Chithandizo cha endoscopic cha zotupa za submucosal za m'mimba: mfundo zazikulu zitatu zomwe zafotokozedwa m'nkhani imodzi

Zilonda za submucosal (SMT) za m'mimba ndi zilonda zokwera zomwe zimachokera ku muscularis mucosa, submucosa, kapena muscularis propria, ndipo zitha kukhalanso zilonda zakunja kwa luminal. Ndi chitukuko cha ukadaulo wazachipatala, njira zochiritsira opaleshoni zachikhalidwe zalowa pang'onopang'ono munthawi ya chithandizo chocheperako, monga lopaleshoni ya aparoscopic ndi opaleshoni ya robotic. Komabe, m'machitidwe azachipatala, zitha kupezeka kuti "opaleshoni" siyoyenera odwala onse. M'zaka zaposachedwa, kufunika kwa chithandizo cha endoscopic kwakhala kukulandiridwa pang'onopang'ono. Mtundu waposachedwa wa mgwirizano wa akatswiri aku China pa matenda a endoscopic ndi chithandizo cha SMT watulutsidwa. Nkhaniyi iphunzira mwachidule chidziwitso chofunikira.

1. Khalidwe la mliri wa SMTmalamulo

(1) Kuchuluka kwa matenda a SMMatenda a T ndi osafanana m'magawo osiyanasiyana am'mimba, ndipo m'mimba ndiye malo ofala kwambiri a SMT.

Kuchuluka kwa mitundu yosiyanasiyanaZiwalo za m'mimba mwawo sizili zofanana, ndipo m'mimba mwawo muli zambiri. Mwa izi, 2/3 zimapezeka m'mimba, kutsatiridwa ndi m'mero, duodenum, ndi m'matumbo akulu.

(2) Katswiri wa za histopathologyMitundu ya SMT ndi yovuta, koma SMT yambiri ndi zilonda zopanda vuto, ndipo zochepa zokha ndi zotupa.

A.SMT ili ndi palibeZilonda za n-neoplastic monga ectopic pancreatic tissue ndi zotupa za neoplastic.

B. Pakati pa chotupa cha neoplastics, leiomyomas ya m'mimba, lipomas, Brucella adenomas, zotupa za maselo a granulosa, schwannomas, ndi zotupa za glomus nthawi zambiri zimakhala zopanda vuto, ndipo zosakwana 15% zimatha kuwoneka ngati minofu. Phunzirani zoyipa.

C. Stroma ya m'mimbaMatenda a l (GIST) ndi matenda a neuroendocrine (NET) mu SMT ndi matenda omwe ali ndi mphamvu inayake yoipa, koma izi zimatengera kukula kwake, malo ake ndi mtundu wake.

D. Malo a SMT ndi ofananaku gulu la matenda: a. Ma Leiomyoma ndi mtundu wofala wa SMT m'mero, womwe umakhala 60% mpaka 80% ya SMT ya m'mero, ndipo nthawi zambiri amapezeka pakati ndi pansi pa mmero; b. Mitundu ya matenda a SMT ya m'mimba ndi yovuta kwambiri, yokhala ndi GIST, leiomyoMa ndi ectopic pancreas ndizofala kwambiri. Pakati pa SMT ya m'mimba, GIST imapezeka kwambiri mu fundus ndi thupi la m'mimba, leiomyoma nthawi zambiri imapezeka mu cardia ndi kumtunda kwa thupi, ndipo ectopic pancreas ndi ectopic pancreas ndizofala kwambiri. Ma Lipomas amapezeka kwambiri mu antrum ya m'mimba; c. Ma Lipomas ndi ma cysts amapezeka kwambiri m'malo otsika komanso okulirapo a duodenum; d. Mu SMT ya m'mimba, ma lipomas amapezeka kwambiri m'matumbo, pomwe ma NET amakhala ambiri mu rectum.

