食管、胃黏膜下肿瘤内镜规范化治疗研究

发布时间：2018-09-04 11:39

【摘要】：第一部分:819例上消化道黏膜下病变流行特点分析目的:了解青海地区上消化道黏膜下病变的流行特点。方法:回顾性分析近年来在青海省人民医院内镜检出黏膜下病变一般生物学特点。结果:共完成超声内镜检查1926例,共检出黏膜下病变819例,黏膜下病变占超声内镜检查例数的42.5%;男女分别为424、395例;其中检出食管、胃、十二指肠黏膜下病变分别为321、395、103例。其中SMT506例,非SMT313例,二者比例为1.617:1。检出间质瘤320例,男女之比为1:1.19,年龄25-85岁,胃间质瘤占上消化道间质瘤62.8%,胃是上消化道间质瘤好发器官;胃底与胃体是胃间质瘤好发部位,占胃间质瘤的71.1%;食道间质瘤多来源于黏膜肌层而胃间质瘤多起源于固有肌层。检出平滑肌瘤123例,男女之比1.16:1,发病年龄15-82岁;食道为上消化道平滑肌瘤好发部位,占77.24%;食道平滑肌瘤多来源于肌层而胃平滑肌瘤多起源于固有肌层。检出脂肪瘤55例,男女之比1.62:1,年龄25-81岁,胃为上消化道脂肪瘤好发器官,占63.64%;胃窦为胃脂肪瘤好发部位,占胃脂肪瘤的80%;脂肪瘤绝大多数起源于黏膜下层,占93.36%。检出异位胰腺125例,男女之比为1:1.08,年龄17-79岁,分布于胃和十二指肠,胃为上消化道异位胰腺好发器官,占86.4%,胃窦是胃异位胰腺的好发部位,占63.9%,异位胰腺全部起源于黏膜下层。检出囊肿160例,男女比例为1.5:1,年龄23-84岁,食管、十二指肠是上消化道囊肿好发部位,占86.9%,囊肿绝大多数起源于黏膜下层,占98.1%。结论:青海地区上消化道胃黏膜下病变流行特点与国内外报道并不完全一致,了解本地区不同性质病变特点有助于内镜医师提高对粘膜下病变的认识。第二部分:内镜下切除食管黏膜下肿瘤有效性、安全性评价目的:评价内镜下治疗食管黏膜下肿瘤的有效性及安全性。方法:使用EMR、ESE、STER术式分别切除食管黏膜下肿瘤38例,分析不同术式治疗后,肿瘤切除率、患者并发症的发生率、患者住院时间、手术耗时、术后禁食时间及住院费用。结果:38例食管黏膜下肿瘤均被完整切除,成功率为100%,其中EMR切除13例、ESE切除20例、STER切除5例;EMR术中出血率为30.8%,ESE、STER术中出血率为100%,术中出血均可用热活检钳电凝止血;术后发生并发症7例,并发症发生率为18.4%,分别为创面出血1例、穿孔后食管胸腔瘘1例、皮下及纵膈气肿3例、感染2例;EMR术式平均耗时、患者住院费用明显低于ESE、STER组;并发症的发生与肿瘤大小有关,并发症发生后,患者禁食时间、住院时间、住院费用均明显高于未发生并发症者。结论:开展食管黏膜下肿瘤内镜下治疗术是安全、有效的。第三部分:ESE、EFR术式切除胃黏膜下肿瘤对比研究目的:评价内镜下治疗胃黏膜下肿瘤的有效性及安全性。方法:纳入胃黏膜下肿瘤患者57例并行ESE、EFR术式切除治疗,分析不同术式肿瘤切除率、患者并发症的发生率、手术耗时、术中出血量、术后住院天数及住院费用。结果:57例胃黏膜下肿瘤内镜下完整切除56例,失败1例,成功率为98.2%,术后总发生并发症6例,并发症发生率为10.7%;其中ESE切除44例,发生并发症1例,并发症发生率为2.3%,EFR切除12例,发生并发症5例,并发症发生率为41.7%,EFR术式并发症发生率明显高于ESE术式,两种手术方式并发症发生率有统计学差异(P0.05);ESE术式平均耗时45.2min,EFR平均耗时65.8min,两种手术方式耗时时间有统计学差异(P0.05);ESE平均出血23.6ml,EFR平均出血56.1ml,两种术式平均术中出血差异有统计学意义(P0.05);ESE和EFR术式在术后住院时间、住院总费用方面无差异(P0.05);有并发症组肿瘤大小平均28mm,明显大于无并发症组12.58mm,差异有统计学意义(P0.05);有并发症组手术平均耗时66.7min,明显大于无并发症组45.6min,差异有统计学意义(P0.05);有并发症组患者平均住院费用RMB 31940.8元,大于无并发症组的RMB 22510.8元,差异有统计学意义(P0.05)。结论:ESE是切除胃黏膜下肿瘤安全、有效的内镜治疗手段,EFR切除虽然有效,但对术者技术要求高、并发症发生率高,需要谨慎开展。第四部分:内镜与腹腔镜切除胃黏膜下肿瘤对比研究目的:评价无腹腔镜辅助的内镜消化道壁全层切除术与腹腔镜楔形切除术治疗胃黏膜下肿瘤的有效性及安全性。方法:纳入胃黏膜下肿瘤23例,分为内镜组与腹腔镜组,内镜组利用无腹腔镜辅助的内镜消化道壁全层切除术(EFR)切除病变13例,腹腔镜组利用楔形切除术(LWR)切除病变10例,分析不同术式治疗后,肿瘤切除率、患者并发症的发生率、手术耗时、术中出血量、患者术后住院时间及住院费用。结果:内镜组纳入13例患者,EFR成功切除12例,失败1例,手术成功率为92.3%;腹腔镜成功切除10例,无切除失败病例,成功率为100%;术后内镜组发生并发症5例,并发症发生率为41.7%%,腹腔镜组发生并发症1例,并发症发生率为10.0%,两组之间并发症发生率无统计学差异(P0.05);内镜组手术平均耗时65.8min,腹腔镜组平均耗时139.5min,两组平均手术耗时有统计学差异(P0.05);内镜组术后平均住院7.0天,腹腔镜组平均10.7天,腹腔镜组住院时间长于内镜组,两组总住院时间有统计学差异(P0.05);内镜组平均住院费用RMB 24970.7元,腹腔镜组RMB 35891.0元,腹腔镜组住院费用明显高于内镜组,两组平均住院费用差异有统计学意义(P0.05)。内镜组与腹腔镜组在手术成功率、并发症发生率及术中出血量方面无统计学差异(P0.05)。结论:LWF在治疗胃黏膜下肿瘤有较好的有效性和安全性,EFR虽然与LWR有效性一致,但EFR术式安全性较低,临床中应谨慎开展。
