Hoʻomaʻamaʻa endoscopic o nā ʻōpū submucosal o ka digestive tract: 3 mau mea nui i hōʻuluʻulu ʻia i hoʻokahi ʻatikala

ʻO nā maʻi maʻi submucosal (SMT) o ka ʻōpū o ka ʻōpū he mau ʻeha hoʻokiʻekiʻe mai ka muscularis mucosa, submucosa, a i ʻole muscularis propria, a he mau ʻeha extraluminal paha.Me ka hoʻomohala ʻana o ka ʻenehana lapaʻau, ua komo mālie nā koho lapaʻau kuʻuna maʻamau i ke au o ka lāʻau lapaʻau liʻiliʻi loa, e like me lʻoki ʻoki aparoskopiko a me ka ʻoki ʻana i ka robotic.Eia nō naʻe, ma ka hoʻomaʻamaʻa lapaʻau, hiki ke ʻike ʻia ʻaʻole kūpono ka "ʻoki" i nā maʻi āpau.I nā makahiki i hala iho nei, ua loaʻa mālie ka waiwai o ka mālama endoscopic.Ua hoʻokuʻu ʻia ka mana hou loa o ka ʻikepili loea Kina e pili ana i ka maʻi endoscopic a me ka mālama ʻana iā SMT.E aʻo pōkole kēia ʻatikala i ka ʻike pili.

1.SMT ano ahulauristics

(1) Ka nui o SMʻAʻole kūlike ʻo T ma nā ʻāpana like ʻole o ka ʻāpana digestive, a ʻo ka ʻōpū ka wahi maʻamau no SMT.

ʻO ka loaʻa ʻana o nā ʻano like ʻoleʻAʻole kūlike nā ʻāpana o ka digestive tract, ʻoi aku ka maʻamau o ka ʻāpana digestive luna.ʻO kēia mau mea, hiki i ka 2/3 i loko o ka ʻōpū, a ukali ʻia e ka esophagus, duodenum, a me ka colon.

(2) ʻO ka histopathologicaʻO nā ʻano SMT he paʻakikī, akā ʻo ka hapa nui o SMT he mau liona maikaʻi, a he liʻiliʻi wale nō ka maʻi ʻino.

A.SMT komo non-neoplastic lesions e like me ectopic pancreatic tissue a me neoplastic lesions.

B. Ma waena o ka lesion neoplastics, gastrointestinal leiomyomas, lipomas, Brucella adenomas, granulosa cell tumors, schwannomas, and glomus tumors are most not benign, a emi iho ma lalo o 15% hiki ke puka mai ma ke ano o ke kino E aʻo i ka hewa.

C. ʻōpū ʻōpūʻO nā maʻi maʻi (GIST) a me nā maʻi neuroendocrine (NET) ma SMT he mau maʻi maʻi me kekahi mau mea ʻino, akā pili kēia i kona nui, kahi a me ke ʻano.

D. Pili ka wahi o SMTi ka mahele pathological: a.ʻO Leiomyomas kahi ʻano pathological maʻamau o SMT i loko o ka esophagus, e helu ana i ka 60% a hiki i ka 80% o nā SMT esophageal, a ʻoi aku ka nui o ke ʻano ma waena a me lalo o ka esophagus;b.The pathological 'ano o ka gastric SMT mea paʻakikī, me GIST, leiomyoma a me ka ectopic pancreas ka mea maʻamau.Ma waena o ka gastric SMT, ʻike pinepine ʻia ka GIST i loko o ka waihona a me ke kino o ka ʻōpū, ʻo ka leiomyoma ka mea maʻamau i ka cardia a me ka ʻāpana o ke kino, a ʻo ka ectopic pancreas a me ka ectopic pancreas ka mea maʻamau.ʻOi aku ka maʻamau o nā lipomas i ka antrum ʻōpū;c.ʻOi aku ka maʻamau o nā lipomas a me nā cysts i nā ʻāpana iho a me nā puʻupuʻu o ka duodenum;d.I ka SMT o ka ʻōpū o ka ʻōpū haʻahaʻa, ʻoi aku ka nui o nā lipoma ma ke kolonā, ʻoiai ʻo NETs ka mea nui i ka rectum.

(3) E hoʻohana i ka CT a me MRI no ka hoʻopaʻa ʻana, mālama, a loiloi i nā ʻōpū.No nā SMT i manaʻo ʻia he maʻi ʻino a loaʻa paha nā maʻi maʻi nui (lōʻihiʻO ke anawaena o ka 2 knm), ua ʻōlelo ʻia ʻo CT a me MRI.