(3) Gwiritsani ntchito CT ndi MRI kuti muyese, kuchiza, ndikuwunika zotupa. Kwa SMTs zomwe zikuganiziridwa kuti zitha kukhala zoopsa kapena zotupa zazikulu (zazitali).m'mimba mwake > 2 cm), CT ndi MRI ndizoyenera.

Njira zina zojambulira zithunzi, kuphatikizapo CT ndi MRI, ndizofunikira kwambiri pakupeza matenda a SMT. Zingathe kuwonetsa mwachindunji malo omwe chotupacho chachitika, kukula kwake, kukula kwa chilonda, mawonekedwe ake, kukhalapo kapena kusakhalapo kwa malo otupa, kuchulukana kwake, kufanana kwake, kuchuluka kwa kukula kwake, ndi mawonekedwe ake, ndi zina zotero, ndipo zimatha kudziwa ngati ndi kuchuluka kwa makulidwe ake.Kutsekeka kwa khoma la m'mimba. Chofunika kwambiri, kufufuza kumeneku kumatha kuzindikira ngati pali kufalikira kwa ziwalo zapafupi za chotupacho komanso ngati pali kufalikira kwa maselo m'mimba yozungulira, ma lymph nodes ndi ziwalo zina. Ndi njira yayikulu yowunikira matenda, chithandizo, komanso kuwunika momwe khansa ikuyendera.

(4) Kusankha minofu sikunakonzedwensoYapangidwira ma SMT abwino omwe angadziwike ndi endoscopy yachikhalidwe pamodzi ndi EUS, monga lipomas, cysts, ndi ectopic pancreas.

Pa zilonda zomwe zikuganiziridwa kuti ndi zowopsa kapena pamene endoscopy yachikhalidwe yophatikizidwa ndi EUS singathe kuwona zilonda zabwino kapena zoyipa, EUS-guided fine-sindle aspiration/biopsy ingagwiritsidwe ntchito (endoscopic ultrasonography guided fine nKuchotsa chimbudzi/kuchotsa poizoni m'thupi, EUS-FNA/FNB), biopsy ya mucosal incision (biopsy yothandizidwa ndi mucosalincision, MIAB), ndi zina zotero. Chitani zitsanzo za biopsy kuti muwunikenso matenda asanayambe opaleshoni. Poganizira zofooka za EUS-FNA ndi zotsatira zake pa kuchotsa endoscopic resection, kwa iwo omwe ali oyenerera opaleshoni ya endoscopic, poganizira kuti chotupacho chikhoza kuchotsedwa kwathunthu, mayunitsi okhala ndi ukadaulo wokhwima wa chithandizo cha endoscopic amatha kuchiritsidwa ndi katswiri wodziwa bwino ntchito. Dokotala wa endoscopist amachita opaleshoni ya endoscopic resection mwachindunji popanda kupeza matenda asanayambe opaleshoni.

Njira iliyonse yopezera zitsanzo za matenda musanachite opaleshoni ndi yowononga ndipo imawononga mucosa kapena kuyambitsa kumamatira ku minofu ya submucosal, motero imawonjezera zovuta za opaleshoni ndipo mwina imawonjezera chiopsezo cha kutuluka magazi, kuchita bwino.Kuyeza magazi, ndi kufalikira kwa chotupa. Chifukwa chake, biopsy isanachitike opaleshoni sikofunikira kwenikweni. Zofunikira, makamaka kwa ma SMT omwe amatha kuzindikirika pogwiritsa ntchito endoscopy yachikhalidwe pamodzi ndi EUS, monga lipomas, cysts, ndi ectopic pancreas, sizifunikira kuyesedwa kwa minofu.

