ʻO ka mālama ʻana i ka endoscopic o nā ʻōpū submucosal o ke ala ʻai: 3 mau kumu nui i hōʻuluʻulu ʻia i loko o hoʻokahi ʻatikala

ʻO nā puʻupuʻu submucosal (SMT) o ke ala gastrointestinal he mau ʻeha i hoʻokiʻekiʻe ʻia e puka mai ana mai ka muscularis mucosa, submucosa, a i ʻole muscularis propria, a hiki ke lilo i mau ʻeha extraluminal. Me ka hoʻomohala ʻana o ka ʻenehana lapaʻau, ua komo mālie nā koho lapaʻau kuʻuna i ka wā o ka mālama minimally invasive, e like me lʻoki kino aparoscopic a me ke ʻoki kino robotic. Eia nō naʻe, i ka hana lapaʻau, hiki ke ʻike ʻia ʻaʻole kūpono ke "ʻoki kino" no nā maʻi āpau. I nā makahiki i hala iho nei, ua loaʻa mālie ka nānā ʻana i ka waiwai o ka mālama ʻana endoscopic. Ua hoʻokuʻu ʻia ka mana hou loa o ka ʻaelike loea Kina ma ka ʻike endoscopic a me ka mālama ʻana iā SMT. E aʻo pōkole kēia ʻatikala i ka ʻike pili.

1.SMT ʻano ahulaunā mea hoʻokalakupua

(1) Ka nui o ka maʻi SMHe ʻokoʻa ʻole ʻo T ma nā ʻāpana like ʻole o ke ala ʻai, a ʻo ka ʻōpū ka wahi maʻamau no SMT.

ʻO ka nui o nā ʻano like ʻoleʻAʻole like nā ʻāpana o ke ala ʻai, ʻoi aku ka nui o ke ala ʻai o luna. Ma waena o kēia mau mea, aia ka 2/3 ma ka ʻōpū, ukali ʻia e ka esophagus, duodenum, a me ka colon.

(2)ʻO ka histopathologicaHe paʻakikī nā ʻano SMT, akā ʻo ka hapa nui o SMT he mau ʻeha maikaʻi ʻole, a he kakaikahi wale nō nā ʻeha ʻino.

ʻAʻole i komo ʻo A.SMTnā ʻeha n-neoplastic e like me ka ʻiʻo pancreatic ectopic a me nā ʻeha neoplastic.

B. Ma waena o ka ʻeha neoplasticʻO nā leiomyomas gastrointestinal, lipomas, Brucella adenomas, granulosa cell tumors, schwannomas, a me nā glomus tumors he benign ka hapanui, a ʻoi aku ka liʻiliʻi ma mua o 15% e hiki ke ʻike ʻia he ʻiʻo Aʻo hewa.

C. Stroma GastrointestinalʻO nā puʻupuʻu l (GIST) a me nā puʻupuʻu neuroendocrine (NET) ma SMT he mau puʻupuʻu me kekahi hiki ke hoʻopilikia ʻia, akā pili kēia i kona nui, kahi a me ke ʻano.

D. Pili ka wahi o SMTi ka hoʻokaʻawale ʻana o ka pathological: a. ʻO Leiomyomas kahi ʻano pathological maʻamau o SMT i loko o ka esophagus, e helu ana no 60% a 80% o nā esophageal SMTs, a ʻoi aku ka nui o ka hiki ke kū i nā ʻāpana waena a me lalo o ka esophagus; b. He paʻakikī nā ʻano pathological o ka gastric SMT, me GIST, leiomyoʻO ka ma a me ka ectopic pancreas ka mea maʻamau. Ma waena o ka gastric SMT, ʻike pinepine ʻia ʻo GIST ma ka fundus a me ke kino o ka ʻōpū, aia ka leiomyoma ma ka cardia a me ka ʻaoʻao o luna o ke kino, a ʻo ka ectopic pancreas a me ka ectopic pancreas ka mea maʻamau. ʻOi aku ka maʻamau o nā lipomas ma ka gastric antrum; c. ʻOi aku ka maʻamau o nā lipomas a me nā cysts ma nā ʻāpana iho a me nā bulbous o ka duodenum; d. Ma SMT o ka ʻāpana gastrointestinal haʻahaʻa, ʻoi aku ka nui o nā lipomas ma ka colon, ʻoiai ʻoi aku ka nui o nā NET ma ka rectum.

