内镜经黏膜下隧道肿瘤切除术治疗颈部食管黏膜下良性肿瘤策略和并发症分析

目的评估内镜经黏膜下隧道肿瘤切除术(STER)治疗颈部食管黏膜下肿瘤的可行性及安全性。方法收集2017年1月至2018年1月本院收治的12例颈部食管黏膜下良性肿瘤并接受STER治疗的患者资料,分析其整块切除率、治愈性切除率、手术及住院时间、术后相关并发症。结果 12例颈部食管黏膜下肿瘤均行STER治疗,男7例,女5例,年龄(58.3±11.6)岁,病灶距门齿(19.41±0.51)cm,切除瘤体直径(16.25±6.44)mm,手术时间为(45.00±6.57)min,整块切除率91.67%(11/12),治愈性切除率100%(12/12)。术中出血1例(8.33%,1/12),无穿孔,术后有8例(66.67%,8/12)出现不同程度发热,有9例(75.00%,9/12)出现咽喉部不适或胸骨后烧灼不适,住院时间为(8.17±1.11)d,术后随访未发现病变残留、复发及食管狭窄。结论 STER治疗颈部食管黏膜下良性肿瘤是安全有效的治疗方法。     

多层螺旋CT及超声内镜对胃肠道间叶源性肿瘤的诊断价值

目的：探讨胃肠道间叶源性肿瘤（GIMT）的16层螺旋CT（MSCT）和超声内镜（EUS）表现及其诊断价值。方法：回顾性分析手术病理证实的GIMT37例，术前37例均行CT平扫，35例行双期增强扫描，17例行超声内镜检查。结果：胃肠道间质瘤（GIST）31例（食道1例，胃19例，小肠6例，直肠1例，胃肠外4例），平滑肌瘤4例（食道3例，胃1例），胃神经源性肿瘤2例。①CT表现：黏膜下富血供肿块，倾向腔外生长，可有囊变、坏死、出血、钙化，无淋巴结转移。增强后良性GIMT及交界性GIST均匀强化，边界清楚，良性GIMT肿块直径1．0-3．0cm，平均2．16cm。胃交界性GIST直径1．2～3．5cm，平均2．24cm。恶性GIMT强化不均匀，肿瘤最大径3．5-16．0cm，平均6．9cm，可有邻近脏器侵犯。定位准确率30／37（81．08％），定性准确率20／37（54．05％）。②EUS表现：内镜表现为黏膜下隆起性病变，EUS显示肿瘤起源于黏膜肌层或固有肌层的低回声改变，良性GIMT内部回声均匀，边界清楚，肿瘤最大径0．5-3．5cm，平均1．75cm。恶性GIMT回声多不均匀，可伴有液性暗区，形态不规则，可有浸润性改变，肿瘤最大径6．0-10cm，平均9．2cm。定位准确率16／17（94．12％），定性准确率15／17（88．23％）。结论：MSCT和EUS能准确显示肿瘤的部位、形态、大小，内部结构及浸润情况，有利于良恶性的判断，对临床治疗及预后有着重要的指导价值。     

内镜超声检查对食管隆起性病变的诊断价值

目的 探讨超声内镜对食管隆起性病变的诊断价值。方法 对161例食管隆起性病变患者行内镜超声检查。结果 发现黏膜下肿瘤92例，其中肌原性肿瘤86例，脂肪瘤4例，囊肿2例，息肉14例，静脉瘤（静脉曲张）34例；外压性改变21例，其中胸主动脉外压18例，纵隔肿瘤3例。结论 内镜超声检查能较清楚地显示食管壁的5层结构，比较准确地判断隆起性病变与食管壁的关系，对食管隆起性病变的诊断、鉴别诊断和指导治疗均有很大价值。     

