胃肠道间质瘤治疗新方法的探讨

目的探讨胃镜与腹腔镜双镜联合、内镜黏膜下挖除术(endoscopic submucosal excavation,ESE)及内镜黏膜下隧道肿瘤切除术(submucosal tunneling endoscopic resection,STER)治疗胃肠道间质瘤(GIST)的效果和安全性。方法经胃(肠)镜、超声内镜及病理学、免疫组化证实GIST患者86例,对其中53例患者采用ESE、29例患者采用胃镜与腹腔镜双镜联合、4例患者采用STER法进行瘤体切除。结果 ESE、双镜联合及STER治疗的所有患者均完整切除瘤体,术后风险评估极低危56例、低危17例、中危8例、高危5例。三种方法均无术中及术后迟发性出血、剧烈腹痛等并发症,瘤体位于贲门者切除后患者贲门功能保持良好,术后随访无反流性食管炎等并发症。术后随访有1例中危GIST患者因术后未服用格列卫发生盆腔转移,其他患者无远处转移及复发。结论胃镜与腹腔镜双镜联合技术、ESE及STER是治疗胃肠道间质瘤的微创、安全、有效的新方法。     

消化道黏膜下肿物内镜下切除及其并发症防治

目的探讨消化道黏膜下肿物(gastrointestinal submucosal tumor,SMT)的内镜下切除方法及其并发症的防治。方法对382例SMT采用内镜黏膜下挖除术(ESE)、胃镜与腹腔镜双镜联合、内镜黏膜下隧道肿瘤切除术(STER)以及内镜全层切除术(EFTR)进行肿物切除。结果 ESE切除332例,胃镜与腹腔镜双镜联合切除36例(其中20例为腹腔镜为主内镜辅助腹腔镜治疗,16例为瘤体较大,与浆膜层分界不清,单独内镜下挖除瘤体困难,术中转外科腹腔镜与胃镜双镜联合治疗),STER切除10例,EFTR切除4例。术中穿孔24例,其中内镜下瘤体剥离后发生胃壁穿孔转外科腹腔镜下缝合穿孔7例、内镜下尼龙绳荷包缝合9例、内镜下钛夹缝合6例、内镜下OTSC金属夹闭合器达到严密缝合2例。术后发生迟发性出血1例。术后感染1例。无死亡病例发生。结论 ESE、胃镜与腹腔镜双镜联合、STER以及EFTR是目前切除SMT微创、有效、安全、可行的方法。穿孔是其主要并发症,大多数穿孔可在内镜下达到严密缝合。     

胃肠道间质瘤治疗新方法的探讨

目的探讨胃镜与腹腔镜双镜联合及内镜黏膜下挖除术(endoscopic submucosal excavation,ESE)治疗胃肠道间质瘤的效果和安全性。方法经胃(肠)镜、超声内镜及病理学、免疫组化证实的胃肠道间质瘤患者37例,对其中28例患者采用ESE、9例采用胃镜与腹腔镜双镜联合进行瘤体切除。结果 ESE及双镜联合治疗的所有患者均完整切除瘤体,两种方法均无术中及术后迟发性出血、剧烈腹痛等并发症,瘤体位于贲门者,切除后患者贲门功能保持良好,术后随访无复发。结论胃镜与腹腔镜双镜联合技术及ESE是治疗胃肠道间质瘤的微创、安全、有效的新方法。     

食管下段及食管胃连接处黏膜下肿物内镜经黏膜下隧道肿瘤切除术的疗效分析

目的比较内镜经黏膜下隧道肿瘤切除术(submucosal tunnelling endoscopic resection,STER)与内镜黏膜下肿物挖除术(endoscopic submucosal excavation,ESE)治疗食管下段及食管胃连接处(esophagogastric junction,EGJ)黏膜下肿物的疗效及安全性。方法 2015年7月至2016年12月,武汉大学人民医院内镜中心共对23例发现食管下段及EGJ黏膜下肿物患者进行了STER治疗,选取同时段23例行ESE的病例作为对照组。回顾性分析其临床资料,对比分析两组的手术特点及术后并发症情况。结果两组患者黏膜下肿物均完全切除,STER组肿物面积、肿物直径均较ESE组更大,但STER组术后住院时间较ESE组更短,肿物单位面积手术费用较ESE组低,差异均有统计学意义(P0.05)。STER组患者中有1例患者出现纵膈积气及术后发热,ESE组中有1例患者出现术后发热,均经保守治疗后好转。两组患者均无术后迟发型出血、穿孔、局部病灶复发。结论 STER相较ESE在治疗食管下段及EGJ部黏膜下肿物更加经济和高效。     

