Chithandizo cha endoscopic cha zotupa zam'mimba zam'mimba: mfundo zazikulu 3 zomwe zafotokozedwa mwachidule m'nkhani imodzi.

Submucosal tumors (SMT) ya m'mimba ndi zotupa zokwezeka zochokera ku muscularis mucosa, submucosa, kapena muscularis propria, komanso zitha kukhala zotupa za extraluminal.Ndi chitukuko chaukadaulo wazachipatala, njira zopangira opaleshoni zachikhalidwe zalowa pang'onopang'ono m'nthawi ya chithandizo chochepa kwambiri, monga l.opaleshoni ya laparoscopic ndi opaleshoni ya robotic.Komabe, muzochita zachipatala, zikhoza kupezeka kuti "opaleshoni" si yoyenera kwa odwala onse.M'zaka zaposachedwa, mtengo wa chithandizo endoscopic walandira chidwi pang'onopang'ono.Mtundu waposachedwa wa mgwirizano wa akatswiri aku China pa matenda a endoscopic ndi chithandizo cha SMT watulutsidwa.Nkhaniyi iphunzira mwachidule chidziwitso choyenera.

1.Mliri wamtundu wa SMTotsutsa

(1) Zochitika za SMT ndi yosiyana m'madera osiyanasiyana a m'mimba, ndipo m'mimba ndi malo omwe amapezeka kwambiri a SMT.

Zochitika zosiyanasiyanas mbali za m`mimba thirakiti ndi wosagwirizana, ndi chapamwamba m`mimba thirakiti kukhala ambiri.Mwa izi, 2/3 imapezeka m'mimba, ndikutsatiridwa ndi esophagus, duodenum, ndi colon.

(2) The histopathologicall mitundu ya SMT ndi yovuta, koma ma SMT ambiri ndi zilonda zowopsa, ndipo ochepa okha ndi owopsa.

A.SMT imaphatikizapo ayiN-neoplastic zotupa monga ectopic pancreatic minofu ndi zotupa za neoplastic.

B. Pakati pa zotupa za neoplastics, ma leiomyomas a m'mimba, lipomas, Brucella adenomas, zotupa zama cell a granulosa, schwannomas, ndi zotupa za glomus nthawi zambiri zimakhala zowopsa, ndipo zosakwana 15% zimatha kuwoneka ngati minofu Phunzirani zoyipa.

C. M'mimba stromal zotupa (GIST) ndi zotupa za neuroendocrine (NET) mu SMT ndi zotupa zomwe zili ndi mphamvu zina zowopsa, koma izi zimadalira kukula kwake, malo ndi mtundu wake.

D. Malo a SMT ndi okhudzanaku gulu la pathological: a.Leiomyomas ndi mtundu wamba wamtundu wa SMT mum'mero, womwe umawerengera 60% mpaka 80% ya SMTs zam'mimero, ndipo nthawi zambiri zimachitika pakati ndi m'munsi zigawo za mmero;b. Mitundu ya matenda a m'mimba ya SMT ndi yovuta kwambiri, yokhala ndi GIST, leiomyoMa ndi ectopic kapamba omwe amapezeka kwambiri.Pakati pa chapamimba SMT, GIST imapezeka kwambiri mu fundus ndi thupi la m'mimba, leiomyoma nthawi zambiri imapezeka kumtima ndi kumtunda kwa thupi, ndipo ectopic pancreas ndi ectopic pancreas ndizofala kwambiri.Lipomas amapezeka kwambiri m'mimba;c.Lipomas ndi cysts ndizofala kwambiri m'madera otsika ndi a bulbous a duodenum;d.Mu SMT ya m'munsi m'mimba thirakiti, ma lipomas ndi omwe amapezeka kwambiri m'matumbo, pomwe ma NET ndi omwe amapezeka kwambiri mu rectum.

(3) Gwiritsani ntchito CT ndi MRI kuti muwerenge, kuchiza, ndikuwunika zotupa.Kwa ma SMT omwe akuganiziridwa kuti ndi owopsa kapena ali ndi zotupa zazikulu (zautalim'mimba mwake> 2 cm), CT ndi MRI akulimbikitsidwa.

