肝胆胰疾病超声内镜介入治疗的新进展

超声内镜应用于临床已30多年。早期EUS仅作为一种诊断方法应用于临床,随着线阵式EUS尤其纵轴式彩色EUS的发展,除诊断作用外,EUS出现了兼具微创治疗的重大功能变革,进入了EUS诊断和治疗新阶段。超声内镜（EUS）引导的穿刺在临床越来越受欢迎,其治疗技术要优于经皮穿刺引流和常规手术治疗,如超声内镜引导下胰腺假性囊肿引流和腹腔神经丛阻滞术的疗效已被国内外相关研究所证实。然而,其他EUS引导技术如胆管及胰管穿刺引流仍处于初步研究阶段,我们就超声内镜引导治疗肝胆胰疾病的现状作一综述,让大家了解超声内镜技术在肝胆胰方面潜在的研究方向。     

内镜超声检查术在消化道外科疾病诊治中的应用

内镜超声检查术(ultrasonic endo-scope,EUS)最早于1980年由美国的DiMagno首次报告应用,近年来,随着腔内超声新器械的不断开发,适合消化系各种管腔,且有多种频率的超声内镜被广泛应用于临床,极大地拓宽了EUS在消化系疾病中的诊疗范围。在诊断方面,超声内镜的发展有利于某些消化系疾病手术方式的选择,在治疗方面,超声内镜微创介入治疗技术的发展,在某些疾病甚至取代了外科手术治疗。一、EUS在胃肠道疾病中的应用由于EUS是胃镜和超声的结合,因而具备其特有的优势。既能观察到消化道黏膜的情况,如溃疡、糜烂、黏膜隆起等,又能显示消化道…     

胆源性胰腺炎内镜治疗现状和发展趋势

急性胆源性胰腺炎（ABP）是急性胰腺炎的最主要类型，占急性胰腺炎50%以上。ABP以胆道疾病为诱发因素，其中胆道微结石是最常见的原因。鉴于消化内镜治疗在胆胰疾病中的广泛应用，其在ABP的诊疗全过程中所起的作用越来越重要。从内镜下辅助ABP治疗决策、ABP病因治疗、处理ABP并发症、预防ABP复发以及进行ABP肠道营养5方面对内镜治疗ABP进行剖析：超声内镜（EUS）可从病因诊断和预后判断辅助ABP治疗决策；内镜逆行胰胆管造影（ERCP）是目前伴随胆管炎或者胆管梗阻的ABP首选治疗方式；EUS或ERCP下建立通道引流减压及后期内镜下清创可缓解胰周液体积聚和胰腺坏死所带来的严重并发症；腹腔镜下胆囊切除术可显著降低ABP的复发率；内镜下放置肠内营养管可保证ABP肠道屏障功能障碍的营养供给。随着内镜微创理念的普及、内镜微创技术的成熟、内镜器械的研发，有望建立内镜贯穿ABP诊治全过程的微创”升阶梯”治疗模式。     

超声内镜对胰腺癌的诊断与治疗进展

随着超声内镜仪的普及,内镜超声检查术(endoscopic ultrasonography,EUS)已成为诊断胰腺疾病的首选方法,尤其是EUS引导下FNA技术的应用极大地提高了胰腺肿瘤的诊断准确率,新型超声内镜仪及三维微型高频超声探头的应用提高了小胰癌的显示率.EUS已经历了3个重要阶段,即EUS诊断(EUS imaging);EUS穿刺活检(EUS-guided FNA);EUS注射治疗(EUS-guided fine needle injection,FNI),现在已进入介入性EUS(interveiltional EUS)时代.     

胆胰疾病的内镜治疗——胆胰疾病的内镜超声治疗

在过去的20年中，内镜超声(EUS)已从一种单纯的临床诊断方法发展为集诊断与介入治疗于一身的临床手段。EUS对胆胰疾病具有较高的诊断价值，其所具有的高分辨率图像，可以清晰地显示胆总管和胰腺的疾病，并可以在EUS的引导下，通过胃肠道对相应的病变以最短的距离进行精确的定位穿刺。正是EUS的这些独特优势，使其在胆胰疾病的治疗中起着重要作用。在EUS的引导下细针穿刺已广泛应用于胆胰疾病的引流治疗和注射治疗。     

超声内镜在胰腺恶性肿瘤诊断中的应用

超声内镜(endoscopic ultrasound,EUS)作为临床上的重要工具已经应用于胰腺肿瘤的诊断和治疗中。所谓超声内镜是指在内镜前端部安装有微型超声探头的特殊内镜。其分辨率高,可以清晰显示胃肠道壁的层次结构,并能观察临近周围脏器,如胰腺、胆道系统,淋巴结,左肾上腺及肝脏     

