超声小探头评估食管黏膜隆起性病变中的作用探讨

[目的]探讨超声小探头评估食管黏膜隆起性病变中的作用。[方法]采用回顾性分析法,选取2013年3月~2015年6月我院收治的120例食管早期病变患者的临床资料,所有患者均经超声内镜EUS检查,并记录患者超声结果,对患者术前超声和术后病理进行对照分析,观察患者病变大小、位置以及对EUS准确性的影响。[结果]超声内镜EUS诊断中120例食管早期病变患者中间质细胞瘤和平滑肌源性肿瘤85例,炎性增生8例,食管壁外压迫18例,脂肪瘤3例,息肉3例,血管瘤2例,囊肿1例;超声内镜EUS评估食管黏膜隆起性病变的灵敏性、特异性及准确性分别为90.3%、71.9%、85.9%。[结论]超声内镜EUS检查对食管黏膜隆起性病变的检查能够根据超声图像比较准确地推断其病理性质,从而对病变做出定位诊断,对食管早期病变具有重要的诊断价值,值得在临床上推广应用。     

超声内镜在胃黏膜下隆起性病变诊断中的应用分析

[目的]探讨超声内镜检查术(endoscopic ultrasonography, EUS)在胃黏膜下隆起性病变临床诊断中的应用价值。[方法]回顾性分析经EUS诊断,并接受内镜微创或外科手术治疗后病理确诊为胃黏膜下隆起性病变的95例患者临床资料,分析病变的部位、病理结果、EUS特征及比较术前EUS诊断与术后病理诊断的符合情况。[结果]95例中病变部位以胃底(58.95%,56/95)、胃窦(22.11%,21/95)常见。最常见的病理类型为间质瘤(56.84%,54/95),其次为平滑肌瘤(22.11%,21/95)。95例中,EUS诊断起源于黏膜肌层28例、黏膜下层23例、固有肌层42例,层次不清2例,EUS对病变起源层次的诊断符合率为88.42%(84/95)。EUS诊断与术后病理诊断的符合率为90.53%(86/95)。[结论]EUS可较好地对胃黏膜下隆起性病变的层次起源、回声特点及病变性质作出准确判断,但对起源于黏膜下层、固有肌层的低回声病变的误诊率较高,对纤维瘤、脓肿等少见病变的诊断存在一定局限性。     

内镜超声对消化道黏膜下隆起性病变的应用价值

目的探讨内镜超声(endoscopic ultrasonography,EUS)在消化道黏膜下隆起性病变中的应用价值。方法回顾性分析选取2018年1月至2020年10月徐州医科大学附属徐州市立医院内镜中心EUS初诊消化道黏膜下隆起性病变并同时获取病理结果的患者117例,通过EUS与病理结果比对,探讨EUS对消化道黏膜下隆起病变的应用价值。结果入组研究患者117例,EUS初诊平滑肌瘤37例、间质瘤32例、神经内分泌肿瘤17例、脂肪瘤9例、异位胰腺10例、十二指肠布氏腺(Brunner)腺瘤3例、胃体淋巴瘤1例、十二指肠血管瘤1例,胃壁外病变外压7例。EUS检查结果显示消化道黏膜下隆起性病变以平滑肌瘤及间质瘤居多,表现为起源于黏膜肌层或固有肌层的低回声病变;所有病变均通过活检、内镜微创手术或外科手术获取病理标本。最终EUS和病理诊断符合率为107/117(91.5%),其中10例病例误诊。结论EUS虽对消化道黏膜下隆起性病变存在一定的误诊,但结合病变声像学特点(回声、起源、大小及有无邻近组织浸润等),仍能很好地评判隆起灶病变性质,规范临床诊疗。     

超声内镜、电子胃镜及CT检查对上消化道黏膜下隆起型病变的诊断价值

目的探讨超声内镜(EUS)、电子胃镜及计算机断层扫描(CT)检查对上消化道黏膜下隆起型病变的诊断价值。方法回顾性分析2016年1月至2018年12月在我院行电子胃镜、EUS检查和CT检查并最终经手术病理活检明确诊断的上消化道黏膜下隆起型病变患者84例,以术后病理为金标准,对EUS、电子胃镜或CT诊断的准确度进行统计分析。结果 84例患者中,以平滑肌瘤及胃间质瘤较为常见,分别占45. 24%、34. 52%。EUS诊断上消化道黏膜下隆起型病变与术后病理的符合率78. 57%;电子胃镜诊断结果与术后病理的符合率42. 86%; CT诊断结果与术后病理的符合率46. 43%。EUS诊断符合率显著高于电子胃镜(P 0. 001)。EUS诊断符合率显著高于CT(P 0. 001)。结论 EUS能够提供病变起源、大小、边界、回声等特征,对于上消化道黏膜下隆起型病变诊断有较高价值,优于电子胃镜或CT。     