Endoscopic Submucosal Dissection in the Era of Proton Pump Inhibitors

Endoscopic submucosal dissection (ESD) has the advantage over endoscopic mucosa resection, permitting removal of gastrointestinal neoplasms en bloc, but is associated with relatively high risk of complications. Indications for early gastric cancer (EGC) are expanded: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings ≤3 cm in diameter; and minute submucosal invasive cancer ≤3 cm in size. The indications for early esophageal cancer (EEC) are the tumors confined to the two-third layer of the lamina propria. The EEC lesions spreading more than three-quarter of circumference of the esophagus are at frequent risk of stenosis. The procedures include marking, submucosal injection, circumferential mucosal incision and exforiation of the lesion along the submucosal layer. Complete ESD can achieve a large one-piece resection, allowing precise histological assessment to prevent recurrence. Clinical outcomes of gastric and esophageal ESD have been promising, and the prognosis of EGC patients treated by ESD is likely to be excellent, though further longer follow-up studies are warranted. Notification of perforation risk is essential in particular for esophageal ESD. Bleeding during ESD can be managed with coagulation forceps, and postoperative bleeding may be reduced with routine use of the stronger acid suppressant, proton pump inhibitors.     

Squamous cell metastases to the gastric cardia

Three patients with squamous cell carcinoma metastasized to the gastric cardia (1 from the esophagus, 1 from the hypopharynx, and 1 of unknown origin) are described. Two patients presented after apparent successful treatment of the primary malignancy. In all 3 cases the lesion appeared as a large solitary submucosal mass in the region of the gastric cardia. Squamous metastases should be considered in the radiographic differential diagnosis of a large submucosal gastric mass. Metastasis to the proximal stomach from carcinoma of the esophagus may be more common than suspected. Contrast evaluation of this area may be indicated in both the initial evaluation and the routine follow-up in these patients.     

Endosonographic features of Brunner's gland hamartomas which were subsequently resected endoscopically

BACKGROUND AND STUDY AIMS: Brunner's gland hamartomas are uncommon duodenal submucosal tumors. We aim to describe their morphological characteristics, with particular attention to the endosonographic features. PATIENTS AND METHODS: We reviewed the radiological, endoscopic, endosonographic, and histological findings from six Brunner's gland hamartomas which were completely removed by endoscopic resection. RESULTS: The lesions appeared as broad-based, sessile, or pedunculated submucosal tumors, measuring 0.7 to 2 cm in maximal diameter. Three lesions contained tiny dimple-like depressions on the surface; in one lesion these were only recognized following the use of an endoscopic dye-spraying technique. All the lesions could be safely removed by endoscopic resection after endosonographic confirmation of the layer origin within the submucosa. The internal echo structure of the tumors appeared to be solid echogenic in two, simple cystic in two, and multicystic in the remaining two lesions. In three lesions with an indistinct boundary, some stromal proliferation and solid Brunner's glands were recognized in an area extending from the mucosa to the submucosa. These endosonographic features corresponded to histological findings comprising stromal proliferation and various degrees of solid and cystic glandular Brunner's glands. CONCLUSIONS: Brunner's gland hamartoma is characterized endosonographically by a heterogeneous solid and/or cystic mass within the submucosa.     

超声内镜对结直肠黏膜下病变的诊断价值

目的探讨超声内镜(EUS)在结直肠黏膜下病变诊断和治疗中的作用。方法对结直肠黏膜下病变进行EUS检查。根据黏膜下病灶的起源层次,部分患者接受深挖活检、超声内镜引导下细针穿刺吸取活检术(EUS-FNA)、内镜下治疗或外科手术。回顾性分析EUS诊断结果与临床病理的相关性。结果 EUS检查的74例患者中,诊断神经内分泌肿瘤28例(均位于直肠);脂肪瘤15例(其中位于回盲部4例、横结肠1例、升结肠8例、乙状结肠2例);直肠间质瘤2例(固有肌层和黏膜肌层各1例);外压性改变14例(卵巢肿瘤9例,淋巴结2例,盆腔肿瘤3例);囊肿5例(横结肠4例、升结肠1例);气囊肿1例;乙状结肠子宫内膜异位3例;直肠周边恶性肿瘤侵犯4例;肠道淋巴瘤2例。所有病灶均接受深挖活检、EUS-FNA、内镜下治疗或外科手术。最终病理和EUS诊断符合率为68/74(91.9%),其中2例EUS考虑直肠类癌最后病理确诊为黏膜肌层来源的平滑肌瘤。1例考虑脂肪瘤最终确诊为肠道淋巴瘤。2例考虑直肠周边恶性肿瘤最终为炎性包块,1例考虑子宫内膜异位症最终诊断为直肠癌。结论 EUS能清晰地显示消化道各层结构,能清楚显示结直肠黏膜下病变的大小、起源及其与相邻结构的关系,并且能较精确地判断各种病变的性质,进而指导结直肠黏膜下病变的治疗。     

