下剥离联合圈套结扎治疗来源于上消化道固有肌层黏膜下肿瘤（SMT）的疗效和安全性。方法对内镜发现的上消化道SMT行EUS,对其中来源于固有肌层的SMT行圈套结扎后应用针形切开刀行对应内镜下剥离治疗：内镜下圈套结扎病变;预切开病变表面中央的黏膜;剥离黏膜下层组织显露病变,完整切除病变。结果来源于上消化道固有肌层的SMT共13例,术后病理诊断为食管平滑肌瘤2例,胃平滑肌瘤3例,胃间质瘤7例,胃血管球瘤1例。病变直径0．8～1．5cm,平均1．2cm。13例病变均一次性完整切除,其中1例术后出现消化道穿孔,应用金属夹成功封闭,未转外科手术。结论微探头超声内镜指导内镜下剥离联合圈套结扎治疗来源于上消化道固有肌层直径≤1．5cm的SMT是安全、有效的,可完整切除病变,提供完整的病理学诊断资料,可达到与外科手术同样的治疗效果。     

超声微探头在上消化道黏膜下隆起性病变中的诊断和指导治疗方式价值

目的探讨超声微探头在上消化道黏膜下隆起性病变中的诊断和治疗价值。方法对胃镜检查发现隆起性病变91例患者进行超声微探头检查,根据超声胃镜图像特点选择治疗方案;并对部分内镜治疗或手术切除病例进行超声微探头复查。结果发现外压性改变5例,黏膜下肿瘤86例,包括良性间质瘤50例,恶性间质瘤3例,浸润性癌5例,胃或食管癌手术后吻合口隆起8例,胃淋巴瘤1例,胃黏膜皱襞肥大2例,Brunner腺增生1例,脂肪瘤2例,异位胰腺2例,孤立性静脉瘤7例,静脉曲张4例,囊肿1例。28例黏膜肌层良性间质瘤和2例黏膜下层脂肪瘤采用胃镜下高频电凝切除,11例黏膜肌层间质瘤术后6个月超声微探头复查有3例在原切除部位见到残留的瘤体,胃或食管癌手术后吻合口隆起8例中4例复发并经病理学证实。结论超声微探头能显示黏膜下隆起病变的层次和性质,有利于治疗方案的选择和对治疗效果的评价,从而提高胃镜医师的诊断水平。     

Therapeutic procedures for submucosal tumors in the gastrointestinal tract

This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal （GI） submucosal tumors （SMTs）. The aim of this paper is to investigate the treatments of GI SMTs and to present a case of a gastrointestinal stromal tumor （GIST）. Literature searches were performed to find information on therapy for GI SMTs. Based on these searches, the optimal therapeutic procedures could be outlined. The choice of treatment of localized tumors is endoscopic resection if possible or, alternatively, laparoscopic resection or surgical resection by an open procedure. However, benign SMTs should only be excised if symptoms are present, and GISTs should be treated with particular precautions. Irresectable or recurrent GISTs may be successfully treated with the tyrosine kinase inhibitor, imatinib.     

Oval mucosal opening bloc biopsy after incision and widening by ring thread traction for submucosal tumor

Gastric submucosal tumors(SMTs) less than 2 cm are generally considered benign neoplasms, and endoscopic observation is recommended, but SMTs over 2 cm, 40% of which are gastrointestinal stromal tumors(GISTs), have malignant potential. Although the Japanese Guidelines for GIST recommend partial surgical resection for GIST over 2 cm with malignant potential as well as en bloc large tissue sample to obtain appropriate and large specimens of SMTs, several reports have been published on tissue sampling of SMTs, such as with endoscopic ultrasound sound fine needle aspiration, submucosal tunneling bloc biopsy, and the combination of bite biopsy and endoscopic mucosal resection. Because a simpler, more accurate method is needed for appropriate treatment, we developed oval mucosal opening bloc biopsy after incision and widening by ring thread traction for submucosal tumor(OMOB) approach. OMOB was simple and enabled us to obtain large samples under direct procedure view as well as allowed us to restore to original mucosa.     