ʻO nāʻano kiʻi kiʻi'ē aʻe, e like me CT a me MRI, he mea nui hoʻi no ka hōʻailona o SMT.Hiki iā lākou ke hōʻike pololei i kahi o ka ulu ʻana o ka maʻi, ka ulu ʻana, ka nui o ka lesion, ke ʻano, ka hele ʻana a i ʻole ka nele o ka lobulation, density, homogeneity, degere o ka hoʻonui ʻana, a me ka contour palena, etc.ʻO ka mea nui loa, hiki i kēia mau hoʻokolohua kiʻi ke ʻike inā he hoʻouka ʻia nā hale pili o ka lesion a inā he metastasis i loko o ka peritoneum a puni, nā lymph nodes a me nā mea ʻē aʻe.ʻO lākou ke ala nui no ka hoʻopaʻa ʻana i ke kauka, ka mālama ʻana a me ka loiloi prognosis o nā maʻi maʻi.

(4) ʻAʻole hoʻihoʻi hou ʻia ka laʻana o ka ʻilimmended no nā SMT maikaʻi i hiki ke ʻike ʻia e ka endoscopy maʻamau i hui pū ʻia me EUS, e like me ka lipomas, cysts, a me ka pancreas ectopic.

No nā ʻeha i manaʻo ʻia he maʻi ʻino a inā ʻaʻole hiki i ka endoscopy maʻamau i hui pū ʻia me EUS ke loiloi i nā ʻeha maikaʻi a i ʻole nā ​​​​ʻeha ʻino, hiki ke hoʻohana ʻia ka aspiration/biopsy i alakaʻi ʻia e EUS (endoscopic ultrasonography guided fine needle aspiration/biopsy, EUS-FNA/FNB), mucosal incision biopsy (mucosalincision-assisted biopsy, MIAB), etc. hana biopsy sampling no ka loiloi pathological preoperative.I ka nānā ʻana i nā palena o ka EUS-FNA a me ka hopena ma hope o ka endoscopic resection, no ka poʻe i kūpono i ka hana endoscopic, ma ke kumu o ka hōʻoia ʻana e hiki ke hoʻopau loa ʻia ka ʻōpū, hiki ke mālama ʻia nā ʻāpana me ka ʻenehana lapaʻau endoscopic makua e ka ʻike. Hana ka endoscopist i ka endoscopic resection pololei me ka loaʻa ʻole o ka maʻi pathological preoperative.

ʻO ke ʻano o ka loaʻa ʻana o nā hōʻailona pathological ma mua o ka hana ʻana he invasive a e hōʻino i ka mucosa a i ʻole e hoʻopili ai i ka ʻiʻo submucosal, ma laila e hoʻonui ai i ka paʻakikī o ka ʻoki ʻana a me ka hoʻonui ʻana i nā pilikia o ke koko, perfoʻai, a me ka hoʻolaha ʻana o ka maʻi tumora.No laila, ʻaʻole pono ka biopsy preoperative.Pono, no nā SMT hiki ke ʻike ʻia e ka endoscopy maʻamau i hui pū ʻia me EUS, e like me ka lipomas, cysts, a me ka pancreas ectopic, ʻaʻohe koi ʻana i kahi laʻana kiko.

2.SMT endoscopic treatment

(1) Nā loina lapaʻau

ʻO nā maʻi i loaʻa ʻole ka lymph node metastasis a i ʻole ka liʻiliʻi loa o ka lymph node metastasis, hiki ke hoʻopau piha ʻia me ka hoʻohana ʻana i nā ʻenehana endoscopic, a he haʻahaʻa haʻahaʻa o ke koena a me ka hoʻihoʻi ʻana i kūpono no ka ʻoki ʻana i ka endoscopic inā pono ka mālama ʻana.ʻO ka wehe piha ʻana o ka ʻōpū e hōʻemi i ke koena o ka ʻōpū a me ka pilikia o ka hoʻi hou ʻana.ʻO kaPono e hahai ʻia ke kumu o ka mālama ʻole ʻana i ka maʻi maʻi i ka wā endoscopic resection, a pono e hōʻoia i ka pono o ka capsule tumor i ka wā o ka wehe ʻana.