超声内镜对食管黏膜下隆起性病变的诊治价值

对于食管黏膜隆起性病变,内镜超声检查（endoscopic uhrasonography,EUS）既可观察病变表面黏膜的形态,又能获得黏膜下病变的起源、大小、边界、可能的性质及与邻近脏器关系等信息,对黏膜下隆起性病变的诊断和鉴别诊断具有重要的临床应用价值,同时,为选择不同的治疗手段提供依据。现回顾本院86例食管黏膜下隆起性病变超声内镜检查和选择相应治疗的情况,旨在探讨超声内镜在食管黏膜下隆起性病变诊治中的价值。     

超声内镜联合EMR或ESD在食管表浅隆起性病变诊断和治疗中的作用

目的：探讨超声内镜（EUS）联合内镜下黏膜切除术（EMR）或内镜下黏膜剥离术（ESD）在食管表浅隆起性病变诊断和治疗中的价值。方法对35例经EUS检查拟诊为食管表浅隆起性病变患者进行EMR或ESD治疗的病例资料进行回顾性研究,分析病变部位的EUS图像、病理诊断结果及随访治疗效果。结果35例中21例经EMR治疗,14例经ESD治疗。经病理组织学检查确诊为早期食管癌9例,重度不典型增生5例,良性间质瘤3例,腺瘤性息肉4例,非腺瘤性息肉6例,平滑肌瘤8例。经EUS及病理证实病变均起源于黏膜层、黏膜肌层和黏膜下层。34例分别于术后1、3、6月复查EUS随访,术后1个月后伤口均完全愈合,无出血、食管狭窄及局部复发现象发生。结论联合应用EUS和EMR或ESD技术,不仅可以提高食管表浅隆起性病变早期的确诊率,而且是一种微创、有效、安全、快速的治疗措施。     

线阵超声内镜对胃黏膜下病变的诊断意义

普通内镜对胃黏膜隆起性病变起源的鉴别是非常困难的,而内镜超声检查(EUS)能够清晰地显示胃壁及其周围结构,因此能对隆起性病变进行诊断及鉴别诊断。我院近年应用线阵式超声内镜对胃隆起性病变的患者进行了EUS,现将结果报告如下。一、材料与方法1.临床材料:2001年4月至2004年4月对内镜检查疑胃黏膜或黏膜下隆起性病变患者67例进行了EUS。男23     

超声内镜对胃癌外科手术及内镜下黏膜可切除性的评价

目的: 阐述EUS对术前胃癌浸润深度(T分期)诊断的准确性, 评价其对胃癌手术或内镜下黏膜可切除性的指导意义.方法: 回顾性分析78例胃癌手术患者临床资料. 患者术前均行超声内镜检查, TNM分期.分析比较术前T分期与术后手术及病理结果.结果: 与术后病理结果对比, EUS术前T分期总准确率为69.2%, T1、T2、T3、T4分期的准确率分别为83.3%、61.9%、40.0%和100%, 对手术可切除性预测的敏感性为80.8%(63/78).其中EUS准确诊断早期胃癌5例, 但1例胃黏膜下层癌, 被诊断为固有肌层癌. T4期胃癌手术切除率仅为42.3%(11/26).结论: EUS对判断胃癌浸润深度准确率较高, 能较准确诊断早期胃癌, 对指导内镜下黏膜切除术有很大帮助. 而对T4期胃癌患者, 虽然诊断准确性很高, 但对指导根治性手术的意义不大.     

