经内镜切除或手术治疗后早期结直肠癌的病理分析和疗效评价

背景:早期结直肠癌因淋巴结转移率低而预后良好,如何提高其检出率并选择合理的治疗方式是亟待解决的临床问题。目的:分析早期结直肠癌在内镜切除或手术后的病理特点,评价内镜切除的疗效。方法:回顾性分析503例接受内镜切除或外科手术的早期结直肠癌病灶的病理资料,分析影响早期结直肠癌浸润深度、淋巴结转移的危险因素,并评价内镜切除的疗效。结果:早期结直肠癌的检出率为10.7%,淋巴结总转移率为1.2%(6/503),其中黏膜高级别瘤变的淋巴结转移率为0%(0/247),黏膜下层癌为2.3%(6/256);内镜切除组黏膜下浅层癌的淋巴结转移率为0%(0/31)。肿瘤位置、肿瘤直径、组织学分型和淋巴结转移对早期结直肠癌的浸润深度有显著影响(P0.05)。内镜切除组病灶的整块切除率为96.0%,完全切除率为94.2%,治愈性切除率为82.1%。浸润深度是导致分块切除、不完全切除以及非治愈性切除的危险因素(P0.05)。结论:早期结直肠癌的淋巴结转移率极低,术前充分判断病灶的性质和浸润深度,有助于选择更为合理的治疗方式。对可能浸润至黏膜下层的病灶行内镜切除应更为慎重,以期提高内镜切除的疗效。     

内镜黏膜下剥离术诊治高度可疑结直肠癌或癌前病变及共聚焦激光显微内镜在随访中的价值

目的探讨内镜黏膜下剥离术(Endoscopic submucosal dissection,ESD)治疗和诊断高度可疑或早期结直肠癌和癌前病变的有效性和安全性,比较整块活检病理与内镜活检病理对早期癌诊断意义及共聚焦激光显微内镜在随访中的价值。方法对于内镜下高度可疑早期结直肠癌或早期结直肠癌及癌前病变的19例患者行ESD治疗,术后评价ESD治疗相关的一次性整块切除率、组织学治愈性切除率、手术并发症;比较术后整块病理与术前内镜活检诊断符合率;在术后随访时用共聚焦激光显微内镜检查(1、3个月)以指导活检并观察局部复发情况。结果 19处病灶一次性整块切除率为94.7%(18/19),组织学治愈性切除率为84.2%(16/19);病变平均大小(2.3±0.5)cm,平均手术时间(70±19.4)min;术后腹痛2例,延迟性出血1例,内镜下钛夹止血成功,其余病例未发生急性或延迟性出血以及穿孔;术后病理:黏膜内癌7例,癌前病变10例,黏膜下癌2例,其中2例黏膜下癌均进一步补充开腹手术,术后切除病变肠段未发现癌组织残留和周边淋巴结转移;所有病例术后平均随访(24.6±8.0)个月,局部未见残留、复发及异时病灶发生;其中7例黏膜内癌ESD术后1、3个月采用共聚焦激光显微内镜检查以指导活检进行随访未见癌组织残留及复发。19处病灶ESD术后大块组织病理诊断符合率为100%,而术前活检病理诊断符合率仅为57.9%,有统计学意义(P0.01)。结论 ESD具有较高一次性整块切除率和组织学治愈性切除率,是一种治疗和诊断高度可疑或早期结直肠癌病变或癌前病变的安全有效的方法。共聚焦激光显微内镜可能对早期结直肠癌的术后随访具有一定的价值。     

食管早期癌和癌前病变超声内镜诊断及内镜下食管黏膜切除术的临床研究

目的探讨食管早期癌和癌前病变超声内镜诊断价值及内镜下食管黏膜切除术的临床治疗价值。方法 61例食管早期癌和癌前病变行超声内镜检查探测病变浸润深度,位于黏膜层及黏膜肌层的食管早期癌和癌前病变行内镜下食管黏膜切除术（EMR）,位于黏膜下层的食管早期癌行外科手术治疗。EMR术28例,外科手术33例。比较超声内镜和术后病理判断病变浸润深度。结果超声内镜判断食管黏膜内癌的特异性和敏感性为94.1%（48/51）、98.0%（48/49）;黏膜下癌的特异性和敏感性为80.0%（8/10）、72.7%（8/11）;鉴别黏膜内癌及黏膜下癌浸润深度准确率为91.8%（56/61）。28例EMR术后病理：14例食管早期癌和12例食管黏膜中重度异型增生完全切除,完全切除成功率为92.9%（26/28）,观察3～45个月无复发。结论超声内镜能较准确鉴别食管早期癌和癌前病变浸润深度,黏膜切除术治疗食管早期癌和癌前病变是安全有效的内镜治疗方法。     

