结直肠侧向发育型肿瘤内镜诊断与治疗

目的探讨结直肠侧向发育型肿瘤(LST)内镜诊断方法,经内镜黏膜切除术(EMR)、分片切除术(EPMR)、内镜黏膜下剥离术(ESD)方法治疗LST的疗效、安全性。方法 LST经色素染色放大内镜或NBI-ME观察病变形态、腺管开口分型(pit)及表面微血管分型(MP),分别进行EMR、EPMR、ESD或外科手术治疗,并分析LST的病理特点。结果在399例病人检出有LST,共407个病变。LST大小在10～80mm。LST部位在直肠128个(31.4%),乙状结肠97个(23.8%),降结肠54个(13.3%),横结肠67个(16.5%),升结肠21个(5.2%),盲肠36个(8.8%),回肠末段4例(1.0%)。LST形态呈颗粒均一型145个,结节混合型161个,扁平隆起型63个,假凹陷型38个。LST腺管开口分型以ⅢL和Ⅳ为多。405个LST经肠镜微创电切治疗,228个行EMR切除,165个行EPMR切除,12个行ESD切除,均在内镜下成功电切,另2例LST行外科手术治疗。出血发生率4.0%,术中即刻出血4例,术后3天迟发出血12例,无肠穿孔发生。LST病理结果:管状腺瘤46个(11.3%),管状绒毛状腺瘤146个(35.9%),绒毛状腺瘤181个(44.5%),增生性息肉10个(2.5%),高级别上皮内瘤变19个(4.7%),黏膜内癌3个(0.7%),黏膜下癌2个(0.4%)。术后复查肠镜无复发。结论色素染色放大内镜或NBI-ME方法有利于检出LST,EMR、EPMR、ESD是内镜下治疗LST安全有效的方法。     

内镜下治疗在大肠侧向发育型肿瘤中的应用

目的 探讨内镜下黏膜切除术（endoscopic mucosal resection,EMR）、黏膜分片切除术（endoscopic piecemeal mucosal resection,EPMR）和内镜翻转黏膜切除术（retroflex endoscopic mucosal resection,REMR）在治疗大肠侧向发育型肿瘤（laterally spreading tumor,LST）中的临床应用价值.方法 选取2009年6月-2012年6月在昆山市中医医院行肠镜检出LST病变的患者18例,10例行注射法EMR切除病灶,6例行注射法EPMR切除病灶,2例行REMR切除病灶.结果 10例行EMR切除的病变,均完整切除,无1例复发.6例行EPMR切除的病变,1例失败,5例完整切除,其中1例复发.2例行REMR切除的病变,完整切除,无复发.结论 内镜下治疗LST操作安全、创伤少、恢复快,在LST的治疗中值得推广.     

内镜下粘膜剥离切除大肠侧向发育型肿瘤的护理

本文报告了13例大肠侧向发育型肿瘤病人接受内镜下粘膜剥离切除治疗，其中4例行注射法粘膜切除术(EMR)，4例行注射法粘膜分片切除术(EPMR)，1例行透明帽辅助粘膜分片切除术(EPMR)，3例行单纯PSD术切除病变。所有内镜治疗均获得成功，无并发症发生。内镜下粘膜剥离切除治疗大肠侧向发育型肿瘤护理的重点是：术前肠道清洁、心理护理、合理术前用药，术后病情观察、饮食管理、排便指导等，有效地控制了并发症的发生，减轻了病人的痛苦，提高了治疗效果，达到了预期目标。     

