上消化道黏膜下肿瘤特点及内镜下治疗的效果和安全性分析

目的分析上消化道黏膜下肿瘤的临床特点及内镜下治疗的效果和安全性。方法收集2012-02~2017-02该院收住的上消化道黏膜下肿瘤患者264例,采用内镜下治疗,切除标本行常规病理及免疫组化检查。统计各种黏膜下肿瘤的性质、起源和分布。所有患者术后随访1年。结果 264例患者中,病变部位食管黏膜下肿瘤占65. 9%,胃黏膜下肿瘤占33. 0%,十二指肠黏膜下肿瘤占1. 1%。病变性质平滑肌瘤占72. 3%,间质瘤占12. 1%,脂肪瘤占5. 3%,异位胰腺占4. 6%,神经鞘瘤占1. 5%,囊肿占1. 1%,神经内分泌瘤占1. 1%,静脉瘤占1. 1%,颗粒细胞瘤占0. 8%。所有患者术后1年复查胃镜,未见复发及并发症。结论上消化道黏膜下肿瘤以良性肿瘤为主,其中分布于食管最多见,其次是胃,十二指肠最少。食管黏膜下肿瘤以平滑肌瘤最多见,胃以平滑肌瘤、间质瘤最多见。对于直径≤4 cm的上消化道黏膜下肿瘤,如平滑肌瘤、间质瘤、脂肪瘤、异位胰腺、神经鞘瘤、囊肿、神经内分泌瘤、静脉瘤、颗粒细胞瘤、血管瘤等,均可采取内镜下手术治疗,且安全、有效。     

经黏膜下隧道内镜肿瘤切除术治疗源于固有肌层的上消化道黏膜下肿瘤初探

目的探讨经黏膜下隧道内镜肿瘤切除术（STER）治疗来源于上消化道固有肌层黏膜下肿瘤（SMTs）的疗效和安全性。方法对26例经超声内镜和CT诊断为来源于固有肌层的上消化道SMTs患者全麻下行STER治疗：（1）内镜寻找到肿瘤,并准确定位;（2）建立黏膜下隧道,显露肿瘤;（3）内镜直视下完整切除肿瘤;（4）缝合黏膜切口。结果来源于固有肌层的上消化道SMTs患者26例中,食管14例,贲门7例,胃5例。来源于固有肌层浅层者11例,深层者15例,其中2例胃SMTs与浆膜层粘连,密不可分。STER成功切除所有黏膜下肿瘤,完整切除率100％,切除病变直径1．0～3．2cm（平均1．9cm）。黏膜切开至黏膜切口完整缝合时间25～145min,平均68．5min;完整缝合创面所用金属夹4—6枚,平均5枚。术后病理诊断为平滑肌瘤17例,间质瘤7例,血管球瘤1例,神经鞘膜瘤1例;切缘均为阴性。发生皮下气肿2例,左侧气胸伴皮下气肿1例,气腹2例,均予保守治疗痊愈。术后无一例出现迟发性消化道出血、消化道漏和胸腔腹腔继发感染,无一例发生黏膜下隧道内积血积液和继发感染。随访3～9个月,无一例病变残留或复发。结论STER治疗来源于固有肌层的上消化道SMTs安全、有效,可以一次性完整切除病变,提供完整的病理学诊断资料,并可避免消化道漏和胸腔腹腔继发感染。     

内镜超声指导食管黏膜下肿瘤的黏膜切除术

目的探讨内镜超声指导食管黏膜下肿瘤黏膜切除术的有效性和安全性。方法对1992年至2005年间656例疑为上消化道黏膜下肿瘤患者进行内镜超声检查，其中97例食管病变内镜超声显示病变来源于黏膜肌层，有43例经知情同意后行内镜下黏膜切除术。切除病变经过病理检查明确病变的层次和病变性质。结果通过与病理结果对照表明，EUS准确地判断肿瘤所在的层次；通过黏膜切除术切除所有病变，无一例发生并发症。结论内镜超声检查能准确判断黏膜肌层来源的肿瘤，可用于指导黏膜切除术。     