Tis期结直肠癌内镜下非治愈性切除后追加外科手术的临床分析

目的探讨Tis期结直肠癌内镜下非治愈性切除的临床特点及外科手术的应用价值。 方法通过回顾性收集2013年1月至2021年12月期间在广东省中医院胃肠肿瘤中心行内镜下非治愈性切除后接受补救手术治疗的34例Tis期结直肠癌患者的临床资料,总结患者的内镜治疗情况、补救手术指征、术后病理等,并分析导致补救手术实施的主要原因。 结果全组34例患者中,男性18例,女性16例,中位年龄58（30~78）岁,病变位于右半结肠6例、左半结肠17例、直肠11例。内镜下观察息肉形态属山田Ⅰ型7例、山田Ⅱ型8例、山田Ⅲ型17例、山田Ⅳ型2例;内镜切除方法包括内镜下黏膜切除术（EMR）20例、内镜黏膜下剥离术（ESD）6例、内镜下黏膜分块切除术（EPMR）以及圈套器套扎切除术各4例。追加外科手术的指征包括可疑黏膜下浸润21例（61.8%）、基底切缘距离肿瘤＜1 mm 21例（61.8%）、基底切缘或侧切缘阳性10例（29.4%）、分块切除8例（23.5%）。息肉病理中判断为肿瘤侵犯黏膜肌层24例（70.6%）,无患者出现淋巴脉管侵犯或肿瘤出芽。内镜切除与手术切除间隔中位时间为14 d。术后病理结果：共10例（29.4%）患者出现癌残留,包括黏膜内癌残留8例（23.5%）和T1期腺癌残留2例（5.9%）;中位淋巴结检出数12（3~34）枚,无患者出现区域淋巴结转移。癌残留的危险因素包括切缘阳性和分块切除,非可疑黏膜下浸润患者均未出现T1期腺癌残留。 结论Tis期CRC内镜下切除后病理诊断的不明确性是导致追加补救手术的主要原因,外科治疗决策中可能高估了Tis期CRC发生黏膜下浸润的风险。对于具有手术指征的Tis期结直肠癌患者,手术治疗的肿瘤学获益并不大,定期内镜复查可能是更加安全的选择。     

超声内镜对结直肠黏膜高级别上皮内瘤变术前诊断的应用价值

[目的]探讨超声内镜(EUS)对术前结直肠黏膜活检为高级别上皮内瘤变(HGIN)的浸润深度判定的准确性。[方法]选取86例结直肠黏膜活检结果为高级别上皮内瘤变患者,术前行EUS检查初步判断病变浸润深度,根据EUS术前分期的结果指导行黏膜下剥离(ESD)或外科手术治疗。观察术后病理结果,比较EUS对病变浸润深度判断的准确率。[结果]86例患者术前EUS示4例为单纯HGIN,20例考虑为早期结直肠癌,其中有17例行ESD,7例选择行外科手术,21例EUS诊断与术后病理检查病变浸润深度符合,62例EUS诊断为进展期结直肠癌,对其行外科手术治疗,59例EUS诊断与术后病理检查病变浸润深度符合,EUS的对HGIN的诊断特异度、敏感性、阳性预测值、约登指数、一致率分别为87.50%、95.16%、87.59%、82.66%、93.02%。对扁平的病变EUS诊断准确率为95.92%。[结论]结直肠HGIN术前的EUS检查,对病变浸润深度具有较高的准确性,对手术方式的选择具有一定的指导意义。     

早期结直肠癌内镜治疗效果、安全性及长期随访

目的探讨早期结直肠癌在内镜下微创治疗的效果、安全性及长期疗效。方法对76例患者的82个早期结直肠癌病变进行了肠镜微创治疗,对病变的内镜下特点、病理特征、临床疗效和安全性进行分析与评估,并连续随访5年,观察内镜治疗的长期效果。结果病变部位以直肠、乙状结肠为最多,占总数的75.6%,在左半结直肠占总数的89.0%。病变大小以1.1~2.0 cm为最多,占总数的47.5%。肠镜下病变形态以隆起型最多,占总数的57.3%。分别用高频电凝电切、EMR、EPMR、ESD、双镜联合方式电切治疗,全部完整切除,内镜下治疗的癌灶一次性完全切除率达100%。病理特点:82个病变中,有78个是在绒毛状-管状腺廇基础上发生恶变,绒毛状-管状腺廇的癌变率为95.1%。高级别上皮内瘤变62个,黏膜内癌12个,黏膜下癌8个,其中高分化腺癌4个,中分化腺癌14个,低分化腺癌1个,黏液腺癌1个。内镜下治疗的并发症:出血发生率为6.5%,内镜下止血或保守治疗可止血,未发生穿孔。远期疗效:连续随访5年,复查肠镜,创面愈合,全部病例均无复发及转移情况,存活率达100%。结论早期结直肠癌行内镜下微创治疗效果好,损伤小,安全性好,远期疗效好。     