Njira zina zojambulira, kuphatikizapo CT ndi MRI, ndizofunikanso kwambiri pozindikira matenda a SMT.Amatha kuwonetsa mwachindunji malo a chotupa, mawonekedwe a kukula, kukula kwa chotupa, mawonekedwe, kupezeka kapena kusapezeka kwa lobulation, kachulukidwe, homogeneity, kuchuluka kwa kukulitsa, ndi mizere yamalire, ndi zina zotero, ndipo amatha kupeza ngati ndi kuchuluka kwaKuchuluka kwa khoma la m'mimba. Chofunika kwambiri, kufufuza kojambula kumeneku kungathe kudziwa ngati pali kuukira kwa ziwalo zoyandikana ndi zilondazo komanso ngati pali metastasis mu peritoneum yozungulira, ma lymph nodes ndi ziwalo zina.Ndiwo njira yayikulu yopangira matenda, chithandizo ndi kuwunika kwa zotupa.

(4) Kuyesa kwa minofu sikubwereransozopangira ma SMTs abwino omwe amatha kuzindikirika ndi endoscopy wamba kuphatikiza ndi EUS, monga lipomas, cysts, ndi kapamba ectopic.

Pa zotupa zomwe zikuganiziridwa kuti ndizowopsa kapena ngati endoscopy yodziwika bwino yophatikizidwa ndi EUS siyingawunikire zotupa zowopsa kapena zowopsa, kuwongolera singano motsogozedwa ndi EUS kungagwiritsidwe ntchito (endoscopic ultrasonography guided fine n.eedle aspiration/biopsy, EUS-FNA/FNB), mucosal incision biopsy(mucosalincision-assisted biopsy, MIAB), ndi zina zotero.Poona zofooka za EUS-FNA ndi zotsatira zotsatila za endoscopic resection, kwa iwo omwe ali oyenerera opaleshoni ya endoscopic, poyang'ana kuti chotupacho chikhoza kuchotsedwa kwathunthu, mayunitsi omwe ali ndi luso lachipatala la endoscopic akhoza kuthandizidwa ndi odziwa zambiri. The endoscopist amachita endoscopic resection mwachindunji popanda kupeza preoperative pathological matenda.

Njira iliyonse yopezera zitsanzo za pathological musanachite opaleshoni imakhala yovuta ndipo idzawononga mucosa kapena kuyambitsa kumamatira ku minofu ya submucosal, potero kumawonjezera vuto la opaleshoni ndipo mwinamwake kuonjezera kuopsa kwa magazi, perfo.kudya, ndi kufalitsa chotupa.Choncho, preoperative biopsy sikofunikira.Zofunikira, makamaka kwa ma SMT omwe amatha kuzindikiridwa ndi endoscopy wamba kuphatikiza ndi EUS, monga lipomas, cysts, ndi kapamba ectopic, palibe zitsanzo za minofu zomwe zimafunikira.

2.SMT endoscopic mankhwalant

(1) Mfundo zachipatala

Zilonda zomwe zilibe ma lymph node metastasis kapena chiopsezo chochepa kwambiri cha lymph node metastasis, chingathe kuchotsedwa kwathunthu pogwiritsa ntchito njira za endoscopic, ndipo zimakhala ndi chiopsezo chochepa chotsalira ndi kuyambiranso ndizoyenera kutulutsa endoscopic ngati kuli kofunikira.Kuchotsa kwathunthu chotupacho kumachepetsa chotupa chotsalira komanso chiopsezo choyambiranso.TheMfundo ya chithandizo chopanda chotupa iyenera kutsatiridwa panthawi ya endoscopic resection, ndipo kukhulupirika kwa kapisozi kotupa kuyenera kutsimikiziridwa panthawi ya resection.

(2) Zizindikiro

i.Zotupa zowopsa zomwe zimaganiziridwa poyesedwa asanachite opaleshoni kapena kutsimikiziridwa ndi biopsy pathology, makamaka omwe akuganiziridwa kuti ali ndi GI.ST ndi kuwunika koyambirira kwa chotupa kutalika kwa ≤2cm ndi chiopsezo chochepa cha kubwereza ndi metastasis, komanso kuthekera kwa kuchotsedwa kwathunthu, kutha kuchitidwanso endoscopically;Kwa zotupa zokhala ndi mainchesi aatali Kwa omwe akuganiziridwa kuti ali pachiwopsezo chochepa cha GIST>2cm, ngati ma lymph node kapena metastasis yakutali idachotsedwa pakuwunikiridwa kusanachitike, powonetsetsa kuti chotupacho chitha kuchotsedwa kwathunthu, opareshoni ya endoscopic imatha kuchitidwa ndi akatswiri odziwa zambiri. chigawo chokhala ndi ukadaulo wokhwima wa endoscopic.resection.

ii.Symptomatic (mwachitsanzo, magazi, kutsekereza) SMT.

iii.Odwala omwe zotupa zawo zimaganiziridwa kuti ndizosavomerezeka ndi kuyesedwa koyambirira kapena kutsimikiziridwa ndi matenda, koma sangathe kutsatiridwa nthawi zonse kapena omwe zotupa zawo zimakula mkati mwa nthawi yochepa panthawi yotsatila komanso omwe ali ndi chikhumbo champhamvu.e chithandizo cha endoscopic.