上消化道黏膜下隆起性病变行微探头超声内镜联合内镜黏膜下剥离术的诊治研究

目的探讨微探头超声内镜联合内镜黏膜下剥离术对上消化道黏膜下隆起性病变的诊断价值和治疗效果。方法选择我院2015年3月至2016年2月收治的经普通胃镜检查为上消化道黏膜隆起性病变的患者共49例,后对所有患者进行微探头超声胃镜探查,明确病变的部位、大小及初步定性,再通过病理学检查进行确诊。然后将所有患者随机分为对照组和观察组,对照组患者给予内镜下黏膜切除术切除病变,观察组患者给予内镜下黏膜剥离术切除病变。观察并记录普通胃镜和微探头超声胃镜对患者的检查结果,并与病理学结果进行比较。比较两组患者接受手术的时间,手术期间的出血量,手术切除病变情况;比较其术后出血、术后穿孔、术后恶心呕吐情况。结果 EUS诊断平滑肌瘤、间质瘤、脂肪瘤、息肉等上消化道黏膜下隆起性病变的诊断价值高于普通胃镜;观察组手术平均时间、术中平均出血量均短于对照组,完全切除率高于对照组;观察组术后并发症总发生率明显低于对照组(P0.05)。结论微探头超声内镜联合内镜黏膜下剥离术对上消化道黏膜下隆起性病变具有重要的临床意义。     

超声内镜是否足以精准诊断上消化道黏膜下肿物?

目的评估超声内镜(endoscopic ultrasonography,EUS)诊断上消化道黏膜下隆起病变的准确率。方法收集四川省人民医院2014年1月至2016年6月经胃镜检查提示上消化道黏膜下隆起者共108例,顺序以EUS拟诊、内镜下切除术(ESD/STER等)、病理结果评估EUS诊断的准确率。以病理结果为金标准,计算EUS的真阳性率及假阳性率。结果 EUS真阳性率为72.2%(78/108),假阳性率为27.8%(30/108)。来源于黏膜肌层及固有肌层隆起病变的假阳性率为23.6%(21/89)。食管及贲门隆起病变多为平滑肌瘤;除贲门外其他上消化道黏膜下隆起病变则以间质瘤为主,真阳性率高达80.3%。来源于固有肌层的钙化性纤维瘤,EUS下极易被误诊为间质瘤。来源于黏膜下层的低回声病灶,如神经内分泌肿瘤、深在性囊性胃炎、神经鞘瘤、脉管瘤等,EUS的假阳性率则高达47.3%(9/19)。结论 EUS对于上消化道黏膜下隆起病变的诊断有较高的临床价值,但对于黏膜下层低回声病灶的精准诊断,EUS仍存在较多困难。因此,对照术后病理结果复习EUS图像,对于提高EUS诊断、鉴别诊断的能力,把握内镜切除指征具有重要的临床意义。     

食管隆起病灶EMR术后创面出血内镜治疗33例

目的:探讨食管隆起病灶内镜下黏膜切除术(EMR)术后创面出血内镜不同止血方法,并分析疗效.方法:33例食管隆起病灶行EMR术合并创面出血,其中直接使用金属肽夹止血8例,余下25例首先采用内镜下喷洒药物止血,成功10例,继续出血的15例中7例采用黏膜注射止血,8例采用内镜下热凝止血,仍然有3例无效采用金属钛夹止血,术后6 wk复查内镜,观察创面愈合情况.结果:8例直接使用金属肽夹止血均成功,25例采用喷洒药物止血成功10例;15例止血无效,对其中7例采用注射药物止血,成功6例;8例采用热凝止血成功6例,剩余3例止血仍然无效加用钛夹止血均成功.术后6 wk内镜复查,创面愈合良好.结论:对于食管隆起病灶EMR术后创面出血,内镜止血方法多样,操作简单、安全、效果好,值得推广.     