超声内镜诊断胃黏膜早期病变浸润深度的准确性分析

目的探讨超声内镜(endoscopic ultrasonography,EUS)诊断胃黏膜早期病变浸润深度的准确性。方法回顾性分析2013年1月-2015年12月在南京医科大学第一附属医院消化内镜中心诊断为胃黏膜高级别上皮内瘤变(high-grade intraepithelial neoplasia,HGIN)的100例患者的EUS资料,包括内镜下病变部位、大小、个数、侵犯层次、黏膜外观等。并与其术后病理进行比较,分析EUS对判断病变浸润深度的准确性及其影响因素。结果 100例活检诊断为胃HGIN患者中,超声示黏膜层57例,黏膜下层43例。内镜切除(endoscopic resection,ER)术后,黏膜层88例,黏膜下层12例;19例术后病理升级为早期胃癌(early gastric cancer,EGC)。活检诊断HGIN准确率为81.0%(81/100)。EUS诊断胃黏膜病变浸润深度的准确性为65.0%(65/100),其中,低估率和过判率分别为2.0%(2/100)和33.0%(33/100)。EUS判断黏膜层病变的敏感性和特异性分别为62.5%(55/88)和83.3%(10/12)。对于黏膜下层及凹陷型病变层次的判断,EUS更易误诊(P0.05)。结论 EUS是判断胃黏膜早期病变浸润深度的有效方法。但对于黏膜下层及凹陷型病变,EUS判断的准确性相对较低。     

转移性相关基因CD_(44v6)在结直肠癌中的表达意义

结直肠癌转移是宿主致死的主要原因之一。近年发现细胞黏附因子ＣＤ44基因表达与结直肠癌的生长、浸润、转移和预后相关。我们运用免疫组化链霉素抗生物素 过氧化酶方法 (Ｓ Ｐ法 )对 165例结直肠癌组织用ＣＤ44ｖ6 单克隆抗体进行标记 ,探讨其与结直肠癌预后的关系。材料与方法一、病例资料165例标本均取自本院 1989～ 1997年肿瘤外科手术切除标本。男 92例 ,女 73例 ,平均年龄为 5 8.3岁 ;肿瘤大小按其最大径测量。按组织学类型将其分为三组 :高分化组(高分化管状腺癌、乳头状腺癌 ) 4 8例 ,中分化组 (中分化管状腺癌、黏液腺癌 ) 10 1例 …     

早期结直肠癌白光内镜下特点分析

目的分析早期结直肠癌的白光内镜下特点。方法对北京军区总医院消化内镜中心2010年1月-2015年9月经结肠镜检查发现并经病理证实的早期结直肠癌病例进行回顾性研究,分析其白光内镜下特点。结果共发现早期结直肠癌319处(292例患者),其中,269例为单发,23例为多原发癌,21例为同时多原发癌,2例为异时多原发癌。早期结直肠癌中228处(71.5%)分布在乙状结肠及直肠。癌灶直径0.4~13 cm,以1.1~2.0 cm最多。隆起型病变(229处,71.8%)明显多于平坦型病变(90处,28.2%),以0-Ⅰs型最多见。71.9%的0-Ⅰp病变蒂部膨大,26.0%病灶表面可见边界清晰的凹陷,19.4%有基底白斑。259处为黏膜内癌,60处为黏膜下癌。结论早期结直肠癌以左半结肠为主,0-Ⅰs型病变多见。表面边界清晰的凹陷、基底白斑及有蒂息肉蒂部膨大是早期结直肠癌白光内镜下常见的形态特点。     

内镜下黏膜切除术治疗早期大肠癌

目的探讨内镜下黏膜切除术治疗早期大肠癌的安全性及治疗效果。方法对26例早期大肠癌患者进行内镜下黏膜切除术切除病变,观察并发症、术后病理及术后内镜随访情况。结果一次性完整切除病变24例,分2块全部切除2例。术中出血2例(发生率7.7%),予止血夹钳夹止血。术后无出血及穿孔等并发症。术后病理:25例黏膜内癌,1例黏膜下癌,切缘距离病变超过2 mm,无肿瘤组织残留,无血管及淋巴管侵犯。26例病变均完全切除,术后6个月复查结肠镜2例创面见息肉样组织增生,予高频电切除,病理诊断为黏膜组织慢性炎,其余病例创面形成瘢痕,无肿瘤复发。1年后复查结肠镜病变均无复发。此后每年复查结肠镜,原切除部位无肿瘤复发。结论内镜下黏膜切除术治疗早期大肠癌是安全、有效的,在完全切除病变的前提下,可达到根治效果。     

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.     

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.     

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.     

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.