(3) E hoʻohana i ka CT a me MRI e māka, mālama, a loiloi i nā ʻōpū. No nā SMT i manaʻo ʻia he hiki ke lilo i mea ʻino a i ʻole he mau ʻōpū nui (lōʻihike anawaena > 2 cm), ua paipai ʻia ʻo CT a me MRI.

ʻO nā ʻano hana kiʻi ʻē aʻe, me CT a me MRI, he mea nui hoʻi no ka ʻike ʻana i ka SMT. Hiki iā lākou ke hōʻike pololei i kahi o ka hanana ʻana o ka tumor, ke ʻano ulu, ka nui o ka lesion, ke ʻano, ke alo a i ʻole ka ʻole o ka lobulation, ka density, homogeneity, ke kekelē o ka hoʻonui ʻana, a me ke contour palena, a pēlā aku, a hiki ke ʻike inā a me ke kekelē o ka mānoanoa.ka wehe ʻana o ka paia gastrointestinal. ʻOi aku ka mea nui, hiki i kēia mau hoʻokolohua kiʻi ke ʻike inā he komo ʻana o nā ʻano pili o ka lesion a inā he metastasis i loko o ka peritoneum a puni, nā lymph node a me nā ʻōpū ʻē aʻe. ʻO lākou ke ʻano nui no ka māka ʻana i ke kauka, ka mālama ʻana a me ka loiloi prognosis o nā tumors.

(4) ʻAʻole i ʻōlelo ʻia ka laʻana ʻiʻoi hoʻonohonoho ʻia no nā SMT benign hiki ke ʻike ʻia e ka endoscopy maʻamau i hui pū ʻia me EUS, e like me lipomas, cysts, a me ka ectopic pancreas.

No nā ʻeha i manaʻo ʻia he malignant a i ʻole i ka wā e hiki ʻole ai i ka endoscopy maʻamau i hui pū ʻia me EUS ke loiloi i nā ʻeha benign a malignant paha, hiki ke hoʻohana ʻia ka EUS-guided fine-needle aspiration/biopsy (endoscopic ultrasonography guided fine nka makemake ʻana i ka eedle/biopsy, EUS-FNA/FNB), ka biopsy ʻoki mucosal (mucosalincision-assisted biopsy, MIAB), etc. e hana i ka biopsy sampling no ka loiloi pathological preoperative. Ma muli o nā palena o EUS-FNA a me ka hopena ma hope o ka endoscopic resection, no ka poʻe i kūpono no ke ʻoki endoscopic, ma ke kumu o ka hōʻoia ʻana e hiki ke ʻoki piha ʻia ka puʻupuʻu, hiki ke mālama ʻia nā ʻāpana me ka ʻenehana mālama endoscopic makua e ka poʻe akamai. Hana ka endoscopist i ka endoscopic resection pololei me ka loaʻa ʻole o ka hōʻailona pathological preoperative.

ʻO kēlā me kēia ʻano hana o ka loaʻa ʻana o nā hāpana pathological ma mua o ke ʻoki ʻana he invasive a e hōʻino i ka mucosa a i ʻole e hoʻopili i ka ʻiʻo submucosal, no laila e hoʻonui ai i ka paʻakikī o ke ʻoki ʻana a me ka hoʻonui ʻana paha i nā pilikia o ke kahe koko, perfoka māhele ʻana, a me ka hoʻolaha ʻana o ka puʻupuʻu. No laila, ʻaʻole pono ka biopsy preoperative. Pono, ʻoi aku hoʻi no nā SMT i hiki ke ʻike ʻia e ka endoscopy maʻamau i hui pū ʻia me EUS, e like me lipomas, cysts, a me ka ectopic pancreas, ʻaʻohe koi ʻia o ka laʻana ʻiʻo.

2.SMT endoscopic lapaʻaunt

(1) Nā loina lapaʻau

ʻO nā ʻeha i loaʻa ʻole ka metastasis lymph node a i ʻole ka pilikia haʻahaʻa loa o ka metastasis lymph node, hiki ke ʻoki loa ʻia me ka hoʻohana ʻana i nā ʻano hana endoscopic, a he haʻahaʻa ka pilikia o ke koena a me ka hoʻi hou ʻana he kūpono no ka resection endoscopic inā pono ka mālama ʻana. ʻO ka wehe piha ʻana i ka puʻupuʻu e hōʻemi i ke koena o ka puʻupuʻu a me ka pilikia o ka hoʻi hou ʻana. ʻO kapono e hahai i ke kumumanaʻo o ka mālama ʻole ʻana i ka puʻupuʻu i ka wā o ka endoscopic resection, a pono e hōʻoia ʻia ka pono o ka capsule puʻupuʻu i ka wā o ka resection.