经内镜黏膜下隧道技术切除食管神经鞘瘤1例

最常见的食管肿瘤为食管癌,食管良性原发性肿瘤很少见,约占所有食管肿瘤的2%。食管良性肿瘤80%以上为平滑肌瘤,神经鞘瘤罕见。现报道兰州军区总医院采用内镜黏膜下隧道技术(submucosal tunneling endoscopic resection,STER)切除食管肿物1例,经病理证实为食管神经鞘瘤。     

消化道黏膜下肿物在超声内镜下的表现特征

目的观察消化道黏膜下肿物在超声内镜下的表现特征。方法对2014年1月至2016年3月我院114例消化道黏膜下肿物患者的临床资料进行回顾性分析,所有入选对象均采用超声内镜检查,观察黏膜下肿物在超声内镜下的影像学特征。结果检出的黏膜下肿物包括平滑肌瘤(35例)、胃肠道间质瘤(29例)、脂肪瘤(20例)、类癌(12例)、异位胰腺(8例)、神经鞘瘤(4例)、错构瘤(4例)、血管球瘤(2例);超声内镜诊断符合例数为97例,总诊断符合率为85.96%。其中对平滑肌瘤(94.29%)、胃肠道间质瘤(93.10%)、脂肪瘤(100.00%)、类癌(75.00%)、异位胰腺(75.00%)、血管球瘤(100.00%)均具有较高的诊断率,而对神经鞘瘤(25.00%)和错构瘤(0.00%)诊断符合率相对较低。结论各种消化道黏膜下肿物在超声内镜下具有不同的表现特征,对消化道黏膜下肿物的鉴别及治疗方法的选择具有指导意义。     

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。     

隧道内镜治疗食管固有肌层肿瘤8例

随着内镜诊疗技术的发展,尤其是内镜超声检查术(EUS)和内镜黏膜下剥离术(ESD)的广泛应用,消化道黏膜下肿瘤的内镜诊治水平得到了明显提高,治疗方法主要有内镜黏膜下挖除术(ESE)、内镜下肿瘤全层切除术(EFR)等[1-2].近来还出现了经口内镜肌切开术(POEM),用于治疗贲门失弛缓症[3].我们在上述治疗技术的基础上,对源于食管固有肌层肿瘤采用经内镜黏膜下隧道肿瘤切除术(submucosal tunelling endoscopic resection,STER)进行内镜下切除治疗,取得了较好的疗效,现报道如下.     

超声内镜对上消化道黏膜下肿瘤的诊断价值

目的探讨超声内镜(endoscopic ultrasonography,EUS)对上消化道黏膜下肿瘤(submucosal tumor,SMT)的诊断价值。方法分析经内镜治疗的上消化道SMT 132例的术后病理结果及术前EUS诊断,通过比较术前EUS诊断与术中所见及术后病理结果,评价EUS对SMT起源层次及性质的诊断价值。结果 (1)132例SMT,术后病理示间质瘤57例,平滑肌瘤46例,脂肪瘤10例,异位胰腺9例,囊肿5例,血管瘤3例,神经内分泌瘤2例。(2)EUS诊断共有12例与病理诊断不符,其中有4例间质瘤(3例误诊为平滑肌瘤,1例误诊为异位胰腺);6例平滑肌瘤(3例误诊为间质瘤,误诊为脂肪瘤、异位胰腺、囊肿各1例);1例囊肿误诊为血管瘤;1例神经内分泌瘤误诊为间质瘤。(3)根据病变临床特点及EUS表现分别予以EMR(42例)、ESD/ESE(66例)、EFR(7例)、STER(16例)、EMBM(1例)微创治疗,术后无出血、感染等并发症。所有病例随访3个月~3年复查胃镜示恢复良好,未见局部复发及远处转移。结论 (1)EUS能清晰显示SMT起源层次及与周围组织的关系。(2)EUS诊断与术后病理诊断有较高的符合率。     