内镜下纵切挖除术治疗消化道黏膜下肿瘤患者

目的探讨内镜纵切挖除术（ELE）治疗消化道黏膜下肿瘤（SMT）的疗效和可行性。方法对2011年2月至7月经辅助检查和前期治疗明确诊断为起源于消化道的SMT患者19例,在清醒镇静下行ELE治疗：（1）黏膜下注射生理盐水,纵行切开肿瘤表面黏膜和黏膜下层,显露肿瘤。（2）采用内镜黏膜下剥离术沿肿瘤周围分离至肿瘤基底部。（3）胃镜直视下应用Hook刀、IT刀或圈套器完整切除肿瘤。（4）应用金属夹缝合手术创面。结果19例消化道SMT患者中,病灶位于食道3例、贲132例、胃底3例、胃体5例、胃窦5例、升结肠1例。ELE成功切除所有病变,完整切除率为100．0％;ELE时间为25～125min,平均45min。切除肿瘤直径范围1．5-3．5cm,平均2．0cm;病理诊断为平滑肌瘤11例、脂肪瘤5例、间质瘤3例。术后无一例出现出血及腹膜炎体征。住院时间7。15d,平均10d。术后随访1～3个月,平均2个月,无一例病变残留。结论ELE治疗消化道SMT患者是安全有效的,手术方法较内镜黏膜下剥离术简便,便于缩短手术时间及术后并发症的防治,并且有利于术后创面的愈合。     

Endoscopic management of gastrointestinal smooth muscle tumor

AIM: To systematically evaluate the efficacy and safety of endoscopic resection of gastrointestinal smooth muscle tumors (SMTs, including leiomyoma and leiomyosarcoma) and to review our preliminary experiences on endoscopic diagnosis of gastrointestinal SMTs. METHODS: A total of 69 patients with gastrointestinal SMT underwent routine endoscopy in our department. Endoscopic ultrasonography (EUS) was also performed in 9 cases of gastrointestinal SMT. The sessile submucosal gastrointestinal SMTs with the base smaller than 2 cm in diameter were resected by "pushing" technique or "grasping and pushing" technique while the pedunculated SMTs were resected by polypectomy. For those SMTs originating from muscularis propria or with the base size ≥ 2 cm, ordinary biopsy technique was performed in tumors with ulcers while the "Digging" technique was performed in those without ulcers. RESULTS: 54 cases of leiomyoma and 15 cases of leiomyosarcoma were identified. In them, 19 cases of submucosal leiomyoma were resected by "pushing" technique and 10 cases were removed by "grasping and pushing" technique. Three cases pedunculated submucosal leiomyoma were resected by polypectomy. No severe complications developed during or after the procedure. No recurrence was observed. The diagnostic accuracy of ordinary and the "Digging" biopsy technique was 90.0% and 94.1%, respectively. CONCLUSION: Endoscopic resection is a safe and effective treatment for leiomyomas with the base size ≤2 cm. The "digging" biopsy technique would be a good option for histologic diagnosis of SMTs.     

Accuracy of endoscopic ultrasonographic impression compared with pathologic diagnosis in gastrointestinal submucosal tumors]

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS) is a valuable imaging modality for the evaluation of gastrointestinal submucosal tumor (SMT). EUS is helpful in assessing the layer of origin, tumor diameter, shape, border characteristics, and internal echo patterns of SMTs and thus makes it possible to predict histologic diagnosis with educated guess. However, some studies have found no significant differences in EUS features between benign and malignant mesenchymal tumors. By comparing EUS impressions with histologic diagnosis, we evaluated the accuracy of EUS in differential diagnosis of gastrointestinal SMTs. METHODS: 58 cases of gastrointestinal SMTs with both EUS findings and pathologic reports were compared retrospectively from August 2001 to September 2003. RESULTS: 34 patients had lesions in the stomach and 13, 8, 3 in the esophagus, duodenum, and colon respectively. Benign lesions were predominant (46 of 58). The EUS and pathologic diagnosis coincided in 46/58 (79.3%) of the cases. Use of EUS led to the correct diagnosis in 7/9 (77.8%) of malignant GISTs (gastrointestinal stromal tumor) and leiomyosarcomas. Two small malignant gastric GISTs were diagnosed as benign with EUS. CONCLUSIONS: EUS is a useful tool in the differential diagnosis of gastrointestinal SMTs and predicting malignant lesions. However, some malignant GISTs were diagnosed as benign tumor with EUS examination.     