(2) Nā hōʻailona

ʻO nā maʻi puʻupuʻu me ka maʻi ʻino i manaʻo ʻia e ka hoʻokolokolo preoperative a i hōʻoia ʻia e ka biopsy pathology, ʻoi aku ka poʻe i manaʻo ʻia he GI.ʻO ST me ka loiloi mua o ka lōʻihi o ka tumo o ≤2cm a me ka haʻahaʻa haʻahaʻa o ka hoʻi hou ʻana a me ka metastasis, a me ka hiki ke hoʻopau piha, hiki ke hoʻopau ʻia endoscopically;no nā ʻōpū me ke anawaena lōʻihi No ka mea i manaʻo ʻia he haʻahaʻa haʻahaʻa GIST>2cm, inā ua kāpae ʻia ka ʻōpū lymph a i ʻole ka metastasis mamao mai ka loiloi mua ʻana, ma ke kumu o ka hōʻoia ʻana e hiki ke hoʻopau loa ʻia ke koko, hiki ke hana ʻia ke ʻoki endoscopic e nā endoscopists ʻike. he hui me ka ʻenehana lapaʻau endoscopic makua.ʻoki ʻana.

ii.Hōʻailona (e laʻa, ke koko, keakea) SMT.

iii. ʻO ka poʻe maʻi i manaʻo ʻia he maikaʻi nā maʻi maʻi e ka nānā 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 maʻi koko i loko o kahi manawa pōkole i ka wā hahai a loaʻa iā lākou ka makemake ikaika.e no ka lapaau endoscopic.

(3) Kūʻē

i.E ʻike i nā ʻeha i loaʻa iaʻuʻono i nā ʻōpū lymph a i ʻole nā ​​wahi mamao.

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

iii.Ma hope o ka kikoʻī preoperativeka loiloi, ua hoʻoholo ʻia he ʻilihune ka maʻi maʻamau a ʻaʻole hiki ke ʻoki ʻia endoscopic.

ʻAʻole i hoʻokumu ʻia nā hōʻailona e like me ka ʻeha, ke koko, a me ke keʻakeʻa ʻana i nā ʻeha maikaʻi e like me ka lipoma a me ka pancreas ectopic.I ka manawa a SHōʻike ʻia ʻo MT ma ke ʻano he erosion, ulcer, a i ʻole ka piʻi wikiwiki ʻana i ka manawa pōkole, e piʻi aʻe ana ka hiki ke lilo i lesion malignant.

(4) Koho ʻia o ke ʻano o ka wehe ʻanad

Hoʻokiʻoki ʻia ʻana o ka ʻūhā endoscopic: NoʻO SMT kahi pāpaʻu, puka i loko o ka lua e like me ka mea i hoʻoholo ʻia e nā hoʻokolohua EUS a me CT ma mua o ka hana, a hiki ke hoʻopau piha ʻia i ka manawa hoʻokahi me kahi pahele, hiki ke hoʻohana ʻia ka hoʻoheheʻe endoscopic.

Ua hōʻoia ʻia nā haʻawina kūloko a me nā ʻāina ʻē he palekana a maikaʻi hoʻi i ka SMT superficial <2cm, me ka pilikia o ke koko o 4% a 13% a me kahi perforation.pilikia o 2% a 70%.

Endoscopic submucosal excavation,ESE: No nā SMT me ke anawaena lōʻihi ≥2 knm a i ʻole inā hōʻoia nā hoʻokolohua kiʻi preoperative e like me EUS a me CT.i ka puka ʻana o ka ʻōpū i loko o ka lua, hiki i ka ESE ke wehe i ka lima endoscopic o nā SMT koʻikoʻi.

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

Submucosal Tunneling Endoscopic Resection, STER : No ka SMT mai ka muscularis propria i loko o ka esophagus, hilum, ka liʻiliʻi o ka curvature o ke kino ʻōpū, ka antrum a me ka rectum, he mea maʻalahi ke hoʻokumu i nā tunnels, a ʻo ke anawaena transverse ≤ 3.5 cm, hiki i ka STER ke koho ʻia. ʻano lapaʻau.

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

Endoscopic Full-thickness Resection, EFTR : Hiki ke hoʻohana ʻia no SMT kahi paʻakikī ke hoʻokumu ʻana i kahi tunnel a i ʻole kahi o ke anawaena transverse kiʻekiʻe o ka ʻōpū he ≥3.5 cm a ʻaʻole kūpono no STER.Inā puka ka ʻōpū ma lalo o ka membrane poni a ulu paha ma waho o kahi ʻāpana o ka lua, a ʻike ʻia ka ʻōpū e pili paʻa i ka papa serosa i ka wā o ke kaʻa ʻana a ʻaʻole hiki ke hoʻokaʻawale ʻia, hiki ke hoʻohana ʻia.Hana ʻo EFTR i ka mālama endoscopic.