超声内镜检查在胰腺肿瘤诊断中的作用

在美国，胰腺癌在肿瘤病人死因中占第4位，从发现到死亡，如不进行治疗，一般只有4个月的时间。然而，大部分病人在诊断时已失去手术机会，只有不足20％病人可以手术。因此，早期发现、早期治疗是提高胰腺癌生存时间的关键所在。将超声内镜（endoscopic ultrasound，EUS）技术应用到胰腺疾病的诊断，使胰腺癌的早期诊断成为可能。超声内镜还可提供病理诊断，使胰腺疾病在手术前能有病理学诊断，是诊断上的一个飞跃。     

胆源性胰腺炎内镜治疗现状和发展趋势

急性胆源性胰腺炎（ABP）是急性胰腺炎的最主要类型,占急性胰腺炎50%以上。ABP以胆道疾病为诱发因素,其中胆道微结石是最常见的原因。鉴于消化内镜治疗在胆胰疾病中的广泛应用,其在ABP的诊疗全过程中所起的作用越来越重要。从内镜下辅助ABP治疗决策、ABP病因治疗、处理ABP并发症、预防ABP复发以及进行ABP肠道营养5方面对内镜治疗ABP进行剖析：超声内镜（EUS）可从病因诊断和预后判断辅助ABP治疗决策;内镜逆行胰胆管造影（ERCP）是目前伴随胆管炎或者胆管梗阻的ABP首选治疗方式;EUS或ERCP下建立通道引流减压及后期内镜下清创可缓解胰周液体积聚和胰腺坏死所带来的严重并发症;腹腔镜下胆囊切除术可显著降低ABP的复发率;内镜下放置肠内营养管可保证ABP肠道屏障功能障碍的营养供给。随着内镜微创理念的普及、内镜微创技术的成熟、内镜器械的研发,有望建立内镜贯穿ABP诊治全过程的微创”升阶梯”治疗模式。     

超声内镜在胆源性胰腺炎诊治中应用进展

随着内镜技术的发展和内镜医师操作经验的不断积累,超声内镜（EUS）已成为急性胆源性胰腺炎（ABP）诊治的重要手段,具有较高的敏感度、特异度和安全性。EUS可以减少诊断性内镜逆行胰胆管造影（ERCP）的需求,提高治疗性ERCP的成功率,降低并发症发生率。新的手术方法和新型的支架提高了EUS的治疗能力。对部分ERCP胆道引流失败的病例,EUS治疗也有一定优势。但是EUS也需要在提高成像能力、提高治疗能力、减少并发症、扩展应用人群、制定更详细科学的应用指征等方面取得更多进展。     

中国消化道黏膜下肿瘤内镜诊治专家共识（2018版）

正近年来,由于内镜检查的普及和内镜超声(endoscopic ultrasonography,EUS)技术的发展与成熟,消化道黏膜下肿瘤(submucosal tumor,SMT)的检出率大幅度提高。内镜下切除SMT因创伤小、并发症少、恢复快、费用低等优点受到广泛关注与认可,因此,在提高SMT检出率的基础上进行内镜下微创治疗,是改善SMT病人生活质量、减轻家庭和社会负担、节约国家医疗资源的有效途径。目前,国际上仅有美国消化内镜协会发布的《消化道上     

Utility of a linear array ultrasound endoscope in the evaluation of suspected pancreatic disease

Endoscopic ultrasonography (EUS) is currently being used to evaluate and stage pancreaticobiliary malignancies and neuroendocrine tumors, and to perform aspiration for cytologic diagnosis. There are currently two different commercially available EUS systems for clinical use. One system uses a mechanical radial sector scanner oriented in a plane perpendicular to the long axis of the endoscope, and the other uses an electronic convex scanner that is oriented in the long axis of the endoscope. The vast majority of the current literature reports experience using the radial scanning device in the evaluation of pancreaticobiliary abnormalities. We prospectively evaluated the linear probe as the sole instrument for EUS in 26 patients with suspected pancreatic disease. The results of the endoscopic ultrasound examination were compared with the results of surgery or long-term clinical follow-up. The sensitivity and specificity of linear array EUS for benign pancreatic disease were 93.8% and 88.2%, respectively. The sensitivity and specificity for malignant disease of the pancreas were 80.0% and 88.9%, respectively. The linear array echoendoscope, employed as the only instrument for evaluation of the pancreas, is accurate in the evaluation of pancreatic disease. The addition of EUS-guided pancreatic biopsy would be anticipated to improve the sensitivity of the linear array instrument for detecting malignancy. Presented in part at Digestive Disease Week, Boston, Mass., May 1994, and at the Ninth International Symposium on Endoscopic Ultrasonography, Bologna, Italy, December 1993.     