2. Chithandizo cha SMT endoscopynt

(1) Mfundo zochizira

Zilonda zomwe zilibe ma lymph node metastasis kapena chiopsezo chochepa cha ma lymph node metastasis, zimatha kuchotsedwa kwathunthu pogwiritsa ntchito njira za endoscopic, ndipo zili ndi chiopsezo chochepa cha zotsalira ndi kubwereranso ndizoyenera kuchotsedwa endoscopic resection ngati chithandizo chili chofunikira. Kuchotsa kwathunthu chotupacho kumachepetsa chotupa chotsala ndi chiopsezo cha kubwereranso.Mfundo ya chithandizo chopanda chotupa iyenera kutsatiridwa pochotsa endoscopic resection, ndipo umphumphu wa kapisozi wa chotupa uyenera kutsimikizika panthawi yochotsa.

(2) Zizindikiro

i. Zotupa zomwe zingaoneke ngati zili ndi vuto lalikulu pozifufuza musanachite opaleshoni kapena zomwe zatsimikiziridwa ndi biopsy pathology, makamaka zomwe zikuganiziridwa kuti zili ndi vuto la GIST yokhala ndi kuwunika kwa kutalika kwa chotupa cha ≤2cm isanachitidwe opaleshoni komanso chiopsezo chochepa chobwereranso ndi kufalikira kwa khansa, komanso kuthekera kochotsedwa kwathunthu, ikhoza kuchotsedwa kudzera mu endoscopically; pa zotupa zomwe zili ndi mainchesi ataliatali. Pa GIST yomwe ikuganiziridwa kuti ndi yotsika kwambiri >2cm, ngati lymph node kapena kufalikira kwa khansa yakutali kwachotsedwa pakuwunika isanachitidwe opaleshoni, poganizira kuti chotupacho chikhoza kuchotsedwa kwathunthu, opaleshoni ya endoscopic ikhoza kuchitidwa ndi akatswiri odziwa bwino ntchito ya endoscopic mu chipinda chokhala ndi ukadaulo wokhwima wa chithandizo cha endoscopic.

ii. Zizindikiro (monga kutuluka magazi, kutsekeka) SMT.

iii. Odwala omwe akuganiziridwa kuti zotupa zawo ndi zabwino powafufuza asanachite opaleshoni kapena atatsimikiziridwa ndi matenda, koma sangatsatidwe nthawi zonse kapena omwe zotupa zawo zimakula mkati mwa nthawi yochepa panthawi yotsatiridwa ndipo ali ndi chikhumbo champhamvu.e kwa chithandizo cha endoscopic.

(3) Zotsutsana

i. Dziwani zilonda zomwe zimandipangitsakulowetsedwa m'malo a lymph nodes kapena malo akutali.

ii. Kwa ena a SMT omwe ali ndi lymph yoyeranodekapena kufalikira kwa maselo akutali, biopsy yochuluka imafunika kuti mupeze matenda, omwe angaonedwe ngati choletsa.

iii. Pambuyo pa opaleshoni yathunthuPakuwunika, zapezeka kuti vuto lonse ndi loipa ndipo opaleshoni ya endoscopic siingatheke.

Zilonda zosavulaza monga lipoma ndi ectopic pancreatic nthawi zambiri sizimayambitsa zizindikiro monga kupweteka, kutuluka magazi, ndi kutsekeka.MT imaonekera ngati kukokoloka, zilonda, kapena kukula mofulumira pakapita nthawi yochepa, kuthekera kokhala chotupa choopsa kumawonjezeka.

(4) Kusankha njira yochotsera chilondad

Kuchotsa msampha wa Endoscopic: KwaSMT yomwe ili pamwamba, imatuluka m'bowo monga momwe zatsimikiziridwa ndi mayeso a EUS ndi CT asanachite opaleshoni, ndipo imatha kuchotsedwa kwathunthu nthawi imodzi ndi snare, endoscopic snare resection ingagwiritsidwe ntchito.

Kafukufuku wa m'dziko ndi kunja kwa dziko watsimikizira kuti ndi wotetezeka komanso wogwira ntchito bwino pa SMT yocheperako <2cm, yokhala ndi chiopsezo chotaya magazi cha 4% mpaka 13% komanso kuboolachiopsezo cha 2% mpaka 70%.