多层螺旋CT对胃肠道间质瘤的诊断价值

目的探讨MSCT对胃肠道间质瘤(GIST)的诊断价值.方法回顾性分析13例经手术病理证实的GIST的平扫及增强CT表现.结果 GIST发生于小肠8例,胃部4例,肠系膜1例.肿块向腔外生长者居多,多呈圆形或椭圆形.13例中,良性5例,其中4例直径小于5 cm,密度多均匀,边界清,强化均匀;恶性8例,其中7例直径大于5 cm,密度多不均匀,内部有单发或多发坏死,边界多不清,强化不均匀,4例出现转移.结论 GIST的CT表现没有特异性,但MSCT对其定位准确,对肿瘤良、恶性的判别及预后的估计有重要价值.     

623例膀胱镜活检病理分析

目的分析因膀胱病变行膀胱镜活检患者的病理类型构成,探讨膀胱镜检查的临床价值。方法复习我院623例膀胱病变患者经膀胱镜活检组织病理资料。结果良性肿瘤76例,占12．2％,均为尿路上皮乳头状瘤。恶性肿瘤291例,占46．7％,其中尿路上皮癌254例,腺癌17例,鳞癌6例,转移癌13例,横纹肌肉瘤1例。膀胱黏膜慢性炎症140例,上皮增生50例,分别占22．5％、8．0％;而腺性膀胱炎55例,正常膀胱黏膜8例,前列腺组织3例。结论尿路上皮性肿瘤仍是最常见的膀胱疾病,其次是膀胱炎性病变。膀胱恶性肿瘤以尿路上皮癌最常见,膀胱腺癌、鳞癌或转移癌等比较少见。膀胱镜活检安全、简便,具有重要的临床应用价值。     

内镜经黏膜下隧道肿瘤切除术治疗食管贲门周围黏膜下肿瘤的疗效分析

目的探讨内镜经黏膜下隧道肿瘤切除术(STER)治疗食管贲门周围黏膜下肿瘤(SMT)的临床效果及安全性。方法收集2012年9月-2018年6月在南京医科大学附属南京医院内镜中心采用STER治疗的50例食管贲门周围SMT患者的临床资料,并进行分析。结果 50例患者均完成STER。食管病变33例,贲门周围、胃底病变17例,1例病变为2个瘤体,其他均为单个瘤体。成功切除所有SMT,一次性完整切除率96.0%,手术时间32～115 min,平均(54.0±24.5)min,完整缝合创面所需金属夹4～8枚,平均(5.6±2.1)枚。术后瘤体直径0.8～3.3 cm,平均(1.6±0.4)cm。术后经常规病理及免疫组化染色确诊为平滑肌瘤40例(80.0%),间质瘤7例(14.0%),食管支气管源性囊肿2例(4.0%),钙化性纤维性肿瘤1例(2.0%),切缘均为阴性。4例术中发生穿孔,3例术中发生皮下气肿,3例术后出现发热,均经保守治疗痊愈。住院时间6～15 d,平均(7.8±3.7)d。结论 STER对食管贲门周围SMT有较高的完整切除率,且手术创伤小,恢复快,并发症较少,住院时间较短。     