[Abstract]:Objective: To investigate the epidemiological characteristics of submucosal lesions of upper gastrointestinal tract in Qinghai area. Methods: The general biological characteristics of submucosal lesions detected by endoscopy in Qinghai People's Hospital in recent years were retrospectively analyzed. Results: 1926 cases of submucosal diseases were detected by endoscopic ultrasonography. Submucosal lesions of esophagus, stomach and duodenum were detected in 321,395 and 103 cases, respectively. Among them, 506 cases of SMT and 313 cases of non-SMT were detected, and the ratio of the two was 1.617:1. 320 cases of stromal tumors were detected, the ratio of male to female was 1:1.19, the age of 25-85 years old, and gastric stromal tumors accounted for the upper gastrointestinal tract. 62.8% of the stromal tumors were found in the stomach, which was the predilection organ of the upper gastrointestinal stromal tumors; 71.1% of the stromal tumors were located in the gastric fundus and gastric body; most of the esophageal stromal tumors originated from the mucosal myometrium and most of the gastric stromal tumors originated from the lamina propria. The incidence rate of esophageal leiomyoma was 77.24%. Esophageal leiomyoma mostly originated from myometrium and gastric leiomyoma mostly originated from lamina propria. 125 cases of heterotopic pancreas were detected, the ratio of male to female was 1:1.08, and the age was 17-79 years old. The stomach was the predominant organ of heterotopic pancreas in the upper gastrointestinal tract, accounting for 86.4%. The antrum was the predominant site of heterotopic pancreas in the stomach, accounting for 63.9%. All heterotopic pancreas originated from submucosa. Conclusion: The epidemiological characteristics of gastric submucosal lesions in the upper gastrointestinal tract in Qinghai area are inconsistent with those reported at home and abroad. Understanding the characteristics of different lesions in this area is helpful for endoscopists to improve their understanding of submucosal lesions. Objective: To evaluate the efficacy and safety of endoscopic resection of esophageal submucosal tumors. Methods: 38 cases of esophageal submucosal tumors were resected by EMR, ESE and STER. The resection rate and complications were analyzed. Results: 38 cases of esophageal submucosal tumors were completely resected, the success rate was 100%, including 13 cases of EMR resection, 20 cases of ESE resection, 5 cases of STER resection; the bleeding rate of EMR was 30.8%, the bleeding rate of ESE and STER was 100%. Complications occurred in 7 cases, the incidence of complications was 18.4%. They were wound bleeding in 1 case, esophagothoracic fistula after perforation in 1 case, subcutaneous and mediastinal emphysema in 3 cases, and infection in 2 cases. Conclusion: Endoscopic esophagectomy for submucosal tumors is safe and effective. Part III: Comparative study of ESE and EFR for gastric submucosal tumors. Objective: To evaluate the efficacy and safety of endoscopic treatment for gastric submucosal tumors. Methods: 57 patients with gastric submucosal tumors were included in the study. ESE and EFR were performed in 56 cases of gastric submucosal tumors, 1 case failed, the