(3) Contraindications

ndi.Dziwani zotupa zomwe ndili nazozokometsedwa ndi ma lymph nodes kapena malo akutali.

ii.Kwa ena a SMT okhala ndi lymph yowoneka bwinonodekapena metastasis yakutali, biopsy yochulukira imafunikira kuti mupeze matenda, omwe amatha kuwonedwa ngati chotsutsana ndi wachibale.

iii.Pambuyo mwatsatanetsatane preoperativekuunikira, zimatsimikiziridwa kuti mkhalidwe wamba ndi wosauka komanso opaleshoni ya endoscopic sizingatheke.

Zilonda zowopsa monga lipoma ndi ectopic pancreas nthawi zambiri sizimayambitsa zizindikiro monga kupweteka, kutuluka magazi, ndi kutsekeka.Pamene SMT imawoneka ngati kukokoloka, zilonda zam'mimba, kapena kuchulukirachulukira kwakanthawi kochepa, kuthekera kokhala zilonda zowopsa kumawonjezeka.

(4)Kusankha njira ya resectiond

Endoscopic msampha resection: KwaSMT yomwe ili yachiphamaso, imatuluka mumtsempha monga momwe zimakhalira ndi mayeso a EUS ndi CT, ndipo ikhoza kuchotsedwa kwathunthu nthawi imodzi ndi msampha, endoscopic msampha resection ingagwiritsidwe ntchito.

Maphunziro apakhomo ndi akunja atsimikizira kuti ndi otetezeka komanso ogwira mtima mu SMT <2cm, ndi chiopsezo chotaya magazi cha 4% mpaka 13% ndi kuphulika.chiopsezo cha 2% mpaka 70%.

Endoscopic submucosal excavation,ESE : Kwa ma SMT okhala ndi mainchesi aatali ≥2 cm kapena ngati mayeso oyerekeza asanachitike monga EUS ndi CT amatsimikizirachotupacho chikalowa m'bowo, ESE ndi yotheka kutulutsa ma endoscopic ma SMTs ovuta.

ESE imatsatira zizolowezi zaukadaulo zaendoscopic submucosal dissection (ESD) ndi endoscopic mucosal resection, ndipo nthawi zonse amagwiritsa ntchito "flip-top" chozungulira chozungulira chotupacho kuti achotse mucosa yophimba SMT ndikuwonetsa chotupacho., kuti akwaniritse cholinga choteteza chotupacho kukhala cholimba, kuwongolera kukula kwa opaleshoni, komanso kuchepetsa zovuta zobwera chifukwa cha opaleshoni.Kwa zotupa ≤1.5 masentimita, mlingo wathunthu wa resection wa 100% ukhoza kupezedwa.

Submucosal Tunneling Endoscopic Resection, STER : Kwa SMT yochokera ku muscularis propria kummero, hilum, kupindika pang'ono kwa chapamimba thupi, chapamimba antrum ndi rectum, zomwe zimakhala zosavuta kukhazikitsa ngalande, ndipo m'mimba mwake ndi ≤ 3.5 cm, STER ingakhale yokondedwa njira yothandizira.

STER ndiukadaulo watsopano wopangidwa potengera peroral endoscopic esophageal sphincterotomy (POEM) ndipo ndikuwonjezera kwaukadaulo wa ESD.nology.The en bloc resection rate ya STER ya chithandizo cha SMT imafika 84.9% mpaka 97.59%.

Endoscopic Full-thickness Resection,EFTR :Itha kugwiritsidwa ntchito kwa SMT komwe kumakhala kovuta kukhazikitsa ngalande kapena komwe kutalika kopitilira muyeso kwa chotupa ndi ≥3.5 cm ndipo sikoyenera kwa STER.Ngati chotupacho chimatuluka pansi pa chibakuwa kapena chikukula kunja kwa mtsempha, ndipo chotupacho chimapezeka kuti chimagwirizana kwambiri ndi serosa wosanjikiza panthawi ya opaleshoni ndipo sichikhoza kupatukana, chingagwiritsidwe ntchito.EFTR imapanga chithandizo cha endoscopic.

