EUS并ESD在直径≤1 cm的直肠神经内分泌肿瘤中的应用

[目的]回顾性分析超声内镜(EUS)并内镜黏膜下剥离术(ESD)在直径≤1 cm的直肠神经内分泌肿瘤(rNENs)中的应用价值。[方法]纳入经结肠镜及EUS检查诊断为rNENs、直径≤1 cm的68例患者行ESD治疗。[结果]ESD后病理检查结果示68例为神经内分泌肿瘤;免疫组化分型35例为G1型,无G2型;病理结果切缘报告63例切缘阴性,完整切除率为92.6%;肠镜随访未发现有复发病例。[结论]直径≤1 cm的rNENs患者经EUS评估后,行ESD剥离,具有较高的完整切除价值及较好的预后。     

内镜分片黏膜切除术及黏膜下剥离术治疗十二指肠非壶腹部较大占位的临床观察

目的 评估内镜分片黏膜切除术（endoscopic piecemeal mucosal resection,EPMR）及内镜黏膜下剥离术（endocopic submucosal dissection, ESD）治疗十二指肠非壶腹部较大占位性病变（直径≥10～15 mm）的疗效和安全性。方法 2013年2月至2018年8月,因十二指肠非壶腹部较大占位性病变,在首都医科大学附属北京友谊医院消化分中心接受EPMR或ESD治疗的21例病例纳入回顾性分析,按治疗方式分成EPMR组（n=13）和ESD组（n=8）,主要总结各组的手术时间、手术的病理组织学评价和并发症发生情况等。结果 EPMR组13例病变均起源于黏膜层,内镜下病灶最大直径（22±12）mm,中位手术时间39.0（23.0,45.0）min,12例使用钛夹封闭创面,切除病理最大直径（26±15）mm,胃黏膜异位2例、低级别上皮内瘤变7例、高级别上皮内瘤变4例,水平切缘阳性5例（低级别上皮内瘤变）,2例发生并发症,其中1例围手术期菌血症经抗感染治疗后好转,1例为术中穿孔内镜下治疗不佳转外科急诊开腹行修补术。ESD组病变起源于黏膜层6例、黏膜下层2例,内镜下病灶最大直径（17±5）mm,中位手术时间47.5（34.0,68.0）min,8例均使用钛夹封闭创面,切除病理最大直径（20±7）mm,低级别上皮内瘤变3例、高级别上皮内瘤变3例、淋巴管瘤和囊肿各1例,8例水平切缘阴性,1例垂直切缘存在可疑低级别上皮内瘤变未能达到完全切除,3例发生并发症（围手术期出现穿孔）,其中1例行内镜下治疗后好转出院,1例内镜下治疗不佳转外科手术,1例来源于黏膜下层的病变较大（16 mm）行腹腔镜下十二指肠修补术。结论 对于十二指肠非壶腹部较大占位性病变（直径≥10～15 mm）,初步证实EPMR和ESD治疗均安全、有效,值得临床进一步研究。     

内镜黏膜下剥离术切除原发性早期十二指肠癌9例（含视频）

目的探讨内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗原发性早期十二指肠癌的安全性、有效性。方法采集2018年1月—2019年1月山东第一医科大学第一附属医院内镜诊疗科发现并ESD切除的非十二指肠乳头的原发性早期十二指肠癌患者9例临床资料,观察ESD治疗该类疾病的疗效。结果9例患者病变长径（1.01±0.63）cm（0.3~2.5 cm）,切除标本长径（2.27±0.65）cm（1.2~3.2 cm）,手术时间（61.6±27.5）min（36~108 min）。9例病变均一次性整块切除,其中2例术中发生穿孔,均成功闭合。患者术后均无并发症。术后病理证实9例病变均完整切除,切缘阴性。结论ESD治疗原发性早期十二指肠癌安全、有效。     

胃肠神经内分泌肿瘤内镜表现及内镜下治疗效果分析

目的 探讨胃肠神经内分泌肿瘤的超声内镜表现及内镜下治疗效果。 方法 纳入在西安交通大学第一附属医院行内镜下治疗的27例胃肠神经内分泌肿瘤患者资料，回顾性分析其临床特征、超声内镜表现、病理特征及内镜下治疗效果。 结果 27例患者的病变内镜下表现为黏膜下隆起，超声内镜检查示病变长径（0.69±0.44）cm（0.32~2.00 cm），来源于黏膜下层14例（51.9%）、黏膜肌层8例（29.6%）、黏膜层5例（18.5%），诊断准确率92.0%。行内镜黏膜切除术（endoscopic mucosal resection,EMR）6例，内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）21例，ESD术后出血发生率4.8%。术后病理为G1级20例（74.1%），G2级6例（22.2%），G3级伴淋巴管癌栓1例（3.7%）。术后随访3~36个月总生存率96.3%，对于局限于黏膜下层以内、无脉管浸润的G1、G2级神经内分泌瘤患者，EMR术后复发率较ESD高（33.3%比0，P=0.042）；EMR与ESD术后出血、穿孔并发症及患者生存率差异无统计学意义。 结论 超声内镜可用于胃肠神经内分泌肿瘤的术前诊断，对2 cm以内、黏膜下层以内、无脉管浸润的G1、G2级胃肠神经内分泌瘤ESD治疗复发率低于EMR。     