隧道内镜技术联合胸腔镜治疗食管多发平滑肌瘤一例

近年来,内镜微创技术飞速发展,内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)及其衍生技术——内镜黏膜下挖除术(endoscopic submucosa exavaton,ESE)、无腹腔镜辅助的内镜消化道管壁全层切除术(endoscopic full-thickness resection,EFR)和隧道内镜技术(tunnelling endoscopic technique)的治疗范围已从黏膜病变扩展到固有层肿瘤,使大量患者免受了外科手术之苦.但对于消化道壁巨大的或者向腔外生长的黏膜下肿瘤( SMTs),单纯内镜治疗风险较大,联合腹腔镜治疗的双镜联合技术应运而生.我院内镜中心在既往与普外科合作开展腹腔镜联合内镜治疗胃肠肿瘤技术成熟的基础上,近期与胸外科合作,行胸腔镜联合内镜治疗食管来源于固有肌层多发平滑肌瘤1例,取得了很好的疗效.本例中内镜下的手术采用的是隧道内镜技术,保证了手术区食管黏膜的完整性,避免了常规胸腔镜手术较易出现的黏膜破损而致术后瘘的并发症,国内外鲜见类似报道.     

Novel image-enhanced endoscopy with i-scan technology

i-scan technology is the newly developed imageenhanced endoscopy technology from PENTAX,Japan.This consists of three types of algorithms:surface enhancement (SE),contrast enhancement (CE),and tone enhancement (TE).SE enhances light-dark contrast by obtaining luminance intensity data for each pixel and applying an algorithm that allows detailed observation of a mucosal surface structure.CE digitally adds blue color in relatively dark areas,by obtaining luminance intensity data for each pixel and applying an algorithm that allows detailed observation of subtle irregularities around the surface.Both enhancement functions work in real time without impairing the original color of the organ,therefore,SE and CE are suitable for screening endoscopy to detect gastrointestinal tumors at an early stage.TE dissects and analyzes the individual RGB components of a normal image.The algorithm then alters the color frequencies of each component and recombines the components to a single,new color image.This is designed to enhance minute mucosal structures and subtle changes in color.TE works in real time and consists of three modes such as TE-g for gastric tumors,TE-c for colonic tumors,and TE-e for esophageal tumors.TE is suitable mainly for detailed examination of the lesions that are detected in a screening endoscopy.i-scan technology leads us to easier detection,diagnosis and treatment of gastroi ntestinal diseases.     

上消化道间叶源性肿瘤临床病理特征46例

目的:观察上消化道间叶源性肿瘤(GIMTs)的临床病理及免疫组化特征,探讨其临床诊断及处置策略.方法:46例内镜超声检查拟诊为上消化道间质瘤的病例,采用光镜观察其手术或黏膜切除术(EMR)标本的病理特征,免疫组化检测其CD117,CD34,平滑肌抗体(SMA)和S-100的表达状况,并分析其病理诊断与临床的关系.结果:46例GIMTs中食管肿瘤占24例,其中间质瘤5例(20.8%),平滑肌瘤19例(79.2%);22例胃GIMTs中间质瘤20例(90.9%),平滑肌瘤1例,神经鞘瘤1例.25例上消化道间质瘤中CD117阳性21例(84%)、CD34阳性24例(96%).而平滑肌瘤与神经鞘瘤分别仅表达SMA和S-100.结论:上消化道间叶源性肿瘤光镜下病理特征相似,联合检测CD117,CD34,SMA和S-100等免疫组化标记物可区别上消化道GIMTs.在食管以平滑肌瘤多见;而在胃则以间质瘤多见,平滑肌瘤与神经鞘瘤非常少见.     