Suturing yoyenera ya perforationmalo pambuyo pa EFTR ndiye chinsinsi cha kupambana kwa EFTR.Pofuna kuwunika molondola kuopsa kwa chotupa chobwerezabwereza komanso kuchepetsa chiopsezo cha kufalikira kwa chotupa, sikuvomerezeka kudula ndi kuchotsa chitsanzo chotupa chotupa pa EFTR.Ngati kuli kofunikira kuchotsa chotupacho mzidutswa, chotupacho chiyenera kukonzedwa kaye kuti chiwopsezo cha chotupacho chisafalikire ndi kufalikira.Njira zina zopangira suturing ndi monga: suture clip suture, suction-clip suture, omental patch suture technique, "purse bag suture" njira ya chingwe cha nayiloni chophatikizana ndi chitsulo chachitsulo, rake metal clip closure system (over the scope clip, OTSC) OverStitch suture ndi zina. matekinoloje atsopano okonzekera kuvulala kwa m'mimba komanso kuthana ndi magazi, ndi zina zotero.

(5)Zovuta za pambuyo pa opaleshoni

Kutaya magazi m’mitsempha: Kutuluka magazi komwe kumapangitsa kuti hemoglobini ya wodwalayo itsike ndi kupitirira 20 g/L.
Kuti muchepetse magazi m'thupi mwachangu,jekeseni wokwanira wa submucosal ayenera kuchitidwa pa opaleshoni kuti awonetse mitsempha yokulirapo ndikuthandizira electrocoagulation kuti asiye magazi.Kutaya magazi m'kati mwa opaleshoni kumatha kuthandizidwa ndi mipeni yosiyanasiyana yocheka, ma hemostatic forceps kapena zitsulo zachitsulo, komanso kuteteza kukhetsa kwa magazi kwa mitsempha yowonekera yomwe imapezeka panthawi ya dissection.

Kutuluka magazi pambuyo pa opaleshoni: Kutuluka magazi pambuyo pa opaleshoni kumaonekera ngati kusanza magazi, melena, kapena magazi m'chimbudzi.Pazovuta kwambiri, mantha a hemorrhagic amatha kuchitika.Nthawi zambiri zimachitika mkati mwa sabata la 1 mutatha opaleshoni, koma imathanso kuchitika masabata awiri mpaka 4 mutatha opaleshoni.

Kutaya magazi kwa postoperative nthawi zambiri kumakhudzana ndizinthu monga kusayenda bwino kwa magazi pambuyo pochita opaleshoni komanso kuwonongeka kwa mitsempha yotsalira ndi chapamimba asidi.Kuonjezera apo, magazi a postoperative amakhalanso okhudzana ndi malo a matendawa, ndipo amapezeka kwambiri m'mimba ya m'mimba ndi rectum yochepa.

Kuchedwetsa kubowola: Nthawi zambiri kumawoneka ngati kutuluka kwa m'mimba, kupweteka kwa m'mimba kumakulirakulira, zizindikiro za peritonitis, kutentha thupi, ndi kuyezetsa kwazithunzi kumawonetsa kuchuluka kwa mpweya kapena kuchuluka kwa gasi poyerekeza ndi kale.

Nthawi zambiri zimakhudzana ndi zinthu monga kusachita bwino kwa mabala, kukomoka kwambiri ndi electrocoagulation, kudzuka molawirira kwambiri kuti usayende, kudya khutu kwambiri, kuwongolera shuga m'magazi, komanso kukokoloka kwa mabala ndi asidi am'mimba.a.Ngati chilondacho ndi chachikulu kapena chakuya kapena chilondacho chili ndi zipserakusintha kotsimikizika, nthawi yopumula bedi ndi nthawi yosala kudya ziyenera kukulitsidwa moyenerera ndipo kuwonongeka kwa m'mimba kuyenera kuchitidwa pambuyo pa opaleshoni (odwala pambuyo pa opaleshoni yochepa ya m'mimba ayenera kukhala ndi ngalande yamphongo);b.Odwala matenda a shuga ayenera mosamalitsa kuwongolera shuga wawo wamagazi;omwe ali ndi zotupa zazing'ono komanso matenda ocheperako am'mimba ndi m'mimba ayenera kupatsidwa chithandizo chamankhwala monga kusala kudya, anti-infection, ndi kupondereza asidi;c.Kwa omwe ali ndi effusion, ngalande yotsekedwa pachifuwa ndi kubowola m'mimba zitha kuchitidwa Machubu ayenera kuyikidwa kuti asasunthike bwino;d.Ngati matendawa sangadziwike pambuyo pa chithandizo chodziletsa kapena akuphatikizidwa ndi matenda aakulu a thoracoabdominal, opaleshoni ya laparoscopy iyenera kuchitidwa mwamsanga, ndi kukonza zowonongeka ndi kutulutsa madzi m'mimba.

