内镜全层切除术（EFTR）治疗胃固有肌层肿瘤的疗效观察

发布时间：2018-07-07 20:47

本文选题：内镜全层切除术 + 胃固有肌层肿瘤　；参考：《山东大学》2017年硕士论文

【摘要】：研究背景最近几十年,随着内镜操作水平和人们健康意识的提高,胃粘膜下肿瘤(submucosal tumors,SMT)的检出率越来越高,其多种内镜切除方式也得到迅猛展开。通常情况下,小于2cm的粘膜下肿瘤无症状,患者常因其他不适或体检时于胃镜或影像学检查中偶然发现。而病变较大、恶性程度较高的粘膜下肿瘤可能会引起出血,腹痛、腹胀甚至腹部包块及体重下降等临床症状。胃肠道粘膜下肿瘤主要分为四类—具有潜在恶性的间质瘤、平滑肌来源的平滑肌瘤和平滑肌肉瘤、神经源性肿瘤如神经鞘瘤和神经纤维瘤、血管源性肿瘤如血管瘤和淋巴管瘤等。其中,间质瘤是胃肠道间质来源的具有潜在恶性的肿瘤,起源于Cajal间充质细胞,由突变的c-kit基因或血小板源性生长因子受体α(PDGFRA)驱动,组织学上多见束状或弥漫排列的梭形细胞和上皮样细胞等,免疫组织化学检测常常显示为CD117或DOG-1阳性。间质瘤基于其复发和转移的潜力可分为极低危险度、低危险度、中危险度和高危险度。传统的治疗方式为外科手术切除胃粘膜下肿瘤,主要包括开腹手术和腹腔镜手术。开腹手术可以在直视下直接切除肿瘤,做到完整切除,减少复发和转移的风险,且不受肿瘤位置、大小、浸润深度的影响。但是,开腹手术创伤大,并发症发生率高,恢复时间长,显著损害了患者术后的生活质量。腹腔镜手术相对于开腹手术来说,微创、恢复时间短,并且安全、有效、术式的选择也更加灵活,这些优点使其得到广泛应用。然而,当肿瘤较小且向管腔内生长时,难以确定肿瘤的精确位置,尤其是肿瘤位于胃后壁和胃小弯时,手术时易导致胃壁的不完整切除或过度切除,从而导致术后胃畸形。追求更微创的内镜治疗方法是人们的迫切要求。随着微创观念的深入,内镜粘膜下剥离术(endoscopic submucosal dissection,ESD)等内镜技术的成熟和发展,医疗技术及器械的不断更新,以及修补消化道穿孔技术的应用并取得显著疗效,内镜全层切除术(Endoscopic full-thickness resection,EFTR)应运而生。内镜全层切除术对于切除起源于固有肌层的消化道SMT并提供准确的病理诊断,具有较好的效果,已经成为起源于固有肌层消化道SMT的治疗选择之一。研究目的探讨内镜全层切除术(Endoscopic full-thickness resection,EFTR)治疗起源于胃固有肌层肿瘤的疗效、方法、可行性及安全性。研究方法选取24例自2014年12月至2016年12月于山东大学齐鲁医院消化科一病房行EFTR治疗的胃固有肌层肿瘤的患者,收集临床资料,评价肿瘤切除率、并发症发生及肿瘤复发情况。患者均于术前行超声内镜(EUS)检查明确瘤体来源于胃固有肌层,且无远处转移。EFTR步骤:①确定肿瘤位置,标记病灶边缘,粘膜下注射,预切开肿瘤表面粘膜层和粘膜下层,显露肿瘤;②沿肿瘤周围分离固有肌层;③沿肿瘤边缘切开浆膜层,造成"主动"穿孔;④胃镜直视下完整切除肿瘤;⑤胃镜直视下自创面一侧向另一侧完整对缝创面。研究结果24例胃固有肌层肿瘤患者中,男性9例,女性15例,平均年龄59.75±10.83岁。肿瘤位于胃底者15例,胃体者7例,胃窦者2例。肿瘤平均大小1.56±0.86cm,平均手术时间为95.83±44.37min,患者平均住院时间10.2±2.50d,平均住院花费33719.97元。24例固有肌层肿瘤患者均经EFTR完整切除肿瘤,完整切除率为100%,无术中大出血、术后迟发性出血、腹膜炎、腹腔脓肿等并发症。术后病理结果显示间质瘤18例(极低危险度13例,低危险度5例),平滑肌瘤3例,神经鞘瘤2例,丛状纤维粘液瘤1例。对24例患者进行术后随访,随访时间为3～23个月,其间未发现复发或转移。结论内镜全层切除术(EFTR)是治疗胃固有肌层肿瘤的一种安全、有效的微创方法,具有突出的临床应用价值。
[Abstract]:In recent decades, the detection rate of submucosal tumors (SMT) is increasing with the level of endoscopic operation and people's awareness of health, and a variety of endoscopic excision methods have also been developed rapidly. Generally, submucosal tumors less than 2cm are asymptomatic and patients often suffer from other discomfort or physical examination at the gastroscope or A large lesion and a higher malignant submucosal tumor may cause bleeding, abdominal pain, abdominal distention, even abdominal mass and weight loss. The submucosal tumors of the gastrointestinal tract are divided into four types - potentially malignant stromal tumors, smooth muscle leiomyoma and smooth muscle sarcoma, and neurosarcoma. Source tumors such as neurilemmoma and neurofibroma, angiogenic tumors such as hemangioma and lymphangioma. Among them, the stromal tumor is a potentially malignant tumor of the gastrointestinal stromal origin, derived from Cajal mesenchymal cells, driven by the mutant c-kit gene or platelet derived growth factor receptor alpha (PDGFRA), and histologically common in the fascicle or in the fascicle. A diffuse array of spindle cells and epithelioid cells, immunohistochemical detection is often shown to be CD117 or DOG-1 positive. Stromal tumors can be divided into very low risk, low risk, middle risk and high risk based on their potential for recurrence and metastasis. Traditional methods of treatment are surgical hand resection of submucosal tumors of the stomach, mainly including open hands. Surgery and laparoscopy. Open surgery can remove the tumor directly under direct vision, complete resection, reduce the risk of recurrence and metastasis, and not be affected by tumor location, size, and depth of infiltration. However, open surgery has a large trauma, high complication rate, long recovery time, and significant damage to the patient's quality of life after the operation. Laparoscopy surgery Compared with