微探头超声内镜指导内镜下剥离联合圈套结扎治疗上消化道固有肌层肿瘤的初探

目的探讨微探头超声内镜指导内镜下剥离联合圈套结扎治疗来源于上消化道固有肌层黏膜下肿瘤（SMT）的疗效和安全性。方法对内镜发现的上消化道SMT行EUS,对其中来源于固有肌层的SMT行圈套结扎后应用针形切开刀行对应内镜下剥离治疗：内镜下圈套结扎病变;预切开病变表面中央的黏膜;剥离黏膜下层组织显露病变,完整切除病变。结果来源于上消化道固有肌层的SMT共13例,术后病理诊断为食管平滑肌瘤2例,胃平滑肌瘤3例,胃间质瘤7例,胃血管球瘤1例。病变直径0．8～1．5cm,平均1．2cm。13例病变均一次性完整切除,其中1例术后出现消化道穿孔,应用金属夹成功封闭,未转外科手术。结论微探头超声内镜指导内镜下剥离联合圈套结扎治疗来源于上消化道固有肌层直径≤1．5cm的SMT是安全、有效的,可完整切除病变,提供完整的病理学诊断资料,可达到与外科手术同样的治疗效果。     

超声内镜引导下Trucut穿刺活检诊断上消化道黏膜下肿瘤的初步经验

目的评估超声内镜引导下Trucut穿刺活检技术(EUS-TCB)对消化道黏膜下肿瘤穿刺活检的有效性及安全性。方法回顾性分析EUS-TCB对12例患者上消化道黏膜下肿瘤的穿刺活检,其中食管黏膜下肿瘤4例,胃黏膜下肿瘤6例,十二指肠黏膜下肿瘤2例。行超声内镜检查及其引导下的Trucut穿刺活检,穿刺获取的组织标本通过免疫组化染色等进行病理组织学检查,并观察穿刺部位的出血状况。结果对12例黏膜下病灶共穿刺36次,30次(83．3%)成功获取组织条块,6次(16．7%)穿刺未取得有效组织；7次(23．3%)穿刺获得的组织为片段状碎块,23次(76．7%)为完整的条状组织。病理检查证实食管鳞癌1例,食管平滑肌瘤3例,胃间质瘤4例,胃平滑肌瘤1例,胃癌(印戒细胞癌)1例,十二指肠降段间质瘤1例。无严重并发症发生。结论超声内镜引导下Trucut穿刺活检诊断上消化道黏膜下肿瘤安全、有效,可获得满意的病理组织,对十二指肠黏膜下肿瘤的诊断效果尚待进一步研究。     

内镜对穿隧道肿瘤切除术治疗贲门巨大黏膜下肿瘤的临床分析

目的探讨内镜对穿隧道肿瘤切除术(submucosal tunnel docking endoscopic resection, SDER)治疗贲门巨大黏膜下肿瘤的安全性、有效性。方法回顾性收集2021年1月—2022年1月在复旦大学附属中山医院和徐汇区中心医院内镜中心行SDER治疗的贲门巨大黏膜下肿瘤患者资料, 分析手术记录、术后病理、并发症、住院情况及随访情况。结果本研究共纳入6例患者, 病变平均长径为4.0 cm, 均位于贲门。所有患者成功完成SDER治疗, 手术时间为23～42 min。术后病理提示4例为平滑肌瘤, 2例为胃肠间质瘤, 所有病变完全切除。术后住院时间为3～5 d。6例患者术后均未出现严重并发症。所有患者术后3个月和6个月复查胃镜恢复良好。结论初步认为, 利用SDER治疗贲门巨大黏膜下肿瘤是安全、有效的。     