(2)Nā Hōʻailona

i.Nā puʻupuʻu me ka hiki ke hoʻopilikia ʻia e ka hoʻokolokolo mua ʻana a i ʻole i hōʻoia ʻia e ka pathology biopsy, ʻoiai nā mea i manaʻo ʻia he GIʻO ST me kahi loiloi ma mua o ke ʻoki ʻana o ka lōʻihi o ka puʻupuʻu o ≤2cm a me kahi pilikia haʻahaʻa o ka hoʻi hou ʻana a me ka metastasis, a me ka hiki ke resection piha, hiki ke ʻoki ʻia ma o ka endoscopically; no nā puʻupuʻu me ke anawaena lōʻihi No ka GIST haʻahaʻa haʻahaʻa i manaʻo ʻia >2cm, inā ua kāpae ʻia ka lymph node a i ʻole ka metastasis mamao mai ka loiloi ma mua o ke ʻoki ʻana, ma ke kumu o ka hōʻoia ʻana e hiki ke ʻoki piha ʻia ka puʻupuʻu, hiki ke hana ʻia ke ʻoki endoscopic e nā endoscopists akamai i loko o kahi ʻāpana me ka ʻenehana lapaʻau endoscopic makua. resection.

ii. Nā hōʻailona (e laʻa, ke kahe ʻana o ke koko, ke ālai ʻia) SMT.

iii. Nā maʻi i manaʻo ʻia he maikaʻi ʻole ko lākou mau puʻupuʻu ma ka hoʻokolokolo mua ʻana a i ʻole i hōʻoia ʻia e ka pathology, akā ʻaʻole hiki ke hahai mau ʻia a i ʻole e hoʻonui ʻia ko lākou mau puʻupuʻu i loko o kahi manawa pōkole i ka wā hahai a he makemake nui ko lākoue no ka mālama ʻana endoscopic.

(3) Nā mea e pale aku ai

i. E ʻike i nā ʻeha i loaʻa iaʻuhoʻouna ʻia i nā lymph nodes a i ʻole nā ​​​​​​wahi mamao aku.

ii. No kekahi SMT me ka lymph maopoponodea i ʻole metastasis mamao, pono ka biopsy nui e loaʻa ai ka pathology, hiki ke manaʻo ʻia he contraindication pili.

iii. Ma hope o ke ʻano kikoʻī ma mua o ke ʻoki ʻanaloiloi, ua hoʻoholo ʻia he maikaʻi ʻole ke kūlana maʻamau a ʻaʻole hiki ke hana ʻoki endoscopic.

ʻO nā ʻeha maikaʻi e like me ka lipoma a me ka ectopic pancreas ma ke ʻano laulā, ʻaʻole lākou e hana i nā hōʻailona e like me ka ʻeha, ke kahe ʻana o ke koko, a me ke ālai ʻana. Ke SHōʻike ʻia ʻo MT e like me ka ʻino ʻana, ka ʻōpū, a i ʻole ka piʻi wikiwiki ʻana i loko o kahi manawa pōkole, piʻi aʻe ka hiki ke lilo i ʻeha ʻino.

(4) Koho o ke ʻano hana resectiond

ʻO ka ʻoki ʻana i ka pahele endoscopic: No kaʻO ka SMT i ʻano papau, e puka mai ana i loko o ke ana e like me ka mea i hoʻoholo ʻia e nā hoʻokolohua EUS a me CT ma mua o ke ʻoki ʻana, a hiki ke ʻoki loa ʻia i ka manawa hoʻokahi me kahi pahele, hiki ke hoʻohana ʻia ka endoscopic snare resection.

Ua hōʻoia nā haʻawina kūloko a me nā haole he palekana a he pono hoʻi ia i ka SMT superficial <2cm, me ka pilikia o ke kahe koko o 4% a 13% a me ka perforation.ka pilikia o 2% a i 70%.