A typical presentation of a rare cause of obscure gastrointestinal bleeding

A 52-year-old white woman had suffered from intermittent gastrointestinal (GI) bleeding for one year. Upper GI endoscopy, colonoscopy and peroral doubleballoon enteroscopy (DBE) did not detect any bleeding sour ce, suggesting obscure GI bleeding. However, in video capsule endoscopy a jejunal ulceration without blee ding signs was suspected and this was endoscopically conf irmed by another peroral DBE. After transfusion of packed red blood cells, the patient was discharged from our hospital in good general condition.Two weeks later she was readmitted because of another episode of acute bleeding. Multi-detector row computed tomography with 3D reconstruction was performed revealing a jejunal tumor causing lower gastrointestinal bleeding. The patient underwent exploratory laparotomy with partial jejunal resection and end-to-end jejunostomy for reconstruction. Histological examination of the specimen confirmed the diagnosis of a low risk gastrointestinal stromal tumor (GIST). Nine days after surgery the patient was discharged in good health. No signs of gastrointestinal rebleeding occurred in a followup of eight months. We herein describe the comp lex presentation and course of this patient with GIST and also review the current approach to treatm ent.     

Localized intra-abdominal fibromatosis of the small bowel mimicking a gastrointestinal stromal tumor： A case report

Intra-abdominal fibromatosis (IAF) is a benign mesenchymal lesion that can occur throughout the gastrointestinal tract. Although rare, it is the most common primary tumor of the mesentery and can develop at any age. We describe a rare case of primary IAF involving the mesentery and small bowel which clinically, macroscopically and histologically mimicked malignant gastrointestinal stromal tumor (GIST). This report highlights the fact that benign IAF can be misdiagnosed as a malignant GIST localized in the mesentery or arising from the intestinal wall. Their diagnostic discrimination is essential because of their very different biological behaviors and the fact that the introduction of effective therapies involving tyrosine kinase inhibitor STI571 (imatinib mesylate) has greatly changed the clinical approach to intra-abdominal stromal spindle cell tumors.     

Synchronous incidental gastrointestinal stromal and epithelial malignant tumors

AIM： To investigate the incidence of incidental gastrointestinal stromal tumor （GIST） and its etiopathogenesis. METHODS： From January 1, 2000 to December 31, 2007, 13804 cases of gastrointestinal epithelial malignant tumor （EMT） and 521 cases of pancreatic adenocarcinoma （PAC） were successfully treated with surgery at the Department of General Surgery and the Department of Thoracic Surgery, West China Hospital, Sichuan University, China. The clinical and pathologic data of 311 cases of primary GIST, including 257 cases with clinical GIST and 54 cases of incidental GIST were analyzed. RESULTS： Of the 311 patients, 54 had incidental GIST, accounting for 17.4%. Of these tumors, 27 were found in 1.13% patients with esophageal squamous cell carcinoma （ESCC）, 22 in 0.53% patients with gastric adenocarcinoma （GAC）, 2 in 0.38% patients with PAC, 2 in 0.03% patients with colorectal adenocarcinoma, and 1 in one patient with GAC accompanying ESCC, respectively. Patients with incidental GIST presented symptoms indistinguishable from those with EMT. All incidental GIST lesions were small in size, and the majority had a low mitotic activity while only 1.9% （5/257） of clinical GIST lesions had a high risk.CONCLUSION： Incidental GIST may occur synchronously with other tumors and has a high prevalence in males. Surgery is its best treatment modality.     

胃肠道间质瘤4例报道

间质瘤主要发生在胃肠道,指在光镜下主要由梭形细胞和上皮样细胞构成,某些免疫组化阳性的肿瘤。本文对4例胃肠道间质瘤手术病人的临床表现、影像学特点、肿瘤大小等进行总结。     