ʻO ka humuhumu kūpono o ka ʻūhākahua ma hope o EFTR ke kī i ka holomua o EFTR.I mea e loiloi pono ai i ka pilikia o ka hoʻi hou ʻana o ka maʻi maʻi a e hōʻemi i ka hopena o ka hoʻolaha ʻana i ka maʻi maʻi, ʻaʻole ia e ʻōlelo ʻia e ʻoki a wehe i ka hōʻailona maʻi i hoʻihoʻi ʻia i ka wā EFTR.Inā pono e wehe i ka maʻi koko ma nā ʻāpana, pono e hoʻoponopono mua ʻia ka perforation i mea e hōʻemi ai i ka hopena o ke kanu ʻana a me ka laha.ʻO kekahi mau ʻano hana humuhumu ʻana: ʻo ka humuhumu ʻana i ke kaula metala, ke ʻano o ka humuhumu ʻana, ke ʻano omental patch suture, "purse bag suture" ke ʻano o ke kaula nylon i hui pū ʻia me ke kiʻi metala, ʻōnaehana pani rake metala (ma luna o ka clip scope, OTSC) OverStitch suture a me nā mea ʻē aʻe. nā ʻenehana hou e hoʻoponopono i nā ʻeha o ka ʻōpū a me ka hoʻoponopono ʻana i ke koko, etc.

(5) Nā pilikia postoperative

ʻO ke koko i loko o ka hana: Ke koko e hāʻule ai ka hemoglobin o ka mea maʻi ma mua o 20 g/L.
No ka pale ʻana i ke koko intraoperative nui,pono e hana ʻia i ka wā o ka hana ʻana e hōʻike i nā kīʻaha koko nui a maʻalahi i ka electrocoagulation e hoʻōki i ke koko.Hiki ke mālama ʻia ke koko intraoperative me nā pahi ʻoki like ʻole, hemostatic forceps a i ʻole nā ​​pahu metala, a me ka hemostasis pale ʻana o nā kīʻaha koko i ʻike ʻia i ka wā o ka wehe ʻana.

Ke koko ma hope o ka hana ʻana: ʻike ʻia ke koko ma hope o ka ʻoihana e like me ka luaʻi ʻana i ke koko, melena, a i ʻole ke koko i loko o ka waihona.I nā hihia koʻikoʻi, hiki i ka hemorrhagic shock.Loaʻa ka hapa nui i loko o 1 pule ma hope o ka ʻoki ʻana, akā hiki ke hana ʻia ma 2 a 4 mau pule ma hope o ke ʻoki ʻana.

Hoʻopili pinepine ʻia ke koko postoperativeʻO nā kumu e like me ka maikaʻi ʻole o ka mālama ʻana i ke koko postoperative a me ka ʻino ʻana o nā kīʻaha koko koena e ka ʻakika ʻōpū.Eia kekahi, pili pū ke koko postoperative i kahi o ka maʻi, a ʻoi aku ka maʻamau i ka antrum gastric a me ka rectum haʻahaʻa.

Hoʻopaneʻe ʻia ka perforation: ʻike pinepine ʻia e like me ka ʻōpū o ka ʻōpū, ka ʻeha nui o ka ʻōpū, nā hōʻailona o ka peritonitis, ke kuni, a me ka nānā ʻana i ke kiʻi e hōʻike ana i ka hōʻiliʻili kinoea a i ʻole ka hoʻonui ʻana i ke kinoea i hoʻohālikelike ʻia me mua.