ʻO ka ʻeli ʻana o ka submucosal endoscopic, ESE: No nā SMT me ke anawaena lōʻihi ≥2 cm a inā paha e hōʻoia nā hoʻokolohua kiʻi preoperative e like me EUS a me CT i kai ka puka ʻana o ka puʻupuʻu i loko o ke ana, hiki ke hana ʻia ka ESE no ka ʻoki ʻana i ka lima endoscopic o nā SMT koʻikoʻi.

Ke hahai nei ʻo ESE i nā ʻano loea oʻo ka endoscopic submucosal dissection (ESD) a me ka endoscopic mucosal resection, a hoʻohana mau i kahi ʻoki poepoe "flip-top" a puni ka puʻupuʻu e wehe i ka mucosa e uhi ana i ka SMT a hōʻike piha i ka puʻupuʻu. , e hoʻokō i ke kumu o ka mālama ʻana i ka pono o ka puʻupuʻu, hoʻomaikaʻi i ka radicalness o ke ʻoki ʻana, a me ka hōʻemi ʻana i nā pilikia intraoperative. No nā puʻupuʻu ≤1.5 cm, hiki ke hoʻokō ʻia kahi helu resection piha o 100%.

ʻO ka ʻoki ʻana o ka endoscopic tunneling submucosalʻion, STER: No ka SMT e hoʻomaka ana mai ka muscularis propria i loko o ka esophagus, hilum, ka curvature liʻiliʻi o ke kino gastric, gastric antrum a me ka rectum, kahi maʻalahi ke hoʻokumu i nā tunnels, a ʻo ke anawaena transverse he ≤ 3.5 cm, hiki iā STER ke ʻano lapaʻau makemake ʻia.

He ʻenehana hou ʻo STER i hoʻomohala ʻia ma muli o ka peroral endoscopic esophageal sphincterotomy (POEM) a he hoʻonui ia o ka ʻenehana ESD.nology. ʻO ka helu resection en bloc o STER no ka mālama ʻana iā SMT e hōʻea i 84.9% a i 97.59%.

ʻO ka ʻoki ʻana i ka mānoanoa piha o ka EndoscopicʻIona, EFTR: Hiki ke hoʻohana ʻia no SMT kahi paʻakikī ke hoʻokumu i kahi tunnel a i ʻole kahi o ke anawaena transverse kiʻekiʻe loa o ka puʻupuʻu he ≥3.5 cm a ʻaʻole kūpono no STER. Inā puka ka puʻupuʻu ma lalo o ka membrane poni a ulu paha ma waho o kahi ʻāpana o ka lua, a ʻike ʻia ka puʻupuʻu e pili pono ana i ka papa serosa i ka wā o ke ʻoki ʻana a ʻaʻole hiki ke hoʻokaʻawale ʻia, hiki ke hoʻohana ʻia. Hana ʻo EFTR i ka mālama endoscopic.

Ka humuhumu kūpono o ka perforationʻO ke kahua ma hope o ka EFTR ke kī i ka holomua o ka EFTR. I mea e loiloi pololei ai i ka pilikia o ka hoʻi hou ʻana o ka puʻupuʻu a hōʻemi i ka pilikia o ka hoʻolaha ʻana o ka puʻupuʻu, ʻaʻole ʻōlelo ʻia e ʻoki a wehe i ka hāpana puʻupuʻu i ʻoki ʻia i ka wā o ka EFTR. Inā pono e wehe i ka puʻupuʻu i nā ʻāpana, pono e hoʻoponopono mua ʻia ka perforation e hōʻemi i ka pilikia o ka lūlū ʻana a me ka laha ʻana o ka puʻupuʻu. ʻO kekahi mau ʻano suturing: metal clip suture, suction-clip suture, omental patch suture technique, "purse bag suture" ke ʻano o ke kaula nylon i hui pū ʻia me ka metal clip, rake metal clip closure system (over the scope clip, OTSC) OverStitch suture a me nā ʻenehana hou ʻē aʻe e hoʻoponopono i nā ʻeha gastrointestinal a me ka hana ʻana me ke kahe ʻana o ke koko, a pēlā aku.