Advancements in the Diagnosis of Gastric Subepithelial Tumors

A diagnosis of subepithelial tumors (SETs) is sometimes difficult due to the existence of overlying mucosa on the lesions, which hampers optical diagnosis by conventional endoscopy and tissue sampling with standard biopsy forceps. Imaging modalities, by using computed tomography and endoscopic ultrasonography (EUS) are mandatory to noninvasively collect the target’s information and to opt candidates for further evaluation. Particularly, EUS is an indispensable diagnostic modality for assessing the lesions precisely and evaluating the possibility of malignancy. The diagnostic ability of EUS appears increased by the combined use of contrast-enhancement or elastography. Histology is the gold standard for obtaining the final diagnosis. Tissue sampling requires special techniques to break the mucosal barrier. Although EUS-guided fine-needle aspiration (EUS-FNA) is commonly applied, mucosal cutting biopsy and mucosal incision-assisted biopsy are comparable methods to definitively obtain tissues from the exposed surface of lesions and seem more useful than EUS-FNA for small SETs. Recent advancements in artificial intelligence (AI) have a potential to drastically change the diagnostic strategy for SETs. Development and establishment of noninvasive methods including AI-assisted diagnosis are expected to provide an alternative to invasive, histological diagnosis.     

53例胃肠道间叶性肿瘤内镜特点及病理研究

目的 观察53例胃肠道间叶性肿瘤的内镜和病理特点,加强对间叶性肿瘤的鉴别诊断.方法 收集53例胃肠道间叶性肿瘤患者的影像、病理资料,并完成CD117、CD34、SMA和Desmin的免疫组化检查,分析胃肠道间叶性肿瘤的临床、内镜、病理和免疫组化特征.结果 间质瘤和平滑肌源性肿瘤在内镜超声中有一定的影像学特点;胃和食管发生间质瘤和平滑肌瘤比例高于消化道其他部位,分别为64.71%和68.42%;间质瘤中CD117和CD34为弥漫性阳性表达,SMA和Desmin阳性表达率较低,但在小肠病例中SMA表达较CD34高;平滑肌源性肿瘤中SMA和Desmin呈弥漫阳性表达,而CD117和CD34的表达显著低于间质瘤;同时根据相关性分析证实,Desmin阴性对间质瘤的诊断意义增强,CD117和CD34阴性有利于平滑肌瘤的诊断.结论 内镜超声检查结合CD117、CD34、SMA和Desmin的联合检测可以提高对梭状细胞形态的间叶性肿瘤的诊断准确性.     

A gastrointestinal stromal tumor of the duodenum masquerading as a pancreatic head tumor

Gastrointestinal stromal tumor （GIST） represents the most common kind of mesenchymal tumor that arises from the alimentary tract. GIST is currently defined as a gastrointestinal tract mesenchymal tumor showing CD117 （c-kit protein） positivity at immunohistochemistry. Throughout the whole length of the gastrointestinal tract, GIST arises most commonly from the stomach followed by the small intestine, the colorectum, and the esophagus. Only 3%-5% of GISTs occur in the duodenum, and especially, if GIST arises from the C loop of the duodenum, it can be difficult to differentiate from the pancreas head mass because of its anatomical proximity. Here, we report a case of duodenal GIST, which was assessed as a pancreatic head tumor preoperatively.     

Thy-1 as a potential novel diagnostic marker for gastrointestinal stromal tumors

Purpose Only few immunohistochemical markers besides c-kit exist for gastrointestinal stromal tumors (GISTs). Thy-1, a cell-surface glycoprotein, is a marker for several types of stem cells and particularly for neuronal precursor cells. The aim of this study was to determine Thy-1 expression in GISTs. Materials and methods Fifty-seven surgically resected and paraffin-embedded GIST samples were analyzed by immunohistochemistry with peroxidase method for Thy-1 molecule. Results Thy-1 was detected in the majority of 57 GIST samples (54 out of 57 patients, 95%). All samples were c-kit positive and 90% were CD34 positive. All three Thy-1 negative samples were CD34 positive, had a low proliferative index (Ki-67 ≤ 10%) and were located in the upper gastrointestinal tract (one in esophagus and two in the stomach). As a tendency, Thy-1 negative patients had a better prognosis, although not reaching level of significance due to low numbers. Conclusions Thy-1 is expressed in the majority of GISTs, suggesting a novel, additional standard marker for identifying GIST. Future studies should focus on the role of Thy-1 in the pathogenesis of GIST and subsequently on its potential to act as a molecular target for adjuvant therapy with new molecular antitumor agents. Financial support for this study was provided by research grants from the Hamburger Krebsgesellschaft e. V. (J.T.K., E.F.Y., J.R.I.).