大肠侧向发育型肿瘤内镜下的诊断与治疗

目的探讨大肠侧向发育型肿瘤（LST）临床病理特征及内镜下黏膜切除术的有效性、安全性。方法经普通内镜检查发现LST 119例,染色后观察病灶大小及部位并进行形态分型,再结合放大内镜确定腺管开口类型。有治疗适应证者行内镜下黏膜切除术,切除病灶黏膜送病理检查。结果 28个月中共发现119例LST 124个病变。内镜下分型：颗粒均一型44个,结节混合型48个,平坦隆起型23个,假凹陷型9个。病变直径：10～20 mm 65个,21～30 mm 23个,31 mm以上36个,最大病变110 mm×100 mm。病变部位：直肠50个,乙状结肠25个,降结肠11个,横结肠10个,升结肠＋盲肠28个。黏膜腺管开口类型：Ⅲ型30个,其中17个为管状绒毛状腺瘤,12个为管状腺瘤;Ⅳ型56个,其中30个为绒毛状腺瘤,4个为黏膜内癌;Ⅴ型5个,其中2个为黏膜内癌,2个累及黏膜下层下1/3以下;Ⅱ型7个,其中5个为炎性增生性息肉,2个为锯齿状腺瘤（腺瘤性增生性息肉）：其余为ⅢL＋V型,其中23个为管状绒毛状腺瘤。符合适应证95例98个病变择期进行内镜下黏膜切除治疗,发生出血11例,均在操作过程中,无肠穿孔发生。结论大肠LST内镜形态具有一定特殊性,内镜下黏膜切除术是治疗在大肠的有效而安全的方法,可达到根治目的 。     

大肠侧向发育型肿瘤的诊断及粘膜剥离切除治疗

目的：探讨放大染色内镜对大肠侧向发育型肿瘤（Laterally Spreading Tumor，LST）的诊断与治疗价值，以及LST的临床意义。方法：使用日本Olympus光学仪器公司生产的CF-Q240I和CF-Q240ZI电子肠镜，对2001年12月12日至 2002年7月31日在我院作肠镜检查患（共1052例），发病病变后采用0.4％靛胭脂行病变粘膜染色，放大内镜观察，确定病变腺管开口分型；同时或择期进行注射法粘膜剥离（EMA）或注射法粘膜分片切除（EPMR）治疗。结果：检出LST患9例，检出率0.85％；其中直肠4例，乙状结肠1例，横结肠2例，升结肠2例；颗粒均一型4例，结节混合型5例；表现为ⅢL型腺管开口3例（33.3％），Ⅳ型腺管开口6例（66.7％）。全部病例行EMR或EPMR治疗，未发生任何出血或穿孔等并发症。结论：大肠LST在我国有较高的检出率，LST与大肠癌关系密切，对其应足够重视，放大内镜结合粘膜染色技术是发现病变的重要手段，治疗上采用内镜下粘膜剥离术是安全可行的。     

大肠侧向发育型肿瘤的内镜诊断与治疗

目的观察大肠侧向发育型肿瘤（LST）的大体形态、隐窝开口及其与病理组织学的相关性；评价内镜下黏膜切除术（EMR）及氩离子凝固术（APC）联合治疗LST的疗效。方法应用黏膜染色技术对42例（45个病灶）大肠侧向发育型肿瘤隐窝开口形态观察，并进行EMR或内镜下分片黏膜切除（EPMR）及APC治疗，切除的标本进行病理组织学检查，术后随访。结果2450例结直肠瘤中发现LST 42例（45个病变），占1．7％；该42例中9例有家族性大肠肿瘤史，占21．4％。45个LST病变中颗粒均一型、结节混合型、扁平隆起型和假凹陷型分别为26．7％，28．9％，40．0％和4．4％；其中管状腺瘤20个，绒毛管状腺瘤23个，锯齿状腺瘤（Serrated腺瘤）2个，中度以上异型增生64．4％（29个），局部癌变11．1％（3个m癌，2个sm癌）。病理诊断的23个绒毛管状腺瘤中Ⅳ型隐窝开口20个，Ⅳ型隐窝开口与病理诊断符合率为86．9％（20／23）。3个病变行外科手术治疗，42个病变在内镜下治疗，经3个月～6年随访，除1例sm2癌外科手术后发生肝转移死亡外，其余病变均治疗成功。结论观察LST的大体形态、隐窝开口改变和“非提起征”改变，有助于在内镜下正确估计病变的组织学改变和黏膜下浸润深度，从而指导选择正确的治疗方案，EMR或EPMR联合APC治疗LST安全、有效，长期随访观察疗效可靠。     