微型探头超声内镜对上消化道黏膜下肿瘤的诊治价值

目的探讨微型探头超声内镜（InEus）在上消化道黏膜下肿瘤的诊断和治疗中的作用。方法对30例疑为上消化道黏膜下肿瘤的患者进行微型探头超声内镜检查,根据黏膜下肿瘤的起源层次．部分患者接受内镜下治疗或外科手术。结果mEUS检查的30例患者中,发现消化道壁外压迫1例（主动脉弓1例）;黏膜下肿瘤29例,包括平滑肌瘤12例,良性间质瘤4例,恶性间质瘤1例,脂肪瘤4例,静脉瘤3例,异位胰腺1例,囊肿4例。12例起源于黏膜肌层的肿瘤行高频电切除术切除,3例静脉瘤行尼龙圈套结扎,4例脂肪瘤及4例囊肿行高频电切除。结论mEUS检查能清楚显示上消化道黏膜下肿瘤的大小．起源层次、生长方向及邻近组织结构关系,较准确地判断肿瘤的性质。进而指导黏膜下肿瘤治疗方案的选择。     

超声内镜用于食管黏膜下肿瘤定性诊断及指导手术治疗的临床意义

目的探究超声内镜(EUS)用于食管黏膜下肿瘤定性诊断及指导手术治疗的临床价值。方法选取胃镜检查中发现的食管黏膜下肿瘤患者50例,对其行超声内镜检查,以食管黏膜下肿瘤的病变大小、起源层次及性质为依据,决定内镜下手术治疗方式,包括内镜下黏膜切除术(EMR)、内镜下黏膜分片切除术(EPMR)、内镜黏膜下剥离术(ESD),将病变完整切除,并对瘤体标本进行病理活检。结果术前EUS诊断起源于黏膜肌层的食管平滑肌瘤、淋巴管瘤分别有45例、2例,起源于黏膜下层的脂肪瘤、食管囊肿分别有2例、1例,以病理诊断为金标准,EUS诊断的准确率为98.0%。食管SMT患者病灶直径为0.4~2.3(1.38±0.21)cm,行EMR、EPMR、ESD切除者分别有37例、6例、7例,均完全切除,手术成功率为100.0%。EMR术中无并发症,ESD术中1例患者创面出血,并成功止血。术后6个月EUS复查结果显示创面无病变残留及复发,愈合良好。结论 EUS能对食管SMT进行定性和起源诊断,在食管SMT治疗中具有很好的指导意义,EUS辅助下行内镜微创手术是安全、有效的SMT治疗手段,既能完整切除病变,又可提供病理诊断。     

内镜超声指导下皮圈套扎治疗上消化道黏膜下良性肿瘤的临床价值

上消化道黏膜下肿瘤(upper-gastrointestinal submucosal tumors,SMT)中,在食管最常见是平滑肌瘤[1],而胃内则以间质瘤( gastrointestinal stromal tumor,GIST)居多[2].自内镜超声引入临床,上消化道黏膜下肿瘤起源、大小、性质得以术前探查,使内镜下微创切除部分良性病变成为可能.     

食管上皮源性恶性肿瘤误诊病例的内镜超声及组织病理学特点分析

为了分析误诊为食管黏膜下肿瘤的食管上皮源性恶性肿瘤的内镜超声及组织病理学特点,回顾性分析2012年1月—2020年12月在南京鼓楼医院术前诊断为食管黏膜下肿瘤但术后病理证实为食管上皮源性恶性肿瘤的患者资料,记录患者的年龄、性别、病变大小、病变部位、超声下病变起源、病变回声、内镜治疗方式以及术后病理等临床资料。11例患者中男9例、女2例,年龄（65.5±6.2）岁,9例病变长径≤2 cm,8例病变位于胸中段食管。11例患者中10例术前行内镜超声检查,病变起源于黏膜下层6例、固有肌层2例、黏膜肌层2例,病变回声9例为低回声改变,仅1例为等回声病变。11例患者中3例行内镜黏膜切除术,6例行内镜黏膜下剥离术,2例行隧道法内镜黏膜下肿物切除术。组织病理学类型包括3例中低分化鳞癌,3例基底细胞样鳞癌,2例腺样囊性癌（其中1例为腺样囊性癌碰撞鳞癌）,2例腺癌,1例食管肉瘤样癌合并基底细胞样鳞癌。食管上皮源性恶性肿瘤内镜下表现为黏膜下隆起极为罕见,内镜超声有助于鉴别诊断,诊断性治疗可明确诊断。     

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.