食管入口病变的X线钡剂和CT检查及其临床意义

目的：分析食管入口病变的临床以及X线和CT表现,探讨食管入口病变的影像学检查方法,以提高食管入口病变的影像学诊断水平。方法：回顾分析34例经临床、手术、穿刺和病理证实的食管入口病变患者的临床和影像学资料。34例均行CT检查,其中27例行增强前后CT扫描,7例仅行CT平扫。34例中有28例行X线钡剂检查。结果：34例食管入口病变包括原发于食管入口的肿瘤14例（鳞癌12例、未分化癌2例）、食管入口括约肌肥厚3例、食管入口憩室5例、食管入口损伤12例。34例食管入口病变均有吞咽障碍的临床症状,食管入口癌的中晚期,吞钡检查可见食管入口黏膜破坏。肿瘤早期CT表现不明显,中晚期病人食管入口壁可有不规则增厚或肿块。环咽肌肥厚者,CT表现为食管壁局部增厚,黏膜光滑。食管入口憩室者,CT表现为食管入口侧壁不强化的软组织肿块,吞钡可见食管一侧囊袋状龛影,有钡剂进入。食管入口破裂者吞钡时,可见钡剂溢入颈部软组织,2例食管入口破裂、穿孔并发纵膈脓肿者CT可见上纵膈增宽,增强扫描后见低密度脓腔。结论：X线钡剂检查对食管入口病变的诊断,目前仍有不可替代的作用,它简便易行、费用低廉、易被患者接受。CT对食管入口肿瘤的定性、分期,对食管入口损伤及其并发症的观察有重要意义,若将两者结合起来,能提高食管入口病变的影像学诊断水平。     

Large leiomyoma of lower esophagus diagnosed by endoscopic ultrasonography–fine needle aspiration: A case report

BACKGROUNDBenign esophageal tumors are rare accounting for < 1% of esophageal tumors; two-thirds of which are leiomyomas. Esophageal leiomyoma is a benign tumor derived from mesenchymal tissue that is completely muscularly differentiated. Most esophageal leiomyomas are < 5 cm. Esophageal leiomyomas > 5 cm are rare. We describe a case of a large esophageal leiomyoma involving the cardia and diaphragm.CASE SUMMARYA 35-year-old woman presented to the doctor because of a choking sensation after eating. Physical examination showed no positive signs. Gastroscopy indicated an uplifted change in the cardia. Enhanced computed tomography revealed space-occupying lesions in the lower part of the esophagus and cardia, which were likely to be malignant. Positron emission tomography–computed tomography showed increased metabolism of soft tissue masses in the lower esophagus and near the cardia. Malignant lesions were considered, and mesenchymal tumors were not excluded. Endoscopic ultrasonography was performed to examine a hypoechoic mass in the lower esophagus, which was unclear from the esophageal wall. Clinical evaluation suggested diagnosis of esophageal and cardiac stromal tumors. Finally, histological specimens obtained by endoscopic ultrasonography– fine needle aspiration suggested leiomyoma. The patient underwent laparoscopic local resection of the tumor. The postoperative pathological diagnosis was leiomyoma.CONCLUSIONEndoscopic ultrasonography-fine needle aspiration is necessary for the diagnosis of gastrointestinal leiomyomas. It provides a strong basis for diagnosis of gastrointestinal tumors of unknown nature and origin.     

Endoscopic sonographically guided fine-needle aspiration yield in submucosal tumors of the gastrointestinal tract.

OBJECTIVE: To study the yield of endoscopic ultrasonographically guided fine-needle aspiration cytologic examination in the diagnosis of submucosal masses. METHODS: From 1999 to 2003, 10 patients underwent ultrasonographically guided fine-needle aspiration for the cytologic diagnosis of submucosal masses in our institution. The endoscopic ultrasonography records and the cytology database were consulted, and the reports were analyzed, as were slide material and the technical aspects related to these procedures. All procedures were performed under conscious sedation and cardiorespiratory monitoring on an outpatient basis. Ten patients (4 men and 6 women; mean age, 60.8 years) were studied. RESULTS: Eight lesions were located in the stomach, and 2 were located in the esophagus, with a mean diameter of 3.3 cm. An experienced cytopathologist was present on-site during all procedures for assessment of adequacy and preliminary cytologic examination. Cytologic diagnoses were obtained in 8 cases as follows: 6 gastrointestinal stromal tumors, 1 organizing submucosal hematoma, and 1 low-grade mucosa-associated lymphoid tissue-associated lymphoma. Two cases consisted of scant gastric epithelium only and were considered nondiagnostic. The cytologic diagnoses guided further clinical treatment. CONCLUSIONS: Ultrasonographically guided fine-needle aspiration with cytopathologic analysis has a high accuracy rate (80%) for diagnosing submucosal lesions. These findings potentially affect clinical decision making.     