Is the invasive approach for all the upper gastrointestinal mesenchymal tumors necessary?]

BACKGROUND/AIMS: Mesenchymal tumors are the most frequent submucosal tumors in gastrointestinal trail. We reviewed the mesenchymal tumors which are confirmed by pathology to examine whether the invasive approach of all mesenchymal tumors is necessary. METHODS: This study was performed on fifty-nine patients who has mesenchymal tumors confirmed by endoscopic or surgical resection from January 2000 to June 2004. RESULTS: Mesenchymal tumors consisted of thirty-six gastrointestinal stromal tumors (GISTs), 20 leiomyomas and 3 schwannomas. All the esophageal tumors were leiomyoma (12/12, 100%). In stomach, there were 32 GISTs (76.2%), 7 leiomyomas (16.7%) and 3 schwannomas (7.1%). And there were 4 GISTs (80.0%) and 1 leiomyoma (20.0%) in duodenum. Tumors less than 1 cm in maximal diameter were leiomyoma or GISTs with very low risk of aggressive behavior. 56.1% of the tumors larger than 1 cm consisted of low, intermediate or high risk GISTs. CONCLUSIONS: Biopsy must be considered according to its size and anatomic location of mesenchymal tumors. The invasive approach for every esophageal submucosal tumor is not necessary unless the size is very large, because most of them are benign in nature. However, the gastric submucosal tumor with more than 1 cm in diameter should be carefully and regularly followed up or biopsied because it cannot be assumed to be benign for any GIST more than 1 cm in size at the present time, safely.     

微型探头超声内镜对上消化道黏膜下肿瘤的诊治价值

目的探讨微型探头超声内镜（InEus）在上消化道黏膜下肿瘤的诊断和治疗中的作用。方法对30例疑为上消化道黏膜下肿瘤的患者进行微型探头超声内镜检查,根据黏膜下肿瘤的起源层次．部分患者接受内镜下治疗或外科手术。结果mEUS检查的30例患者中,发现消化道壁外压迫1例（主动脉弓1例）;黏膜下肿瘤29例,包括平滑肌瘤12例,良性间质瘤4例,恶性间质瘤1例,脂肪瘤4例,静脉瘤3例,异位胰腺1例,囊肿4例。12例起源于黏膜肌层的肿瘤行高频电切除术切除,3例静脉瘤行尼龙圈套结扎,4例脂肪瘤及4例囊肿行高频电切除。结论mEUS检查能清楚显示上消化道黏膜下肿瘤的大小．起源层次、生长方向及邻近组织结构关系,较准确地判断肿瘤的性质。进而指导黏膜下肿瘤治疗方案的选择。     