Kufukula kwa submucosal ya endoscopic, ESE: Kwa ma SMT okhala ndi mainchesi aatali ≥2 cm kapena ngati mayeso owunikira zithunzi asanachite opaleshoni monga EUS ndi CT atsimikizira iziChotupa chikatuluka m'chimake, ESE ndi yotheka kuchotsa ma SMT ofunikira m'chimake pogwiritsa ntchito endoscopic sleeve resection.

ESE ikutsatira zizolowezi zaukadaulo zaKuduladula kwa endoscopic submucosal (ESD) ndi kuchotsa kwa endoscopic mucosal, ndipo nthawi zonse amagwiritsa ntchito kudula kozungulira "flip-top" kuzungulira chotupacho kuti achotse mucosa yomwe imaphimba SMT ndikuwulula chotupacho mokwanira. , kuti akwaniritse cholinga chosunga umphumphu wa chotupacho, kukonza kufalikira kwa opaleshoni, ndikuchepetsa zovuta mkati mwa opaleshoni. Pa zotupa ≤1.5 cm, kuchuluka kwathunthu kwa kuchotsa kwa 100% kumatha kuchitika.

Submucosal Tunneling Endoscopic Resection, STER: Pa SMT yochokera ku muscularis propria mu esophagus, hilum, kupindika kochepa kwa thupi la m'mimba, gastric antrum ndi rectum, zomwe zimakhala zosavuta kukhazikitsa ma tunnel, ndipo m'mimba mwake wopingasa ndi ≤ 3.5 cm, STER ikhoza kukhala njira yabwino kwambiri yochizira.

STER ndi ukadaulo watsopano wopangidwa kutengera njira ya peroral endoscopic esophageal sphincterotomy (POEM) ndipo ndi njira yowonjezera yaukadaulo wa ESD.Chiŵerengero cha kuchotsedwa kwa STER pa chithandizo cha SMT chafika pa 84.9% mpaka 97.59%.

Endoscopic Full-makulidwe Resection, EFTR: Ingagwiritsidwe ntchito pa SMT komwe kuli kovuta kukhazikitsa ngalande kapena komwe m'mimba mwake wopingasa wa chotupa ndi ≥3.5 cm ndipo sikoyenera STER. Ngati chotupacho chituluka pansi pa nembanemba yofiirira kapena chikukulira kunja kwa gawo la m'mimba, ndipo chotupacho chikupezeka kuti chimamatira kwambiri ku serosa wosanjikiza panthawi ya opaleshoni ndipo sichingalekanitsidwe, chingagwiritsidwe ntchito. EFTR imachita chithandizo cha endoscopic.

Kusoka koyenera kwa kubowolaMalo otsatira EFTR ndiye chinsinsi cha kupambana kwa EFTR. Pofuna kuwunika molondola chiopsezo cha kubwereranso kwa chotupa ndikuchepetsa chiopsezo cha kufalikira kwa chotupa, sikulimbikitsidwa kudula ndikuchotsa chitsanzo cha chotupa chomwe chachotsedwa panthawi ya EFTR. Ngati pakufunika kuchotsa chotupacho m'zidutswa, kubowoka kuyenera kukonzedwa kaye kuti kuchepetse chiopsezo cha kumera kwa chotupa ndikufalikira. Njira zina zomangira ndi monga: suture yachitsulo, suture yolumikizira, njira yolumikizira ya omental patch, njira ya "thumba la thumba" ya chingwe cha nayiloni chophatikizidwa ndi clip yachitsulo, njira yotsekera ya rake metal clip (over the scope clip, OTSC) suture ya OverStitch ndi ukadaulo wina watsopano wokonzanso kuvulala kwa m'mimba komanso kuthana ndi kutuluka magazi, ndi zina zotero.