超声微探头对上消化道黏膜下肿瘤的诊断价值

目的为提高上消化道黏膜下肿瘤的诊断率，探讨微型超声探头的诊断价值。方法对84例疑黏膜下肿瘤的患者进行微探头超声检查。结果发现外压性改变9例，黏膜下肿瘤75例，包括肌源性肿瘤49例．胃异位胰腺2例，胃脂肪瘤2例，胃底静脉曲张2例，食管静脉瘤2例。食管囊肿2例，胃囊肿1例，食管癌4例，胃癌3例，胃基质瘤8例。经病理证实23例。结论USP能清楚显示消化道管壁各层，准确判断肿瘤浸润层次，用于指导黏膜下肿瘤的诊断有较高价值，但由于其微探头探查深度有限，对较大肿瘤的后方情况探查受限，对部分肌源性肿瘤的良恶性鉴别诊断仍有一定困难。     

共聚焦内镜对上消化道黏膜病变诊断价值的初步研究

目的初步探讨共聚焦内镜对上消化道黏膜病变的诊断价值。方法应用共聚焦内镜对9例患者进行常规胃镜检查,对正常黏膜和可疑病变部位用共聚焦内镜观察,与相应病变部位活检的病理学结果进行比较分析。结果对患者74个部位进行共聚焦扫查,采集图像1587帧,其中正常黏膜39个,慢性胃炎31个,食管癌3个,食管异位胃黏膜1个。不同部位和病变黏膜的共聚焦图像具有不同的形态学特点,共聚焦内镜对慢性胃炎患者胃黏膜肠上皮化生诊断的敏感性、特异性和准确性分别为85.7%、95.8%和93.5%。结论共聚焦内镜能显示上消化道黏膜的组织和细胞形态,对胃黏膜肠上皮化生的诊断具有较高的准确度。     

胃肠道间质瘤的CT分析

目的：探讨CT对胃肠道间质瘤的诊断价值。材料和方法：回顾性分析经手术病理证实的14例胃肠道间质瘤的CT资料。结果：14例胃肠道间质瘤中7例良性，4例潜在恶性，2例恶性，1例未定性；2例发生肝转移，1例合并结肠腺癌。1例位于食管，8例位于胃，3例位于小肠，2例位于结肠。14例胃肠道间质瘤最大径1~15cm不等。4例形态不规则，10例为规则的圆形或类圆形。1例混合性生长，境界不清，2例腔内生长，11例腔外生长。肿瘤密度不均匀，轻~重度强化，2例见钙化。结论：CT是胃肠道间质瘤术前诊断及判断其生物学行为的主要工具。     

Thoracoscopic resection of a large lower esophageal schwannoma: A case report and review of the literature

BACKGROUNDEsophageal schwannomas originating from Schwann cells are extremely rare esophageal tumors. They commonly occur in the upper and middle esophagus but less frequently in the lower esophagus. Herein, we report a rare case of a large lower esophageal schwannoma misdiagnosed as a leiomyoma. We also present a brief literature review on lower esophageal schwannomas.CASE SUMMARYA 62-year-old man presented with severe dysphagia lasting 6 mo. A barium esophagogram showed that the lower esophagus was compressed within approximately 5.5 cm. Endoscopy revealed the presence of a large submucosal protuberant lesion in the esophagus at a distance of 32-38 cm from the incisors. Endoscopic ultrasound findings demonstrated a 4.5 cm × 5.0 cm hypoechoic lesion. Chest computed tomography revealed a mass of size approximately 53 mm × 39 mm × 50 mm. Initial tests revealed features indicative of leiomyoma. After multidisciplinary discussions, the patient underwent a video-assisted thoracoscopic partial esophagectomy. Further investigation involving immunohistochemical examination confirming palisading spindle cells as positive for S100 and Sox10 led to the final diagnosis of a lower esophageal schwannoma. There was no tumor recurrence or metastasis during follow-up.CONCLUSIONThe final diagnosis of esophageal schwannoma requires histopathological and immunohistochemical examination. The early appropriate surgery favors a remarkable prognosis.     