Pancreatic solid pseudopapillary tumours – EUS FNA is the ideal tool for diagnosis

Background: Solid pseudopapillary tumour (SPT) is a rare tumour of the pancreas with low malignant potential affecting mainly young women difficult to diagnose preoperatively. The aim of this study is to describe the endoscopic ultrasound (EUS) features and utility of EUS‐guided fine needle aspiration (FNA) in diagnosing these tumours. Methods: A retrospective analysis of SPTs identified in a tertiary institution EUS database between April 2002 and April 2009 was performed. Medical records, imaging, EUS features, cytology and histology specimens were reviewed. Patients were followed up until April 2009. Results: Seven cases of SPTs were indentified out of 2400 EUS performed. All patients were females with a mean age of 41 years (range 22–69). The tumours were solitary with a mean diameter of 2.9 cm (range 2–4.3 cm). Five tumours were located in the body and tail of the pancreas and two in the neck. All lesions were hypoechoic, heterogenous and well circumscribed, with five having a cystic component and two having a calcified rim. FNA using a 22‐gauge needle was performed in six cases with no complications. A preoperative diagnosis of SPT based on cytology was obtained in 5/6 cases (83%). Surgical resection was done in six cases with confirmation of SPT and no metastatic disease. Conclusion: EUS‐guided FNA is a minimally invasive, safe and reliable way of diagnosing SPT by providing characteristic cytological specimens. Definitive preoperative diagnosis leads to targeted and minimally invasive surgical resection.     

Impact of miniprobe ultrasonography on planning of minimally invasive surgery for gastric and colonic tumors

Background The use of minimally invasive procedures for the management of gastrointestinal cancer is increasing. The aim of this study was to investigate the role of high-frequency miniprobe endoscopic ultrasound (EUS) for therapeutic decisions making in patients with gastric or colonic tumors.Methods A total of 137 patients underwent EUS with a 12.5-MHz miniprobe for preoperative staging of tumors of the stomach (n = 49) or colon (n = 88). After resection, the surgical path was reviewed to analyze the role of preoperative staging with miniprobes.Results Miniprobe EUS enabled accurate assessment of the infiltration depth of gastric and colonic tumors. The overall accuracy rates were 88% and 87%, respectively. The lymph node status was predicted correctly in 82% of the patients (sensivity, 61%, specificity, 94%). Based on the results of miniprobe EUS, patients with gastric cancer were accurately selected to undergo endoscopic mucosal resection, laparoscopic resection, or open surgery in 100%, 91%, and 86% of the cases, respectively. In patients with colonic tumors, the treatment decision analysis showed that the stratification was correct in 90% of the patients.Conclusions Miniprobe EUS is a reliable method for validating treatment decisions for patients undergoing minimally invasive procedures for gastric and colonic tumors. This method is particularly valuable in the management of colon cancer, because endoscopic and laparoscopic resections can be offered to selected patients as an alternative to open surgery.     

Postnecrotic cysts of the pancreas: possible ways of minimally invasive external and internal drainage

The authors have shown a possibility of minimally invasive interventional surgery in treatment of postnecrotic cysts of the pancreas and their complications. The most optimal accesses for drainage of the cavities located inside the body and the pancreas head are determined. The use of the methods of internal drainage of the cyst cavity connected with the main pancreatic duct allowed avoidance of open operations. The results of antegrade percutaneous or transcavital as well as retrograde endoscopic restoration of the patency of the main pancreatic duct in treatment of the pancreatic cysts connected with the duct system are shown.     

全内镜下微创治疗颈神经根管狭窄的研究进展

目的综述全内镜下微创治疗颈神经根管狭窄(cervical nerve root canal stenosis,CNRCS)的研究进展。方法广泛查阅近年国内外相关文献,总结全内镜下微创治疗CNRCS的研究历史、现状、进展以及优缺点。结果随着近几年脊柱外科全内镜微创技术的不断发展,CNRCS手术治疗方法也不断革新。与传统开放手术比较,全内镜下微创治疗CNRCS在获得较好临床疗效的同时最大限度保留了术后颈段稳定性,减少了对颈椎活动度的影响以及相关手术并发症的发生,是一种有效的微创技术。结论全内镜下微创治疗CNRCS取得了一定效果,仍需完善,但其利远大于弊,有望成为治疗CNRCS不可或缺的手段之一。     

Therapeutic interventional endoscopic ultrasound in pancreato-biliary disorders: Does it really replace the surgical/percutaneous approach?

