内镜黏膜下剥离术治疗消化道固有肌层肿瘤

目的 探讨内镜黏膜下剥离术(ESD)治疗来源于消化道固有肌层黏膜下肿瘤(SMT)的疗效和安全性.方法 对内镜发现的消化道SMT进行超声检查,对来源于固有肌层的SMT应用头端弯曲的针形切开刀进行ESD治疗:(1)黏膜下注射生理盐水;(2)预切开病变周围黏膜;(3)剥离黏膜下层组织显露病变,一次性完整切除病变.结果 来源于固有肌层的消化道SMT 10例,术后病理诊断为食管平滑肌瘤1例,胃平滑肌瘤1例,胃间质瘤6例,直肠平滑肌瘤和间质瘤各1例.病变最大直径0.5～3.0 cm(平均1.4 cm).9例病变一次性完整剥离,1例创面肿瘤残留接受外科手术.ESD手术时间30～150 min(平均73.5 min).1例术中出现消化道穿孔,应用金属夹成功闭合,未转开腹手术修补.术中平均出血量约40 ml,术后均未出现出血,亦未出现其他并发症.结论 ESD治疗来源于固有肌层的消化道SMT安全、有效,大多可以一次性完整切除病变,提供完整的病理学诊断资料,达到外科手术同样的治疗效果.     

内镜下黏膜剥离术治疗直肠近肛门处巨大侧向发育型肿瘤的临床价值

<正>直径2cm的大肠侧向发育性肿瘤(laterally spreading tumor,LST)采用内镜下黏膜切除术(endoscopic mucosal resection,EMR)进行切除;直径2 cm的LST可采用内镜下分片黏膜切除术(endoscopic piece mucosal resection,EPMR)或内镜下黏膜剥离术(endoscopic submucosal dissedtion,ESD)进行切除~([1]),但EPMR治疗LST往往不能获得完整的病理标本。EMR难以一次性切除的病变主要是LST。在LST中,颗粒性LST病变罕见黏膜下     

内镜黏膜下剥离术治疗大肠侧向发育型肿瘤的体会

[目的]探讨内镜黏膜下剥离术治疗大肠侧向发育型肿瘤(LST)的应用。[方法]对近4年诊断为LST的30例患者进行术前活检、超声内镜评估后行内镜黏膜下剥离术(ESD),分析术前术后组织病理、超声肠镜改变、术中操作技巧及并发症等。[结果]30例大肠ESD一次性完整切除28例、一次性完整切除率93.3%,1例改为内镜下直肠无蒂型息肉分片切除术(EPMR)切除,1例术中穿孔、因病变大改外科手术;手术时间25~120min、平均80min,术中穿孔2例(1例使用钛夹缝合后内科保守治疗成功,1例转外科手术)。术后复查行EPMR切除的1例复发,追加手术治疗。术后病理8例与术前不一致,其中2例合并癌变。超声内镜提示28例病变起源于黏膜层,内部高回声均匀,黏膜下完整,2例有低回声改变者病理提示部分癌变。[结论]对于≥2cm的大肠LST,ESD具有切除彻底、安全性高、复发率低的优点,是一种治疗LST的安全有效手段。     

内镜黏膜下剥离术治疗大肠侧向发育型息肉25例

目的 探讨内镜黏膜下剥离术( ESD)治疗大肠侧向发育型息肉的临床价值.方法 应用染色、放大内镜及超声内镜检测病变范围及侵犯深度,对位于黏膜层或黏膜下层侧向发育型息肉行ESD治疗,完整剥离病变组织后送病检,所有病例术后内镜定期随访.结果 25例均完整剥离,病灶直径2.5 ～6.0 cm,平均4.0 cm;ESD手术时...     

内镜黏膜下剥离术治疗直肠累及齿状线的侧向发育型肿瘤疗效分析

目的探讨直肠累及齿状线的侧向发育型肿瘤（laterally spreading tumor,LST）的特点,评估内镜下黏膜剥离术（endoscopic submucosal dissection,ESD）治疗直肠累及齿状线LST的疗效及安全性。 方法收集2012年10月至2014年10月湖北省肿瘤医院内镜科采用ESD术治疗的45例直肠累及齿状线的LST的临床资料,回顾性分析病变类型、大小、手术时间、一次性完整切除率、并发症的发生、病理诊断、随访情况等。 结果45例直肠累及齿状线的LST,肿瘤直径12 mm~66 mm,平均28±15 mm,45例（100%）均一次性完整切除,ESD手时间45 min~240 min,平均100±25 min。迟发性出血6例,发生率13.3%（6/45）,均行内镜下止血成功,发生术中穿孔2例,发生率4.4%（2/45）,经止血夹夹闭创面后内科治疗后痊愈。术后病理诊断低级别上皮内瘤变37例,高级别上皮内瘤变8例,病变均局限于黏膜层。45例患者平均随访时间30.2个月（10~46个月）,所有患者均无肿瘤复发或残留,术后排便功能正常。 结论ESD治疗直肠累及齿状线的LST切除彻底,安全性好,复发率低,对肛管排便功能无明显影响。     