A case of malignant hemangioendothelioma of the stomach

A case of malignant hemangioendothelioma of the stomach is reported. The patient was a 21-year-old female who developed bloody stool. Pathological studies on the stomach revealed a gastric submucosal tumor. This tumor was growing on the outside of the stomach wall and formed a large abdominal mass. Evidence of metastases was detected in the liver, omentum and parietovisceral peritoneum. Biopsies were taken of the gastric mucosa and the metastatic lesions of the liver and omentum, and histological studies on these specimens led to the diagnosis of malignant hemangioendothelioma. A laparoscopic examination yielded very interesting findings: the presence of small red tumors on the omentum and the parietovisceral peritoneum. The usefulness of laparoscopic examination in the diagnosis of malignant hemangioendothelioma of the stomach is stressed.     

Circumferential endoscopic mucosal resection in Barrett's esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients

BACKGROUND AND STUDY AIMS: Treatment by endoscopic mucosal resection (EMR) has been established for early lesions in Barrett's esophagus. However, the remaining Barrett's esophagus epithelium remains at risk of developing further lesions. The aim of this study was to evaluate the efficacy of circumferential endoscopic mucosectomy (circumferential EMR)s in removing not only the index lesion (high-grade intraepithelial neoplasia (HGIN) or mucosal cancer), but also the remaining Barrett's esophagus epithelium. PATIENTS AND METHODS: A total of 21 patients were included in the study (11 men, 10 women), who had Barrett's esophagus and either HGIN (n = 12) or mucosal cancer (n = 9). Of the patients, 17/21 were at high surgical risk and five had refused surgery. On the basis of preprocedure endosonography their lesions were classified as T1N0 (n = 19) or T0N0 (n = 2). The lesions and the Barrett's esophagus epithelium were removed by polypectomy after submucosal injection of 10-15 ml of saline; a double-channel endoscope was used in 15/21 cases. Circumferential EMR was performed in two sessions, the lesion and the surrounding half of the circumferential Barrett's esophagus mucosa being removed in the first session. In order to prevent the formation of esophageal stenosis, the second half of the Barrett's esophagus mucosa was resected 1 month later. RESULTS: Complications occurred in 4/21 patients (19 %), consisting of bleeding which was successfully managed by endoscopic hemostasis in all cases. No strictures were observed during follow-up (mean duration 18 months) and endoscopic resection was considered complete in 18/21 patients (86 %). For three patients, histological examination showed incomplete removal of tumor: one of these underwent surgery; two received chemoradiotherapy, and showed no evidence of residual tumor at 18 months' and 24 months' follow-up, respectively. Two patients in whom resection was initially classified as complete later presented with local recurrence and were treated again by EMR. Barrett's esophagus mucosa was completely replaced by squamous cell epithelium in 15/20 patients (75 %). CONCLUSIONS: Circumferential EMR is a noninvasive treatment of Barrett's esophagus with HGIN or mucosal cancer, with a low complication rate and good short-term clinical efficacy. Further studies should focus on long-term results and on technical improvements.     

Barrett食管色素内镜与组织学的一致性观察

目的探讨Barrett食管在色素内镜下与组织学的一致性研究，揭示色素内镜在诊断Barrett食管的优越性。方法对125例J艋床诊断为食管病变的患者分为常规内镜组和色素内镜组，常规内镜组在齿状线2cm以上病变处取活检，色素内镜组用2％Lagol＇s液进行染色，根据染色发现的病变取活捡，分别进行组织病理学比较。结果色素内镜组的敏感性和漏诊率分别为73％、27％，常规内镜组为48％、52％，两组比较差异有显著性。结论色素内镜在Barrett食管的诊断和组织学较常规内镜有较好的一致性，且方法简单、实用。