十二指肠非壶腹部神经内分泌肿瘤内镜下切除的回顾性研究

目的 评价内镜超声检查术（EUS）判断十二指肠非壶腹部神经内分泌肿瘤大小和浸润深度的准确性，并对比内镜黏膜下剥离术（ESD）和改良ESD治疗十二指肠非壶腹部神经内分泌肿瘤的有效性和安全性。方法 以2007年1月至2018年1月于中国人民解放军总医院接受ESD（ESD组）或改良ESD（改良ESD组）治疗的22例十二指肠非壶腹部神经内分泌肿瘤患者为研究对象，回顾性纳入患者临床资料。22例患者中，13例行ESD,9例行改良ESD。对比分析ESD组和改良ESD组整块切除率、R0切除率、手术时间、手术相关并发症发生率等指标。以术后病理结果为金标准，评估术前EUS判定病变大小和浸润深度的准确率。结果 22例十二指肠非壶腹部神经内分泌肿瘤大小为（6.9±1.5）mm。与术后组织病理学结果相对照，内镜超声评估病变浸润深度的准确性为95.5%（21/22）。ESD组和改良ESD组的R0切除率分别为13/13和7/9（100.0% 比77.8%, P=1.000）。改良ESD组在手术时间上显著短于ESD组[（16.0±2.2） min 比 （29.8±4.9）min，P<0.001]。ESD组发生1例术中穿孔和1例迟发穿孔，改良ESD组发生1例迟发出血。术后22例患者均成功进行了随访，随访时间为(30.0±24.8)个月。随访期间无患者发生局部复发或者远处转移。结论 内镜超声可以准确评价十二指肠非壶腹部神经内分泌肿瘤的大小和浸润深度。对于直径≤10 mm，浸润深度局限在黏膜下层的十二指肠非壶腹部神经内分泌肿瘤，改良ESD可以获得与ESD相当的临床治疗效果。     

直径≤1 cm的直肠神经分泌肿瘤2种内镜治疗方法的比较

目的 ：比较无黏膜下注射的结扎装置辅助黏膜下组织切除术（endoscopic submucosal resection with ligation, ESMR-L）和内镜黏膜下剥离术（endoscopic submucosal dissection, ESD）治疗直径≤1 cm的直肠神经内分泌肿瘤（neuroendocrine tumor, NET）的有效性及安全性。方法：前瞻性研究2020年10月至2021年10月期间在上海交通大学医学院附属瑞金医院接受内镜治疗的42例直径≤1 cm直肠NET患者,随机化入无黏膜下注射的ESMR-L组和ESD组,分别治疗21个病灶,比较2种内镜治疗方法的平均手术时间、病灶切缘、组织学完整切除率以及肿瘤下缘与垂直切缘距离等临床病理学特点。结果：无黏膜下注射ESMR-L组的手术时间明显短于ESD组[（10.10±1.37） min比（29.90±3.81） min,P<0.001];2组侧切缘及垂直切缘均为阴性,组织学完整切除率均为100%,差异无统计学意义（P>0.05）;无黏膜下注射ESMR-L组的肿瘤下缘到垂直切缘的距离明显长于ESD组...     

内镜超声在结直肠黏膜下隆起性病变的应用分析

目的探讨超声内镜检查术（endoscopic ultrasonography,EUS）在结直肠黏膜下隆起性病变的应用价值,为临床诊疗策略提供依据。方法回顾性分析2015年10月—2019年10月天津市人民医院电子结肠镜检查发现并经EUS及手术切除后病理学确诊的229例结直肠黏膜下隆起性病变患者资料,分析病变的位置分布、种类、EUS特征及EUS初步诊断与病理诊断符合情况。结果病变部位以直肠[44.98%(103/229）]、升结肠[15.28%(35/229）]常见。病理结果显示病变以脂肪瘤最常见[34.93%（80/229）],部位以横结肠[22.50%（18/80）]、升结肠[20.00%（16/80）]为主;其次为神经内分泌瘤[33.63%（77/229）],部位以直肠[96.10%（74/77）]为主;再次为囊肿[18.78%（43/229）]。EUS下229例病变起源于黏膜下层215例,黏膜肌层11例,固有肌层3例。EUS诊断与病理结果整体诊断符合率为89.08%（204/229）,EUS诊断符合率脂肪瘤为100.00%（80/80）、气囊肿为5/5、间质瘤为3/3、神经内分泌瘤为81.82%（72/88）、囊肿为89.13%（41/46）、平滑肌瘤为1/4、淋巴管瘤为2/5,颗粒细胞瘤、神经纤维瘤均为0。结论EUS对结直肠黏膜下病变的起源层次、回声特点及病变性质等具有较准确的诊断,但对颗粒细胞瘤及神经纤维瘤等少见肿瘤的诊断具有一定局限性。     

