大肠侧向发育型肿瘤的内镜特征及治疗

发布时间：2018-05-12 02:10

本文选题：大肠侧向发育型肿瘤 + 形态特点　；参考：《山西医科大学》2017年硕士论文

【摘要】：目的:侧向发育型肿瘤(laterally spreading tumors,LST)特指一类直径大于10mm的平坦型病变,其延肠壁横向生长而非垂直性生长,与结直肠癌关系密切,且容易发生粘膜下浸润。LST在结肠镜检查时容易漏诊,且镜下微创治疗技术要求高,易导致不完全切除和局部复发,因此LST的内镜下诊断及治疗对于结直肠癌的预防很重要。本文研究探讨LST的镜下特点和治疗,为提高LST检出率和进一步治疗方案的选择提供参考依据。方法:回顾性研究陆军总医院消化内镜中心2010年3月-2016年5月经结肠镜检查发现的LST,分析其大体形态、表面隐窝开口、NBI下特征与病理组织学之间的关系,以及不同治疗方法和内镜随访结果。结果:1.共发现LST型息肉615处(551例患者),占同期检出息肉的2.17%,病灶平均直径22.2±14.7mm。其中大小在10-20mm的LST占比最高(66.5%),多见于近端结肠(55.4%),大体形态分型以平坦隆起型(LST-NGF)最多见(占22.76%)。LST中黏膜下癌为3.25%(20/615)。4种亚分类中LST-NGPD发生黏膜下癌比率最高:14.29%(12/84)。直肠的LST相比于结肠的LST直径更大(31.49±23.09 vs 20.82±9.86,p0.05),且发生早癌的概率更高(36.43%vs 14.95%,p0.001)。2.侧向发育型肿瘤的腺管开口以IIIL型(30.56%)、IV型(32.94%)最多见。预示癌的V型pit pattern在LST-GM与LST-NGPD中占相对较多的比例,分别为29.11%、41.93%。所有的黏膜下癌均表现为V型pit pattern,其中VN型pit pattern预测黏膜下癌的准确率为58.33%。有4.19%的NICE2型病灶和55.56%的NICE3型病灶为黏膜下癌。3.在615例LST病灶中,343例(55.77%)行内镜下黏膜剥离术(EMR)或者precutting-EMR,29例(4.72%)行内镜下分片黏膜切除术(EPMR)治疗;228例(37.07%)行内镜黏膜下剥离术(ESD),包括外科手术等其他治疗方式15例.完整切除率(CR)94.80%。其中经ESD治疗发生术中出血共56例(24.57%),延迟性出血1例(4.39%),穿孔12例(5.26%)。经内镜下治疗(EMR、precutting-EMR与ESD)术后病理提示切缘阳性的占4.90%(28/571)。治疗后可随访到患者330例,随访时间中位数为15个月。共有10例复发,其中内镜下分片EPMR复发率较高为13.79%(4/29),EMR复发率为1.32%(2/152),相比近3年经ESD治疗的LST均无复发。结论:侧向发育型肿瘤以近端结肠为主,4种亚分类中LST-NGPD发生黏膜下癌比率最高。直肠的LST相比于结肠的LST直径更大,且发生早癌的概率更高。V型腺管和NICE3型病灶提示黏膜下癌可能性大。对于直径较大LST,分片切除病灶复发率大,完整的内镜粘膜下剥离术(ESD)为其安全有效的治疗方式。
[Abstract]:Objective: lateral spreading tumors (LST) refer to a class of flat lesions whose diameter is larger than 10mm. The transverse rather than vertical growth of the tubule wall is closely related to colorectal cancer. Submucous infiltration. LST is easy to be missed in colonoscopy, and the technique of minimally invasive treatment is high, which can lead to incomplete resection and local recurrence. Therefore, endoscopic diagnosis and treatment of LST is very important for the prevention of colorectal cancer. In this paper, the characteristics and treatment of LST under microscope are studied, which provides a reference for improving the detection rate of LST and the choice of further treatment scheme. Methods: the LSTs from March 2010 to May 2016 in the Center of Digestive Endoscopy, General Hospital of the Army were retrospectively studied, and the relationship between the gross morphology, the features of NBI and the histopathology were analyzed. As well as different treatment methods and endoscopic follow-up results. The result is 1: 1. A total of 551 patients with 615 LST polyps were found, accounting for 2.17% of the polyps detected in the same period. The mean diameter of the lesions was 22.2 卤14.7 mm. The proportion of LST in 10-20mm was the highest (66.5%), and it was more common in the proximal colon (55.4%). The most common type was flat protuberant LST-NGF (3.25% 20% 615.4% of submucosal carcinoma in 22.76%).LST). LST-NGPD had the highest incidence of submucosal cancer in 30% 14.2912% 84%. The LST of the rectum was 31.49 卤23.09 in diameter and 20.82 卤9.86 in the colon, and had a higher incidence of early cancer than that of the colon, 36.43 vs 14.95. The most common adenoductal openings in lateral developmental tumors were IIIL type 30.56C and type IV (n = 32.94). The proportion of V-type pit pattern in LST-GM and LST-NGPD was 29.11% and 41.93%, respectively. All submucosal carcinomas showed V-type pit pattern.The accuracy of VN-type pit pattern in predicting submucosal carcinoma was 58.33. 4.19% of NICE2 lesions and 55.56% of NICE3 lesions were submucosal carcinomas. Of the 615 cases of LST lesions, 343 cases (55.77) were treated with endoscopic mucosal dissection (EMRs) or 29 cases with precutting-EMRA (4.72%) were treated by endoscopic submucosal excision (EMD), 15 cases were treated with endoscopic submucosal dissection (15 cases). The complete excision rate was 94. 80%. There were 56 cases of intraoperative hemorrhage in ESD, 1 case of delayed hemorrhage, and 12 cases of perforation. After endoscopic treatment of EMR-precutting-EMR and ESD, the positive rate of incisal margin was 4.90% or 28 / 571%. 330 patients were followed up after treatment, the median follow-up time was 15 months. There were 10 cases of recurrence, of which the higher recurrence rate of endoscopic EPMR was 13.79% and the recurrence rate of EMR was 1.32% / 152%. Compared with LST treated with ESD in recent 3 years, there was no recurrence. Conclusion: the submucosal carcinoma rate of LST-NGPD is the highest among the four subclassifications of lateral developing tumors. LST in the rectum is larger in diameter than in the colon and is more likely to develop early cancer. Type V adenoducts and NICE3 lesions suggest that submucosal cancer is more likely. For the larger LST, the recurrence rate of the lesion was high. The complete endoscopic submucosal dissection (ESD) was a safe and effective treatment for LST.
【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.34

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