内镜黏膜下剥离术治疗食管早期癌及癌前病变

目的 探讨内镜黏膜下剥离术(ESD)治疗食管早期癌及癌前病变的应用价值.方法 对胃镜发现的食管早癌和上皮内瘤变、深度未超越黏膜卜层者15例进行ESD治疗:(1)黏膜下注射生理盐水抬高病变;(2)预切开病变周围黏膜;(3)沿病变下方黏膜下层完整剥离病变.结果 15例食管早癌和上皮内瘤变病变,最大卣径2.5～4.5 cm(平均3.2 cm).14例病变成功完成ESD治疗,ESD成功率93.3%(14/15).所有剥离病变全部得到病理确诊,基底和切缘未见病变累及.ESD手术时间(白黏膜下注射至完整剥离病变)45～150 min,(平均75 min).术中出血量平均30 ml,均经电凝、氙离子凝固术和止血夹成功止血,未出现需再次内镜下治疗的出血;ESD穿孔发生率0(0/15).术后随访14例,随访期6～18个月(平均11.5个月),创而完全愈合,无一例病变残留和复发.结论 ESD是治疗食管早癌和癌前病变的新方法,不仅能完整切除较大的病变,还能提供完整的病理学诊断资料.     

内镜黏膜下剥离术治疗直肠侧向发育型肿瘤的临床价值(附视频)

目的研究直肠侧向发育型肿瘤(LST)的临床病理学特征,并评价内镜黏膜下剥离术(ESD)治疗直肠LST的疗效及安全性。 方法收集2008年4月至2012年1月期间,复旦大学附属中山医院内镜中心行ESD治疗的120例直肠LST患者的临床资料。首先按内镜下表面形态将120例LST进行分型,统计各型LST的部位、大小、形态特征,然后对LST的临床病理特点以及ESD治疗的切除率、手术时间、并发症和复发情况进行分析。 结果120例直肠LST病变中84例为颗粒型(84/120,70%),36例为非颗粒型(36/120,30%),平均病变大小为35 mm。其中绒毛状管状腺瘤占38.3%,高级别上皮内瘤变28.3%,黏膜下癌7.5%。平均手术时间为：51.8±28.16(17～110)min,整块切除率为98.3%,完整切除率为95.0%,完整治愈切除率为90.8%。ESD术后出血发生率为4.2%,穿孔发生率为3.3%。平均随访时间为32.6个月,复发率为0.8%。 结论直肠LST病变大于2 cm,存在较高的恶变潜能。ESD治疗LST病变整块切除率高,复发率较低,是直肠LST病变安全且有效的治疗方法。     

内镜黏膜下剥离术治疗上消化道神经内分泌肿瘤的临床价值

目的 探讨内镜黏膜下剥离术(ESD)治疗上消化道神经内分泌肿瘤的安全性及其疗效.方法 采用ESD方法对19例上消化道神经内分泌肿瘤进行治疗,术后标本送病理检查,记录不良反应发生情况及疗效,随访肿瘤复发及转移情况.结果 肿瘤直径0.4 ～1.5 cm,平均0.9 cm,均一次性完整剥离切除,ESD手术时间(自黏膜下注射至完整剥离病变)15～ 50 min,平均20 min,无严重出血及穿孔发生.术后18例病理诊断为神经内分泌瘤,其中G1级16例、G2级2例,基底和切缘均未见病变累及;另1例病理显示有浸润性生长倾向,诊断神经内分泌癌(G3级),行外科扩大切除,术后病理未见肿瘤组织残留,无淋巴结转移.平均随访28个月,无一例出现肿瘤复发和转移.结论 ESD治疗上消化道神经内分泌肿瘤具有较好的安全性和疗效,值得在临床上推广应用.     

内镜黏膜下剥离术治疗消化道黏膜下肿瘤的疗效分析

目的探讨内镜黏膜下剥离术(ESD)治疗消化道黏膜下肿瘤(submucosal tumor,SMT)的疗效及安全性。方法选取我院2008年3月-2011年6月经胃肠镜检查发现消化道黏膜下肿瘤48例,回顾性分析48例患者资料,包括患者的基本情况、病变部位、大小、治疗经过以及病理结果等,统计并发症发生情况及术后随访结果。结果病灶直径为0.8～5.8 cm,平均(3.3±0.75)cm,ESD手术时间为27～167 min,平均(71.0±22.6)min,ESD完整切除病灶45例(45/48,93.75%),穿孔3例(3/48,6.25%),其中1例大出血,1例食管患者ESD术后出现食管狭窄,经内镜下球囊扩张食管狭窄消失。所有病人均完成了术后6个月的内镜随访,1例患者见肿瘤复发。结论 ESD技术对较大病变可以整块切除,并提供完整的病理诊断资料;消化道SMT行ESD术是安全、有效的。     

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。     

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.