内镜黏膜下剥离术治疗≥20 mm结直肠肿瘤的临床结局分析

目的 探讨大的结直肠肿瘤经内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗的结局,并分析影响ESD疗效的因素。方法 从2016年11月—2019年12月在北京医院消化内科行ESD治疗的结肠肿瘤患者中,筛选出病变长径≥20 mm、活检病理为结直肠腺瘤或腺癌的患者共82例,收集分析患者的临床特点、ESD及病理结果等资料。结果 82例患者病变均为单发,病变长径（29.72±10.74）mm,分为侧向发育型肿瘤（laterally spreading tumors,LST）组46例,主要位于升结肠及回盲部（47.8%,22/46）;腔内突出型肿瘤组36例,病变均位于左半结肠,其中约一半位于乙状结肠（52.8%,19/36）。总体的整块切除率81.7%(67/82),治愈性切除率72.0%(59/82),出血和穿孔的发生率分别为2.4%(2/82)和1.2%(1/82)。LST-G、LST-NG、腔内突出型肿瘤3组的治愈性切除率[91.4%(32/35)、63.6%(7/11)、55.6%(20/36),P=0.003]和外科手术率[8.6%(3/35)、18.2%(2/11)和36.1%(13/36),P=0.010]差异均有统计学意义。多因素回归分析结果显示,病变形态为腔内突出型肿瘤(OR=3.396,95%CI：1.014～11.374,P=0.047)和黏膜下层重度纤维化（F2型）(OR=5.508,95%CI：2.216～13.692,P=0.001)是长径≥20 mm结直肠肿瘤ESD非治愈性切除的独立危险因素。结论 ESD治疗长径≥20 mm的结直肠肿瘤总体有效、安全,但不同类型病变的黏膜下侵犯比例和治疗结局存在一定差异,腔内突出型肿瘤和严重的黏膜下层纤维化是造成非治愈性切除的危险因素。     

透明帽辅助的内镜黏膜下切除术与内镜黏膜下剥离术治疗直肠神经内分泌肿瘤效果的回顾性分析

目的回顾性分析透明帽辅助的内镜黏膜下切除术(endoscopic mucosal resection with a cap,EMR-C)及内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗直肠神经内分泌肿瘤(neuroendocrine tumors,NETs)的效果差异。方法收集2012年1月至2016年12月在解放军第306医院接受EMR-C(27例)或ESD(15例)治疗的42例直肠NETs患者。分析两组患者在整块切除率、病理完整切除率、根治性切除率、手术时间、并发症、随访复发率等方面的差异。结果 EMR-C组和ESD组的肿瘤平均大小分别为(5.1±1.2)mm和(6.8±2.1)mm(P=0.013),整块切除率分别为92.6%和100%(P=0.280),水平切缘阳性均为0,垂直切缘阳性率分别为11.1%和13.3%(P=0.831),脉管浸润率分别为0和6.7%(P=0.174),根治性切除率分别为81.5%和80.0%(P=0.907),手术时间分别为(5.83±1.32)min和(31.43±8.12)min(P0.001),并发症发生率分别为7.4%和13.3%(P=0.531),随访均未见局部复发及转移。结论 EMR-C是一种简单、安全、有效的直肠NETs内镜治疗方法。     

下咽部早癌及癌前病变内镜黏膜下剥离术治疗的可行性研究（含视频）

目的 评价内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗下咽早癌及癌前病变的价值。方法 回顾性分析浙江省肿瘤医院自2015年9月至2017年9月行ESD治疗的11例下咽病变的临床资料。结果 所有患者均顺利完成ESD治疗,平均手术时间为（70.1±23.1）min。围手术期并发症发生率为27.3%（3/11)。病灶平均长度为2.1±0.6cm,整块切除率为100%,完整切除率为92.3%(10/11)。下咽病变4例为癌前病变（36.3%）,6例为原位癌（54.5%）,1例为中分化鳞癌,浸润至黏膜下层。除1例切缘阳性患者外,其余患者术后2～26个月的随访期间未发现原位复发。结论 ESD治疗下咽早癌及癌前病变技术上是可行的。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.