Zovuta zokhudzana ndi gasi: kuphatikiza subcutaneous emphysema, pneumomediastinum, pneumothorax ndi pneumoperitoneum.

Intraoperative subcutaneous emphysema (yosonyezedwa ngati emphysema pankhope, khosi, khoma pachifuwa, ndi scrotum) ndi mediastinal pneumophysema (s)epiglottis amapezeka pa gastroscopy) nthawi zambiri safuna chithandizo chapadera, ndipo emphysema imatha kuthetsa yokha.

Pneumothorax yoopsa imachitika dopaleshoni ya mkodzo [kuthamanga kwa mpweya kumaposa 20 mmHg panthawi ya opaleshoni

(1mmHg=0.133kPa), SpO2<90%, yotsimikiziridwa ndi X-ray pachifuwa chadzidzidzi], opaleshoni imatha kupitilizidwa pambuyo potsekeka pachifuwa.inage.

Kwa odwala omwe ali ndi pneumoperitoneum yodziwikiratu panthawi ya opaleshoni, gwiritsani ntchito singano ya pneumoperitoneum kuboola mfundo ya McFarland.kumanja m'munsi pamimba kuti deflate mpweya, ndi kusiya puncture singano m'malo mpaka mapeto a opareshoni, ndiyeno kuchotsa pambuyo kutsimikizira kuti palibe mpweya zoonekeratu kutulutsidwa.

Fistula ya m'mimba: Madzi a m'mimba omwe amayamba chifukwa cha opaleshoni ya endoscopic amalowa pachifuwa kapena m'mimba mwa kutuluka.
Matenda a esophageal mediastinal fistulas ndi esophagothoracic fistulas amapezeka kawirikawiri.Fistula ikachitika, tsitsani madzi pachifuwa chotsekeka kupita ku maintamu ngalande zosalala komanso kupereka chakudya chokwanira.Ngati ndi kotheka, tatifupi zitsulo ndi zipangizo zosiyanasiyana kutseka angagwiritsidwe ntchito, kapena chophimba zonse akhoza recycled.Stents ndi njira zina zimagwiritsidwa ntchito kuletsafistula.Milandu yoopsa imafunika kuchitidwa opaleshoni mwamsanga.

3. Kuwongolera pambuyo pa opaleshoni (fkupitilira)

(1) Zotupa zabwino:Pathology samalimbikitsa kuti zotupa zoyipa monga lipoma ndi leiomyoma sizifunikira kutsatiridwa pafupipafupi.

(2) SMT popanda zoipamphamvu ya nyerere:Mwachitsanzo, ma NETs 2cm, ndi GIST yapakati komanso yokhala pachiwopsezo chachikulu, magawo athunthu akuyenera kuchitidwa ndipo chithandizo chowonjezera (opaleshoni, chemoradiotherapy, chithandizo cholunjika) chiyenera kuganiziridwa mwamphamvu.chithandizo).Kapangidwe ka ndondomekoyi kuyenera kuzikidwa pa zokambirana zamagulu osiyanasiyana komanso payekha payekha.

(3) SMT yowopsa yocheperako:Mwachitsanzo, GIST yomwe ili pachiwopsezo chochepa iyenera kuwunikiridwa ndi EUS kapena kujambula pakadutsa miyezi 6 mpaka 12 iliyonse mutatha kulandira chithandizo, kenako ndikuthandizidwa motsatira malangizo azachipatala.

(4) SMT yokhala ndi zowopsa zapakatikati komanso zazitali:Ngati postoperative pathology imatsimikizira mtundu wa 3 chapamimba NET, colorectal NET yokhala ndi kutalika> 2cm, ndi GIST yapakatikati komanso yowopsa kwambiri, magawo athunthu amayenera kuchitidwa ndipo chithandizo chowonjezera (opaleshoni, chemoradiotherapy, chithandizo chamankhwala) chiyenera kuganiziridwa mwamphamvu.chithandizo).Mapangidwe a dongosolo ayenera kukhazikitsidwa[za ife 0118.docx]kukambirana kosiyanasiyana komanso payekhapayekha.