Pancreato-biliary disorders are still incredibly challenging in the field of gastroenterology, as they would sometimes require multi-approach interventional procedures. Recently, therapeutic interventional endoscopic ultrasound (EUS) has emerged as a potential alternative to surgical or percutaneous approaches. Unfortunately, considering the high cost of EUS, lack of facility and expertise, most gastroenterologists still often refer cases to undergo surgical interventions without contemplating the possibility of utilizing EUS first. EUS-guided biliary drainage has become one of the best choices for establishing access to biliary system, given the clear visualization of pancreas, gallbladder, and common bile duct. Although there are still only a few studies which directly compare EUS-guided and surgical approaches for biliary drainage, current evidence demonstrated the superiority of EUS-guided approach in terms of adverse events and re-intervention rates, with similarly high technical and clinical success rates compared to percutaneous and surgical approaches, especially in patients with history of failed endoscopic retrograde cholangiopancreatography attempt. Comparable success rates with shorter length of hospital stay between endoscopic and surgical approaches have also been exhibited for pancreatic pseudocysts and walled-off necrosis. Recent findings about the progress of EUS approach in gastroenterostomy/jejunostomy also indicated a promising potential of EUS, as a less invasive approach, for managing gastric outlet obstruction.     

Mucin secreting cystic lesions of the pancreas: treatment by enucleation

Ninety per cent of pancreatic cysts are inflammatory pseudocysts. The other 10 per cent are congenital or neoplastic and include congenital true cysts, retention cysts, lymphoepithelial cysts, the mucinous cystadenoma, mucinous cystadenocarcinoma, and serous microcystic cystadenomas and the more recently described intraductal papillary mucin-secreting neoplasms. The advent of computerized tomographic scanning, endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasonography (EUS) has brought many of these lesions to light when they are minimally symptomatic or are incidentally found while investigating unrelated problems. If there is any suspicion of actual or potentially malignant disease, then total excision of the lesion with part of or the entire pancreas is indicated to achieve a likely cure, as survival is better than for the more common ductal adenocarcinomas. There are few reliable preoperative studies to distinguish accurately the etiology and prognosis of this spectrum of cystic lesions, and usually the actual diagnosis is made only at the time of operation or histopathologic examination after the cystic lesion has been biopsied or excised. If a cyst is confirmed to be totally benign, as in the congenital true cyst, lymphoepithelial cyst, or a benign mucinous cyst, they may lend themselves to nonoperative observation or excision without sacrifice of pancreatic parenchyma. However, many mucin-producing cystic lesions may evolve into a dysplastic or invasive malignant lesion requiring more aggressive resective treatment, and it is important not to miss that diagnosis early when cure is still possible. This report presents four benign mucin-secreting cysts treated by local excision. All four were in the head of the pancreas and communicated with the main pancreatic duct and lacked ovarian-type stroma, thus categorizing them as side-branch intraductal papillary mucinous neoplasms. These lesions were able to be easily dissected out of the pancreas with only one patient developing a transient pancreatic fistula. Intraoperative and final histopathology confirmed the benign status, and these patients have remained disease free 3 to 5 years postoperatively. A review of benign tumors reported to have been treated by cyst enucleation in the literature confirms the rationale of this approach in highly selected lesions.     

�ھ�����������ͷ���׿����ϼ�ֵ

??Value of endoscopic ultrasonography in diagnozing the pancreatic head mass LI Zhao-shen, ZHAN Xian-bao.Department of Gastroenterology,Changhai Hospital, the Second Military Medical University,Shanghai 200433??China Corresponding author: LI Zhao-Shen, E-mail??zhsli1956@hotmail.com Abstract Common etiologies of pancreatic head mass include carcinoma,cystic lesions,inflammatory lesions and neuroendocrine tumours,etc. The value of traditional imaging modalities in diagnozing pancreatic head mass is limited. Using high frequency and short distance scanning techniqes, endoscopic ultrasound (EUS) can show the details of the mass. And also EUS-guided fine needle aspirations can acquire the specimen and establish pathological and cytologic diagnosis. Presently,EUS is prior to other imaging modalities in early diagnosis and preoperative evaluation of pancreatic carcinoma. There are special EUS features for chronic pancreatitis mass, autoimmune pancreatitis mass and cystic mass. EUS can also localize the pancreatic endocrine tumours accurately and acquire specimen preoperatively. A large amount of evidence confirmed that EUS had high accuracy and specificity in diagnozing pancreatic head mass.