(5) Mavuto pambuyo pa opaleshoni

Kutuluka magazi mkati mwa opaleshoni: Kutuluka magazi komwe kumayambitsa hemoglobin ya wodwalayo kutsika ndi kupitirira 20 g/L.
Pofuna kupewa kutuluka magazi ambiri panthawi ya opaleshoni,Kuthira jakisoni wokwanira wa submucosal kuyenera kuchitika panthawi ya opaleshoni kuti mitsempha ikuluikulu yamagazi iwonekere komanso kuti magazi azitha kutuluka ndi electrocoagulation kuti magazi asiye kutuluka. Kutuluka magazi mkati mwa opaleshoni kumatha kuchiritsidwa ndi mipeni yosiyanasiyana yodulira, hemostatic forceps kapena metal clips, komanso kupewa hemostasis ya mitsempha yamagazi yomwe yapezeka panthawi yodulira.

Kutuluka magazi pambuyo pa opaleshoni: Kutuluka magazi pambuyo pa opaleshoni kumaonekera ngati kusanza magazi, melena, kapena magazi m'chimbudzi. Pa milandu yoopsa, kugwedezeka kwa magazi kumatha kuchitika. Kawirikawiri kumachitika mkati mwa sabata imodzi mutachita opaleshoni, koma kumathanso kuchitika milungu iwiri mpaka inayi mutachita opaleshoni.

Kutuluka magazi pambuyo pa opaleshoni nthawi zambiri kumakhudzana ndiZinthu monga kusalamulira bwino kuthamanga kwa magazi pambuyo pa opaleshoni komanso kuwonongeka kwa mitsempha yotsala ya magazi chifukwa cha asidi wa m'mimba. Kuphatikiza apo, kutuluka magazi pambuyo pa opaleshoni kumagwirizananso ndi komwe matendawa adachitikira, ndipo amapezeka kwambiri m'mimba ndi m'malo otsika a rectum.

Kuboola mochedwa: Nthawi zambiri kumawonekera monga kutupa kwa m'mimba, kupweteka kwa m'mimba kowonjezereka, zizindikiro za peritonitis, malungo, ndipo kuwunika zithunzi kumasonyeza kuchuluka kwa mpweya kapena kuchuluka kwa mpweya poyerekeza ndi kale.

Kawirikawiri zimayenderana ndi zinthu monga kusoka bwino mabala, kuuma kwa magetsi kwambiri, kudzuka msanga kwambiri kuti usayendeyende, kudya kwambiri, kuchepetsa shuga m'magazi, komanso kuwonongeka kwa mabala chifukwa cha asidi m'mimba. a. Ngati bala ndi lalikulu kapena lakuya kapena bala lili ndi fisNgati pali kusintha kulikonse, nthawi yogona pabedi ndi nthawi yosala kudya ziyenera kukulitsidwa moyenera ndipo kuchepetsa m'mimba kuyenera kuchitika pambuyo pa opaleshoni (odwala omwe achitidwa opaleshoni ya m'mimba ayenera kuchotsedwa madzi m'njira ya m'mimba); b. Odwala matenda a shuga ayenera kuwongolera shuga m'magazi mwawo mosamala; omwe ali ndi mabowo ang'onoang'ono komanso matenda ofatsa a pachifuwa ndi m'mimba ayenera kupatsidwa chithandizo monga kusala kudya, kupewa matenda, komanso kuletsa asidi; c. Kwa iwo omwe ali ndi effusion, kutseka kwa chifuwa ndi kubowola m'mimba kumatha kuchitika. Machubu ayenera kuyikidwa kuti madzi aziyenda bwino; d. Ngati matendawa sangathe kupezeka m'malo mwake pambuyo pa chithandizo chokhazikika kapena ataphatikizidwa ndi matenda oopsa a thoracoabdominal, opaleshoni ya laparoscopy iyenera kuchitidwa mwachangu momwe zingathere, ndipo kukonza mabowo ndi kutulutsa madzi m'mimba kuyenera kuchitidwa.

Mavuto okhudzana ndi mpweya: Kuphatikizapo subcutaneous emphysema, pneumomediastinum, pneumothorax ndi pneumoperitoneum.