内镜超声检查在上消化道黏膜下肿瘤微创治疗中的价值研究

目的评价超声内镜检查对上消化道黏膜下肿瘤的诊断价值及指导内镜下微创治疗黏膜下肿瘤的疗效及安全性。方法经超声内镜诊断上消化道黏膜下肿瘤82例,根据黏膜下肿瘤的起源层次、大小及性质分别选择不同的内镜治疗方案,内镜治疗包括高频电凝电切术、内镜下黏膜切除术、皮圈套扎术等。标本行常规病理学及免疫组化检查。术后定期内镜随访。结果26例超声判断起源于黏膜肌层的上消化道黏膜下肿瘤行高频电凝电切术;17例起源于黏膜肌层的平坦型上消化道黏膜下肿瘤行内镜下黏膜切除术;38例起源于固有肌层和1例起源于黏膜肌层的上消化道黏膜下肿瘤行皮圈套扎术。内镜超声诊断与术后病理符合率为91．4％。术后1例出血,其余无严重并发症发生。79例术后随访3—24个月无复发。结论超声内镜能够对消化道黏膜下肿瘤进行起源和定性诊断,超声内镜为内镜微创治疗选择消化道黏膜下肿瘤适应证具有良好的指导作用,内镜治疗是消化道黏膜下肿瘤治疗的安全、有效的手段。     

Yield of tissue sampling for submucosal lesions evaluated by EUS

BACKGROUND: Evaluation of submucosal nodules or large gastric folds is a common indication for EUS. Establishing a tissue diagnosis is challenging because the yield of forceps biopsies is low. The aim of this study was to determine the diagnostic yield of EUS-guided endoscopic submucosal-mucosal resection and forceps biopsy for submucosal nodules and large gastric folds. METHODS: Patients who underwent EUS from March 1997 through January 2002 for evaluation of submucosal nodules or large gastric folds were identified, and the procedure and pathology reports reviewed. Patients were included who underwent endoscopic submucosal-mucosal resection (n = 45) or large-capacity ("jumbo") biopsy (n = 36) of submucosal lesions (arising from third endosonographic layer) or large gastric folds. Endoscopic submucosal-mucosal resection was performed with an electrosurgical snare or with a cap-fitted endoscopic mucosal resection device. RESULTS: Sixty-six patients (62% men; mean age, 61 years; range 27-80 years) underwent 69 EUS procedures to obtain tissue samples of subepithelial lesions. Diagnostic yields were as follows: endoscopic submucosal-mucosal resection 40/45 (89%; 95% CI [80%, 98%]), jumbo biopsy 15/36 (42%; 95% CI [26%, 58%]) (p < 0.001 by two-tailed Fisher exact test). There were 9 complications: 7 instances of bleeding (6 endoscopic submucosal-mucosal resection, 1 jumbo biopsy), 3 requiring hospitalization (2 endoscopic submucosal-mucosal resection, 1 jumbo biopsy) and 2 requiring transfusion; 1 chest pain and odynophagia (esophageal endoscopic submucosal-mucosal resection); and 1 oversedation (requiring administration of reversal agents). CONCLUSIONS: For submucosal lesions and large gastric folds, endoscopic submucosal-mucosal resection has a better diagnostic yield than the jumbo biopsy, but may have a higher complication rate.     

微探头超声指导内镜黏膜下剥离术治疗上消化道黏膜下隆起性病变的价值

背景：微探头超声（MPS）能对上消化道黏膜下隆起性病变进行较准确的定位,并初步定性诊断,内镜黏膜下剥离术（ESD）可完整切除病变,目前MPS指导ESD治疗上消化道黏膜下隆起性病变的研究少见。目的：评价MPS指导ESD治疗上消化道黏膜下隆起性病变的价值。方法：对胃镜检查发现的89例上消化道黏膜下隆起性病变行MPS检查,比较两者的诊断准确率。然后采用ESD切除病变,分析手术情况。结果：上消化道黏膜下隆起性病变以平滑肌瘤和间质瘤为主,MPS对上消化道黏膜下隆起性病变的总体诊断准确率显著高于胃镜（83．1％对51．7％,P〈0．05）。82例病变位于黏膜肌层或黏膜下层,平均直径为12．6mm,平均手术时间28．2min,ESD完整切除率100％;5例病变位于固有肌层,平均直径为13．8mm,平均手术时间48．5min,ESD完整切除率71．4％,其余2例固有肌层病变因难以控制的出血和黏连而行外科手术。所有患者术后随访无病变残留和复发。结论：MPS可对上消化道黏膜下隆起性病变作出较准确的判断,应作为内镜下治疗的术前常规检查。MPS引导ESD治疗上消化道黏膜下隆起性病变安全、有效。     

Miniature ultrasonic probes for diagnosis and treatment of digestive tract diseases