色素内镜联合内镜黏膜切除术诊治结直肠侧向发育型肿瘤的临床研究

背景:结直肠侧向发育型肿瘤(LST)与结直肠癌关系密切。目的:探讨色素内镜联合内镜黏膜切除术(EMR)对结直肠LST的临床诊疗价值。方法:纳入2009年7月～2012年2月于达县人民医院行结肠镜检查发现可疑病灶的患者2200例,对病灶内镜下喷洒0.4%靛胭脂行黏膜染色。对染色发现的LST,观察病灶大小并进行形态分型。对LST病灶行EMR或内镜分片黏膜切除术(EPMR),未能行EMR或EPMR者行内镜下活检。结果:黏膜染色后发现结直肠LST患者28例,共30个LST病灶。30个LST病灶中颗粒均一型14个(46.7%),结节混合型8个(26.7%),平坦隆起型5个(16.7%),假凹陷型3个(10.0%);行EMR19个(63.3%),行EPMR6个(20.0%),行内镜下活检5个(16.7%)。病理学检查示早期结直肠癌4个(13.3%),进展期结直肠癌3个(10.0%),腺瘤23个(76.7%)。结论:色素内镜可有效发现结直肠LST病灶。色素内镜联合EMR或EPMR根除LST病灶对早期结直肠癌的防治具有积极意义。     

内镜分片黏膜切除术治疗巨大结直肠平坦型病变的临床评价及复发率随访

目的评价内镜分片黏膜切除术(endoscopic piecemeal mucosal resection,EPMR)治疗巨大结直肠平坦型病变的疗效、安全性及应用价值,并随访观察其复发率。方法经术前内镜检查评估及病理证实,符合内镜切除适应证,采用EPMR切除46例直径≥30 mm结直肠平坦型病变,均为侧向发育型肿瘤(LST),术后标本全部行精确的病理学评价。结果 46例结直肠LST患者中,病灶位于直肠38例,占82.6%,完全切除率93.5%(43/46),切除治愈率97.8%(45/46)。术后出血发生率为4.3%,均经内镜止血成功,无1例发生穿孔。术后病理均为腺瘤,伴低级别上皮内瘤变30例,伴高级别上皮内瘤变10例,黏膜内癌6例。全组患者随访3~96个月,仅2例复发,复发率4.3%,再次内镜处理获愈。结论 EPMR是治疗巨大结直肠平坦型病变安全、有效的方法,掌握切除方法和技巧,可以完全切除病变,减少残留及复发率。     

染色内镜和放大内镜诊治大肠侧向发育型肿瘤

目的大肠侧向发育型肿瘤(LST)与大肠癌关系密切,其诊治不同于一般的隆起样肿瘤,文章总结LST内镜诊断与治疗的经验,以引起临床上对这个特殊类型肿瘤的重视。方法内镜检查发现肠道黏膜发红或粗糙、血管网不清或消失等病变,行靛胭脂染色后放大内镜观察其腺管开口类型。结果18个月中共发现34例LST 35个病变。其中黏膜内癌4例,锯齿状肿瘤2例。35个病变内镜分型颗粒均一型15个,结节混合型18个,假凹陷型2个。病变最大为68 mm×85 mm;11～20mm 8个,21～30 mm 13个,30 mm以上14个。大肠黏膜腺管开口类型ⅢL型10个,其中8个为管状绒毛状腺瘤;Ⅳ型22个,其中16个为绒毛状腺瘤,1个黏膜内癌;ⅤA型3个,均为黏膜内癌。35个病变全部即时或择期进行内镜下切除治疗,发生出血和局限性腹膜炎各1例。结论应用黏膜染色技术和放大内镜有助于LST的诊断。LST的腺管开口大多数表现为Ⅳ型或ⅢL型,ⅢL型腺管开口多为管状腺瘤,Ⅳ型腺管开口多为绒毛状腺瘤,一旦出现Ⅴ型腺管开口则表明已经有癌变发生。     

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     

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.     

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.     

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.     

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.