ʻO ka hapa nui e pili ana i nā mea e like me ka maikaʻi ʻole o ka humuhumu ʻana i nā ʻeha, ka electrocoagulation nui, ke ala ʻana i ke kakahiaka nui no ka neʻe ʻana, ka ʻai ʻana i ka earl, maikaʻi ʻole ka mālama ʻana i ke kōpaʻa koko, a me ka hoʻoneʻe ʻana o nā ʻeha e ka ʻakika ʻōpū.a.Inā nui a hohonu paha ka ʻeha a i ʻole ka ʻehaʻO nā hoʻololi like ʻole, pono e hoʻolōʻihi ʻia ka manawa hoʻomaha moe a me ka manawa hoʻokē ʻai a pono e hana ʻia ka decompression o ka ʻōpū ma hope o ke ʻoki ʻana (pono nā maʻi ma hope o ke ʻoki ʻana i ka ʻōpū haʻahaʻa e loaʻa i ka wai kahe anal);b.Pono nā poʻe maʻi maʻi diabetic e mālama pono i ko lākou koko koko;ʻO ka poʻe me nā maʻi liʻiliʻi a me nā maʻi ʻeha a me ka ʻōpū e pono e hāʻawi ʻia i nā lāʻau e like me ka hoʻokē ʻai, anti-infection, a me ka hoʻopau ʻana i ka waikawa;c.No ka poʻe me ka effusion, hiki ke hana ʻia ka hoʻoheheʻe ʻana o ka umauma a me ka ʻōpū o ka ʻōpū.d.Inā ʻaʻole hiki ke hoʻokaʻawale ʻia ka maʻi ma hope o ka mālama ʻana a i ʻole i hui pū ʻia me ka maʻi thoracoabdominal koʻikoʻi, pono e hana ʻia ka laparoscopy i ka wā hiki loa, a pono e hana ʻia ka hoʻoponopono perforation a me ka hoʻokahe ʻana o ka ʻōpū.

Nā pilikia pili kinoea: Me ka subcutaneous emphysema, pneumomediastinum, pneumothorax a me ka pneumoperitoneum.

Intraoperative subcutaneous emphysema (hōʻike ʻia he emphysema ma ka maka, ka ʻāʻī, ka paia o ka umauma, a me ka scrotum) a me ka pneumophysema mediastinal (sHiki ke loa'a ka ma'i o ka epiglottis i ka wā gastroscopy) 'a'ole i koi 'ia ka lā'au kūikawā, a e ho'oholo 'ia ka emphysema ma kona iho.

Loaʻa ka pneumothorax koʻikoʻi dʻo ka ʻoki ʻana [ua ʻoi aku ka nui o ke ea ma mua o 20 mmHg i ka wā o ke kaʻa

(1mmHg=0.133kPa), SpO2<90%, i hoʻopaʻa ʻia e ka ʻaoʻao ʻaoʻao o ka pahu X-ray], hiki ke hoʻomau pinepine ʻia ke ʻoki ma hope o ka pani ʻana o ka umauma dra.inage.

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

ʻO ka fistula o ka ʻōpū: kahe ka wai hoʻoheheʻe ma muli o ke kaʻina endoscopic i loko o ka umauma a i ʻole ka ʻōpū ma o ka leak.
He mea maʻamau ka esophageal mediastinal fistula a me ka esophagothoracic fistula.Ke puka mai ka fistula, e hana i ka hoʻokahe ʻana i ka umauma no ka mālama ʻanama ka hoʻoheheʻe ʻana a hāʻawi i ke kākoʻo meaʻai kūpono.Inā pono, hiki ke hoʻohana ʻia nā pahu 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 pale ai i kafistula.ʻO nā maʻi koʻikoʻi e koi koke i ke kaʻina hana.

3. Hoʻoponopono ma hope o ka hana (fhoʻopau)

(1) Nā ʻeha maikaʻi:ʻO ke kino sʻAʻole koi ʻia nā maʻi maʻi e like me ka lipoma a me ka leiomyoma.

(2) SMT me ka hōʻino ʻolehiki i ka ant:No ka laʻana, pono e hoʻokō ʻia nā hoʻomaʻamaʻa ʻokoʻa (ka ʻoki ʻana, chemoradiotherapy, ka lāʻau i hoʻopaʻa ʻia) me ka GIST.pono).Pono e hoʻokumu ʻia ka hoʻolālā ʻana o ka hoʻolālā ma luna o ke kūkākūkā multidisciplinary a ma ke kumu pākahi.

(3) SMT hiki ke hōʻino haʻahaʻa:No ka laʻana, pono e loiloi ʻia ka GIST haʻahaʻa 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 mālama ʻia e like me nā ʻōlelo kuhikuhi.

(4) SMT me ka hikiwawe a me ke kiʻekiʻe hoʻomāinoino:Inā hōʻoia ka pathology postoperative type 3 gastric NET, colorectal NET me ka lōʻihi> 2cm, a me ka GIST waena a me ke kūlana kiʻekiʻe, pono e hoʻokō ʻia ka hoʻokō piha a pono e noʻonoʻo nui ʻia nā lāʻau lapaʻau hou (ke ʻoki, chemoradiotherapy, targeted therapy).pono).Pono e hoʻokumu ʻia ka hoʻolālā ʻana o ka papahana[e pili ana iā mākou 0118.docx] kūkā kamaʻilio multidisciplinary a ma ke kumu pākahi.