(5) Nā pilikia ma hope o ke ʻoki ʻana

Ke kahe koko ʻana i loko o ke ʻoki kino: Ke kahe koko e hoʻohaʻahaʻa ai i ka hemoglobin o ka mea maʻi ma mua o 20 g/L.
I mea e pale ai i ke kahe koko nui i loko o ke ʻoki kino,Pono e hana ʻia ka hoʻokomo submucosal lawa i ka wā o ke ʻoki ʻana e hōʻike i nā kīʻaha koko nui a hoʻomaʻamaʻa i ka electrocoagulation e hoʻōki i ke kahe ʻana o ke koko. Hiki ke mālama ʻia ke kahe koko intraoperative me nā pahi ʻoki like ʻole, nā forceps hemostatic a i ʻole nā ​​​​​​kīpī metala, a me ka hemostasis pale o nā kīʻaha koko i hōʻike ʻia i loaʻa i ka wā o ke kaʻina hana dissection.

Ke kahe koko ma hope o ke ʻoki ʻana: Hōʻike ʻia ke kahe koko ma hope o ke ʻoki ʻana ma ke ʻano he luaʻi koko, melena, a i ʻole ke koko i loko o ka ʻōpala. I nā hihia koʻikoʻi, hiki ke loaʻa ka haʻalulu hemorrhagic. ʻO ka hapa nui ia e hana ʻia i loko o 1 pule ma hope o ke ʻoki ʻana, akā hiki nō hoʻi ke hana ʻia ma hope o 2 a 4 mau pule ma hope o ke ʻoki ʻana.

ʻO ke kahe koko ma hope o ke ʻoki kino e pili pinepine ana menā mea e like me ka kaohi ʻole o ke koko ma hope o ke ʻoki ʻana a me ka pala ʻana o nā kīʻaha koko i koe e ka waikawa gastric. Eia kekahi, pili pū ke kahe koko postoperative i kahi o ka maʻi, a ʻoi aku ka maʻamau ma ka antrum gastric a me ka rectum haʻahaʻa.

Ka lohi o ka perforation: Hōʻike pinepine ʻia e like me ka distension o ka ʻōpū, ka ʻeha ʻana o ka ʻōpū, nā hōʻailona o ka peritonitis, ke kuni, a me ka nānā ʻana i ke kiʻi e hōʻike ana i ka hōʻiliʻili ʻana o ke kinoea a i ʻole ka hoʻonui ʻia ʻana o ka hōʻiliʻili ʻana o ke kinoea i hoʻohālikelike ʻia me ka wā ma mua.

ʻO ka hapa nui e pili ana i nā kumu e like me ke kāpili maikaʻi ʻole o nā ʻeha, ka electrocoagulation nui, ke ala ʻana i kakahiaka nui e neʻe a puni, ka ʻai ʻana i ka earl nui, ka kaohi maikaʻi ʻole o ke kō koko, a me ka ʻino ʻana o nā ʻeha e ka waikawa gastric. a. Inā nui a hohonu paha ka ʻeha a i ʻole he mau māwae ka ʻehanā loli e like me ka maopopo, pono e hoʻolōʻihi kūpono ʻia ka manawa hoʻomaha moe a me ka manawa hoʻokē ʻai a pono e hana ʻia ka decompression gastrointestinal ma hope o ke ʻoki ʻana (pono nā maʻi ma hope o ke ʻoki ʻana i ka ʻōpū gastrointestinal haʻahaʻa e loaʻa ka hoʻokahe ʻana o ke kahawai anal); b. Pono nā maʻi maʻi diabetes e kāohi pono i ko lākou kō koko; pono e hāʻawi ʻia ka poʻe me nā perforations liʻiliʻi a me nā maʻi thoracic a me ka ʻōpū i nā lāʻau lapaʻau e like me ka hoʻokē ʻai, ka anti-infection, a me ka hoʻopau ʻana i ka waikawa; c. No ka poʻe me ka effusion, hiki ke hana ʻia ka hoʻokahe ʻana o ka umauma pani a me ka puncture ʻōpū Pono e kau ʻia nā paipu e mālama i ka hoʻokahe maʻalahi; d. Inā ʻaʻole hiki ke hoʻopaʻa ʻia ka maʻi ma hope o ka mālama conservative a i ʻole e hui pū ʻia me ka maʻi thoracoabdominal koʻikoʻi, pono e hana ʻia ka laparoscopy ʻokiʻoki i ka hikiwawe loa, a pono e hana ʻia ka hoʻoponopono perforation a me ka hoʻokahe ʻana o ka ʻōpū.

Nā pilikia e pili ana i ke kinoea: Me ka subcutateʻO ka maʻi ʻeha o ka lolo, ka emphysema, ka pneumomediastinum a me ka pneumothoraks.