AIM: To investigate the clinical value of miniature ultrasonic probes (MUPs) for the diagnosis and treatment of digestive tract diseases. METHODS: Endoscopic ultrasonography (EUS) was performed for patients with its indications with 7.5-20 MHz MUPs and double-cavity electronic endoscope. According to the diagnosis of MUPs, patients who had indications of treatment received endoscopic resection or surgical excision. Postoperative histological results were compared with the preoperative diagnosis of MUPs. A few patients without endoscopic resection or surgical excision were periodically followed up with MUPs. RESULTS: A total of 537 patients were examined by MUPs, of them, 256 were diagnosed with gastrointestinal submucosal lesions, 146 with pseudo-submucosal lesions, 50 with digestive tract cancers, 17 with peptic ulcer, 11 with cholecystolithiasis, 8 with chronic pancreatitis, and 2 with achalasia and 47 were diagnosed as normal. After MUPs examinations, 220 patients received endoscopic resection or surgical excision, and the postoperative histological results of 211 patients were completely consistent with the preoperative diagnosis of MUPs. The diagnostic accuracy of MUPs was 95.9%. The result of follow-up with MUPs indicated that gastrointestinal leiomyoma, lipoma, phlebangioma and cyst were unchanged within 1-2 years. The patients who received endoscopic resection or centesis did not have any complications. CONCLUSION: MUPs are of value in diagnosing gastrointestinal submucosal lesions, staging of digestive tract cancers and biliary-pancreatic diseases. They play a very important role in making therapeutic plans.     

胃异位胰腺的内镜诊治

目的探讨胃异位胰腺胃镜和超声内镜的表现及内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)对胃异位胰腺的疗效与安全性。方法经胃镜及超声内镜诊断为胃异位胰腺患者17例,总结其临床症状、胃镜和超声内镜下表现,将有临床症状的16例患者行ESD治疗,另1例患者随访观察。结果胃镜下多表现为隆起性病变,顶部可见导管开口呈脐样凹陷;14例患者行超声内镜检查,病灶以累及黏膜下层为主,可累及固有肌层,多数为低回声、等回声或混合回声改变;16例患者接受ESD治疗,术中发现2例患者累及固有肌层,术中、术后无出血、穿孔等并发症。术后病检提示累及固有肌层3例,随访发现1例患者病灶存在,1例未行手术患者病灶无明显变化。结论胃镜及超声内镜检查是诊断胃异位胰腺及指导治疗的重要手段。ESD可安全、有效地应用于胃异位胰腺的治疗,并发症发生率低,无症状患者可随访观察。     

High-frequency probe EUS-assisted endoscopic mucosal resection: a therapeutic strategy for submucosal tumors of the GI tract.

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of high-frequency probe EUS (HFPE)-assisted endoscopic mucosal resection in the management of submucosal tumors of the GI tract. METHODS: HFPE-assisted endoscopic mucosal resection was attempted in 28 patients with submucosal tumors less than 2 cm in diameter. HFPE was performed with a 20-MHz "through-the-scope" probe. Saline solution was injected into the submucosa. After confirming detachment of the lesion from the muscularis propria by repeat HFPE, endoscopic mucosal resection was performed with a lift-and-cut or endoscopic mucosal resection cap technique. Follow-up endoscopy was performed in all patients. RESULTS: Submucosal tumors from the following areas were included: esophagus 3, stomach 4, duodenum 3, and colon 18. The submucosal tumors were located in the upper third (n = 3), middle third (n = 18), and lower third (n = 7) of the submucosa. Twenty-one submucosal tumors were removed by the lift-and-cut technique and 6 by the cap method. One patient required surgical resection after unsuccessful endoscopic mucosal resection. The origin and depth of penetration of all lesions was accurately depicted by HFPE. Median tumor diameter was 9 mm (range 3-20 mm). Resection was successful and complete in 93% of the cases. There were no immediate postprocedure complications (exact 95% CI [0%, 12.3%]). During a median follow-up of 21.5 months (range 2-74 months) no recurrence was found. CONCLUSIONS: HFPE-assisted endoscopic mucosal resection is safe and effective for the management of selected submucosal tumors of the GI tract. A management algorithm based on endoscopic and HFPE findings is proposed.     