open surgery, minimally invasive, short recovery time, safe and effective, and more flexible surgical options are also used. These advantages make it widely used. However, when the tumor is small and grows into the cavity, it is difficult to determine the exact location of the tumor, especially when the tumor is located in the back of the stomach and the stomach. Complete resection or excision, which leads to postoperative gastric malformation. The pursuit of more minimally invasive endoscopic therapy is an urgent requirement. With the deepening of the concept of minimally invasive, endoscopic submucosal dissection (endoscopic submucosal dissection, ESD), the maturation and development of endoscopic techniques, the continuous updating of medical techniques and instruments, and the repair of digestive tract wear Endoscopic full-thickness resection (EFTR) emerges as a result of the application of the hole technique. Endoscopy full layer resection has a good effect on the removal of the digestive tract SMT originating from the intrinsic myometrium and the accurate pathological diagnosis. It has become a choice for the treatment of SMT originating in the intrinsic muscularis. Objective to investigate the efficacy, methods, feasibility and safety of Endoscopic full-thickness resection (EFTR) in the treatment of gastric propria tumors. Methods 24 cases of gastric intrinsic myometrium were selected from December 2014 to December 2016 at the digestive department of Qilu Hospital of Shandong University, Shandong University. The patients were collected the clinical data and evaluated the tumor resection rate, complication and tumor recurrence. The patients were examined by endoscopic ultrasonography (EUS) before the operation to identify the tumor origin from the intratumoral myometrium and no distant metastasis.EFTR steps: (1) determine the location of the tumor, mark the edge of the lesion, submucous injection, precut the surface of the tumor surface and submucous membrane The layer was exposed to the tumor; (2) separation of the intrinsic myometrium along the tumor; (3) incision of the serous layer along the edge of the tumor to cause "active" perforation; (4) complete resection of the tumor under the direct vision of the gastroscope; (5) the wound from one side of the wound to the other side of the wound. Among the 24 cases of gastric myometrium tumor, 9 males and 15 females, with an average age of 59.75. The tumor was 10.83 years old. There were 15 cases in the fundus of the stomach, 7 cases in the stomach body and 2 in the antrum. The average size of the tumor was 1.56 + 0.86cm, the average operation time was 95.83 + 44.37min, the average hospitalization time was 10.2 + 2.50d, the average hospitalization cost was 33719.97 yuan. All the patients with the intrinsic myometrium tumor were all excised by EFTR. The complete resection rate was 100%. There was no large intraoperative hemorrhage. Complications such as delayed hemorrhage, peritonitis and abdominal abscess after operation. Postoperative pathological results showed 18 cases of stromal tumor (13 cases of extremely low risk, 5 cases of low risk), 3 cases of leiomyoma, 2 cases of neurilemmoma and 1 cases of plexiform fibromyxoma. The follow-up time of 24 patients was 3~23 months, and the recurrence or metastasis was not found during the period. Endoscopic full-thickness resection (EFTR) is a safe and effective minimally invasive method for the treatment of tumors of the muscularis propria of the stomach. It has outstanding clinical application value.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.2

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