无腹腔镜辅助的内镜全层切除术治疗源于固有肌层的胃黏膜下肿瘤

目的探讨无腹腔镜辅助的内镜全层切除术（EFR）治疗源于固有肌层的胃黏膜下肿瘤（SMT）的疗效和可行性。方法2007年7月至2009年8月经辅助检查和前期治疗明确诊断为起源于固有肌层的胃SMT患者20例,择期行全麻下EFR治疗：（1）黏膜下注射生理盐水,预切开肿瘤周围黏膜和黏膜下层,显露肿瘤;（2）采用内镜黏膜下剥离术（ESD）技术沿肿瘤周围分离固有肌层至浆膜层;（3）应用Hook刀沿肿瘤边缘切开浆膜;（4）胃镜直视下应用Hook、IT刀或圈套器完整切除包括浆膜在内的肿瘤;（5）应用金属夹缝合胃创面。结果20例源于固有肌层的胃SMT中,病灶位于胃底9例、胃体11例。EFR成功切除所有病变,完整切除率为100％,未使用腹腔镜辅助;EFR时间为60—145min,平均85min。切除肿瘤最大直径1．8～3．5cm,平均2．6cm;病理诊断为问质瘤13例、平滑肌瘤4例、血管球瘤2例、神经鞘瘤1例。术后无一例出现胃出血、腹膜炎体征及腹腔脓肿,术后3d造影无一例造影剂外漏和胃排空障碍。住院天数3～8d,平均5．5d。术后随访1～12个月,平均7个月,无一例病变残留或复发。结论EFR治疗源于固有肌层的胃SMT是安全、有效的,可以切除更深的胃壁肿瘤,并提供准确的病理诊断资料,它的开展可进一步扩大内镜治疗的适应证。     

经黏膜下隧道内镜肿瘤切除术治疗源于固有肌层的上消化道黏膜下肿瘤初探

目的探讨经黏膜下隧道内镜肿瘤切除术（STER）治疗来源于上消化道固有肌层黏膜下肿瘤（SMTs）的疗效和安全性。方法对26例经超声内镜和CT诊断为来源于固有肌层的上消化道SMTs患者全麻下行STER治疗：（1）内镜寻找到肿瘤,并准确定位;（2）建立黏膜下隧道,显露肿瘤;（3）内镜直视下完整切除肿瘤;（4）缝合黏膜切口。结果来源于固有肌层的上消化道SMTs患者26例中,食管14例,贲门7例,胃5例。来源于固有肌层浅层者11例,深层者15例,其中2例胃SMTs与浆膜层粘连,密不可分。STER成功切除所有黏膜下肿瘤,完整切除率100％,切除病变直径1．0～3．2cm（平均1．9cm）。黏膜切开至黏膜切口完整缝合时间25～145min,平均68．5min;完整缝合创面所用金属夹4—6枚,平均5枚。术后病理诊断为平滑肌瘤17例,间质瘤7例,血管球瘤1例,神经鞘膜瘤1例;切缘均为阴性。发生皮下气肿2例,左侧气胸伴皮下气肿1例,气腹2例,均予保守治疗痊愈。术后无一例出现迟发性消化道出血、消化道漏和胸腔腹腔继发感染,无一例发生黏膜下隧道内积血积液和继发感染。随访3～9个月,无一例病变残留或复发。结论STER治疗来源于固有肌层的上消化道SMTs安全、有效,可以一次性完整切除病变,提供完整的病理学诊断资料,并可避免消化道漏和胸腔腹腔继发感染。     

Evolving role of the endoscopist in management of gastrointestinal neuroendocrine tumors

Neuroendocrine tumors(NETs) are uncommon gastrointestinal neoplasms but have been increasingly recognized over the past few decades. Luminal NETs originate from the submucosa of the gastrointestinal tract and careful endoscopic exam is a key for accurate diagnosis. Despite their reputation as indolent tumors with a good prognosis,some NETs may have aggressive features with associated poor long-term survival. Management of NETs requires full understanding of tumor size,depth of invasion,local lymphadenopathy status,and location within the gastrointestinal tract. Staging with endoscopic ultrasound or cross-sectional imaging is important for determining whether endoscopic treatment is feasible. In general,small superficial NETs can be managed by endoscopic mucosal resection and endoscopic submucosal dissection(ESD). In contrast,NETs larger than 2 cm are almost universally treated with surgical resection with lymphadenectomy. For those tumors between 11-20 mm in size,careful evaluation can identify which NETs may be managed with endoscopic resection. The increasing adoption of ESD may improve the results of endoscopic resection for luminal NETs. However,enthusiasm for endoscopic resection must be tempered with respect for the more definitive curative results afforded by surgical treatment with more advanced lesions.