ʻO ka emphysema subcutaneous intraoperative (i hōʻike ʻia he emphysema ma ka maka, ʻāʻī, paia umauma, a me ka scrotum) a me ka mediastinal pneumophysema (s(((((((((Hiki ke loaʻa ka pehu ʻana o ka epiglottis i ka wā o ka gastroscopy) ʻaʻole pono ka mālama kūikawā, a e hoʻoholo wale ka emphysema.)

Hiki mai ka pneumothorax koʻikoʻi di ka wā ʻoki kino [ʻoi aku ke kaomi o ke ea ma mua o 20 mmHg i ka wā o ke ʻoki kino

(1mmHg=0.133kPa), SpO2<90%, i hōʻoia ʻia e ka X-ray umauma ma kahi moe ulia pōpilikia], hiki ke hoʻomau pinepine ʻia ke ʻoki ʻana ma hope o ka pani ʻana o ka umaumaʻelemakule

No nā poʻe maʻi me ka pneumoperitoneum maopopo i ka wā o ke ʻoki ʻana, e hoʻohana i kahi nila pneumoperitoneum e hou i ka kiko McFarland.ma ka ʻōpū ʻākau haʻahaʻa e hoʻoheheʻe i ka ea, a waiho i ka nila hou ma kahi a hiki i ka pau ʻana o ke hana, a laila wehe iā ia ma hope o ka hōʻoia ʻana ʻaʻohe kinoea maopopo i hoʻokuʻu ʻia.

ʻO ka fistula Gastrointestinal: Ke kahe nei ka wai hoʻoheheʻe i hoʻokumu ʻia e ke ʻoki endoscopic i loko o ka umauma a i ʻole ka lua ʻōpū ma o kahi leaka.
He mea maʻamau nā fistula mediastinal esophageal a me nā fistula esophagothoracic. Ke loaʻa kahi fistula, e hana i ka hoʻokahe wai umauma pani e mālama ai.i ka hoʻokahe wai maʻalahi a hāʻawi i ke kākoʻo meaʻai kūpono. Inā pono, hiki ke hoʻohana ʻia nā ʻūpā metala a me nā mea pani like ʻole, a i ʻole hiki ke hana hou ʻia ka uhi piha. Hoʻohana ʻia nā stent a me nā ʻano hana ʻē aʻe e ālai i kafistula. Pono ke komo ʻoki koke ʻana i nā hihia koʻikoʻi.

3. Hoʻokele ma hope o ke ʻoki ʻana (fhoʻi hou ʻana)

(1) Nā ʻeha maikaʻi ʻole:Nā maʻi pathologyManaʻo ʻia ʻaʻole pono nā ʻeha maikaʻi e like me lipoma a me leiomyoma i ka nānā mau ʻana.

(2) SMT me ka ʻole o ka hōʻinohiki i nā ʻanuʻu:No ka laʻana, pono e hana ʻia ke kahua piha o ka rectal NETs 2cm, a me ka GIST waena a me ke kiʻekiʻe, a pono e noʻonoʻo pono ʻia nā lāʻau lapaʻau hou aʻe (ʻoki kino, chemoradiotherapy, therapy i hoʻolālā ʻia). mālama). Pono e hoʻokumu ʻia ka hoʻolālā ma ke kūkākūkā multidisciplinary a ma ke kumu pākahi.

(3) Ka hiki ke hoʻopilikia haʻahaʻa SMT:Eia kekahi laʻana, pono e loiloi ʻia ka GIST haʻahaʻa-pilikia e ka EUS a i ʻole ke kiʻi ʻana i kēlā me kēia 6 a 12 mau mahina ma hope o ka mālama ʻana, a laila e mālama ʻia e like me nā kuhikuhi lapaʻau.

(4) SMT me ka hiki ke hoʻopilikia waena a kiʻekiʻe:Inā hōʻoia ka pathology postoperative i ke ʻano 3 gastric NET, colorectal NET me ka lōʻihi >2cm, a me ka GIST waena a me ke kiʻekiʻe, pono e hana ʻia ke kahua piha a pono e noʻonoʻo pono ʻia nā lāʻau lapaʻau hou (ʻoki kino, chemoradiotherapy, therapy i kuhikuhi ʻia). mālama). Pono e hoʻokumu ʻia ka hoʻokumu ʻana o ka hoʻolālā ma luna o[e pili ana iā mākou 0118.docx]kūkākūkā multidisciplinary a ma ke ʻano pākahi.