Kutsegula m'mimba mwa munthu pogwiritsa ntchito njira ya opaleshoni (yomwe imatchedwa kuti emphysema pankhope, pakhosi, pachifuwa, ndi m'mabele) ndi mediastinal pneumophysema (s).Kutuluka kwa epiglottis kungapezeke panthawi ya gastroscopy) nthawi zambiri sikufuna chithandizo chapadera, ndipo emphysema nthawi zambiri imatha yokha.

Pneumothorax yoopsa imachitika dopaleshoni yopuma [kuthamanga kwa mpweya kumapitirira 20 mmHg panthawi ya opaleshoni

(1mmHg=0.133kPa), SpO2<90%, yotsimikiziridwa ndi X-ray ya pachifuwa chapafupi ndi bedi], opaleshoni nthawi zambiri imatha kupitilizidwa pambuyo potseka chifuwazaka.

Kwa odwala omwe ali ndi pneumoperitoneum yoonekeratu panthawi ya opaleshoni, gwiritsani ntchito singano ya pneumoperitoneum kuti muboole nsonga ya McFarland.Ikani m'mimba mwa kumanja pansi kuti mpweya utuluke, ndikusiya singano yoboola m'malo mwake mpaka kumapeto kwa opaleshoni, kenako muichotse mutatsimikizira kuti palibe mpweya woonekera womwe watuluka.

Fistula ya m'mimba: Madzi otuluka m'mimba omwe amayambitsidwa ndi opaleshoni ya endoscopic amalowa m'chifuwa kapena m'mimba kudzera mu kutuluka kwa madzi.
Fistula ya m'mimba ndi m'mimba ndi yofala kwambiri. Fistula ikayamba, tsegulani chifuwa kuti musamavutike.mu ngalande yosalala komanso kupereka chithandizo chokwanira cha zakudya. Ngati pakufunika, zingwe zachitsulo ndi zida zosiyanasiyana zotsekera zingagwiritsidwe ntchito, kapena chophimba chonsecho chikhoza kubwezeretsedwanso. Ma stenti ndi njira zina zimagwiritsidwa ntchito kutsekaMatenda a fistula. Milandu yoopsa imafuna opaleshoni yachangu.

3. Kusamalira pambuyo pa opaleshoni (f)kuvomereza)

(1) Zilonda zosavulaza:Matendaakusonyeza kuti zilonda zosavulaza monga lipoma ndi leiomyoma sizimafuna kutsatiridwa nthawi zonse.

(2) SMT yopanda njirukuthekera kwa nyerere:Mwachitsanzo, ma NET a rectal 2cm, ndi GIST yapakati komanso yoopsa kwambiri, magawo onse ayenera kuchitidwa ndipo chithandizo china (opaleshoni, mankhwala a chemoradiotherapy, chithandizo cholunjika) chiyenera kuganiziridwa mwamphamvu. Kukonza dongosololi kuyenera kutengera upangiri wa akatswiri osiyanasiyana komanso payekhapayekha.

(3) SMT yochepa yomwe ingayambitse khansa:Mwachitsanzo, GIST yomwe ili ndi chiopsezo chochepa iyenera kuyesedwa ndi EUS kapena kujambula miyezi 6 mpaka 12 iliyonse mutalandira chithandizo, kenako nkuchiritsidwa motsatira malangizo azachipatala.

(4) SMT yokhala ndi mphamvu yapakati komanso yapamwamba ya khansa:Ngati matenda a pambuyo pa opaleshoni atsimikizira mtundu wachitatu wa NET m'mimba, NET ya m'matumbo yokhala ndi kutalika kwa >2cm, ndi GIST yapakati komanso yoopsa kwambiri, kuwunika kwathunthu kuyenera kuchitidwa ndipo chithandizo china (opaleshoni, mankhwala a chemotherapy, chithandizo cholunjika) chiyenera kuganiziridwa mwamphamvu.[za ife 0118.docx]uphungu wa akatswiri osiyanasiyana komanso payekhapayekha.