超声内镜与CT仿真内镜对上消化道隆起样病变的诊断价值

目的 研究超声内镜(EUS)与CT仿真内镜(CTVE)对上消化道隆起样病变的诊断价值。方法 48例经胃镜检查发现有上消化道隆起样病变的患者(食管癌、胃癌、息肉等病例除外)，行CTVE和EUS检查，除9例检查发现为正常脏器外压、2例食管静脉瘤而密切随访观察外，其余均经手术或活检获取病理确诊。将以上三种方法诊断结果与病理结果进行比较。结果 胃镜、EUS、CTVE对上消化道隆起样病变的诊断准确率分别为16．7％、89．6％、66．7％，EUS、CTVE与胃镜检查结果差异有显著性(P＜0．001)；EUS、CTVE两者之间比较差异有显著性(P＜0．05)，EUS优于CTVE；EUS、CTVE对上述疾病的诊断的敏感性、特异性分别为89．7％、88．9％和66．7％、66.7％。结论 EUS和CTVE作为新兴的检查手段在对上消化道隆起样病变的诊断中有较高的临床实用价值，且两者有较强的互补性，可作为胃镜较难诊断的上消化道隆起样病变的确诊方法之一。     

The utility of endoscopic ultrasonography and endoscopy in the endoscopic mucosal resection of early gastric cancer

OBJECTIVE: To clarify the usefulness of endoscopic ultrasonography (EUS) and endoscopy in the endoscopic mucosal resection (EMR) of early gastric cancer. Patients/Methods-EMR was performed in 61 patients with early gastric cancer over the past five years. The accuracy of the assessment of the depth of cancerous invasion was studied in 49 patients who had EUS before EMR. Forty eight patients were treated with endoscopy alone; in these patients, EUS and endoscopic findings correlated with the clinical course. RESULTS: Forty six patients showed no changes in the submucosal layer or deeper structures on EUS. Pathologically these included 37 patients with mucosal cancer and nine with submucosal cancer showing very slight submucosal infiltration. Three patients showed diffuse low echo changes in the submucosal layer on EUS; pathologically, these included two with submucosal cancer and one with mucosal cancer with a peptic ulcer scar within the tumour focus. Of 48 patients receiving endoscopic treatment alone, 45 showed no tumour recurrence or evidence of metastases on EUS and endoscopy. Three cases of recurrence were observed. Two of these patients had a surgical gastrectomy, and one was re-treated endoscopically. In the former cases, the surgical results correlated well with assessment by EUS and endoscopy. In addition, the latter patient who was re-treated endoscopically after evaluation with EUS and endoscopy has so far had no recurrence. CONCLUSION: The combined use of EUS and endoscopy is effective in diagnosing the depth of cancerous invasion in patients undergoing EMR as well as in clarifying changes both within and between anatomic levels during follow up.     

Accuracy of high‐frequency catheter‐based endoscopic ultrasonography according to the indications for endoscopic treatment of early gastric cancer

Background and Aim: The development of endoscopic treatment, such as endoscopic submucosal dissection, extends the indications for endoscopic resection in patients with early gastric cancer (EGC). Endoscopic ultrasonography (EUS) is the first‐choice imaging modality for determining the depth of invasion of gastric cancer. The aim of the present study was to prospectively assess the accuracy of EUS for determining the depth of EGC, according to the accepted/extended indications. Methods: We prospectively included a total of 181 lesions in 178 patients, with an endoscopic diagnosis of EGC, who underwent EUS for staging the depth of tumor invasion using a 20‐MHz catheter probe. We investigated the accuracy of EUS for determining the depth of endoscopically‐suspected EGC and then analyzed the difference in the accuracy of EUS according to the accepted/extended indications. Results: Of the 178 patients, five patients were dropped because of the absence of final histological results. For the 176 lesions in 173 patients, the accuracy of EUS assessment for the depth of tumor invasion was 80.7% (142 of 176 lesions). The accuracy of EUS for the lesions with accepted indications and with extended indications was 97.6% (40 of 41 lesions) and 83.6% (46 of 57 lesions), respectively (P = 0.040). Of the lesions with extended indications, the accuracy of EUS decreased especially for the lesions with ulceration and those with minute submucosal invasion (79.2% and 42.9%, respectively). Conclusions: The accuracy of EUS for the lesions with the extended indications was lower than that for the lesions with the accepted indications. In particular, lesions with ulceration and minute submucosal invasion should be carefully considered prior to endoscopic treatment by pretreatment EUS staging.