success rate was 98.2%, 6 cases had postoperative complications, and the complication rate was 10.7%. There were 44 cases of ESE excision, 1 case of complication, 2.3% complication rate, 12 cases of EFR excision, 5 cases of complication rate, 41.7% complication rate. Complication rate of EFR operation was significantly higher than that of ESE operation, and there was significant difference between the two operation methods (P 0.05); the average time of ESE operation was 45.2 minutes, and the average time of EFR was 65.8 minutes. There were significant differences in time-consuming (P 0.05); mean ESE bleeding was 23.6 ml, mean EFR bleeding was 56.1 ml, and mean intraoperative bleeding was statistically significant (P 0.05); mean postoperative hospitalization time and total hospitalization cost of ESE and EFR were not significantly different (P 0.05); mean tumor size of complications group was 28 mm, significantly larger than that of non-complications group (12.58 mm). The difference was statistically significant (P 0.05); the average operation time of complications group was 66.7 minutes, significantly greater than that of non-complications group 45.6 minutes, the difference was statistically significant (P 0.05); the average hospitalization cost of complications group was RMB 31940.8 yuan, greater than that of non-complications group RMB 22510.8 yuan, the difference was statistically significant (P 0.05). Endoscopic resection of gastric submucosal tumors is safe and effective. Although EFR is effective, it requires a high level of technique and complications. Part IV: Comparative study of endoscopic and laparoscopic resection of gastric submucosal tumors Objective: To evaluate the efficacy of laparoscopic-assisted total gastrointestinal wall resection and laparoscopic wedge resection in the treatment of gastric cancer. Methods: 23 cases of gastric submucosal tumors were divided into endoscopic group and laparoscopic group, 13 cases of gastrointestinal lesions were resected by endoscopic total wall resection (EFR) without laparoscopic assistance, and 10 cases by laparoscopic wedge resection (LWR). Results: 13 patients were enrolled in the endoscopy group, 12 cases of EFR were successfully excised, 1 case was unsuccessful, the success rate was 92.3%; 10 cases were successfully excised by laparoscopy, without failure of excision, the success rate was 100%; 5 cases were complications and complications in the endoscopy group. The incidence of complications was 41.7%. The incidence of complications was 10.0% in the laparoscopic group. There was no significant difference between the two groups (P 0.05). The average hospitalization time of the laparoscopic group was 10.7 days longer than that of the endoscopic group (P 0.05); the average hospitalization cost of the endoscopic group was RMB 24970.7 yuan, and that of the laparoscopic group was RMB 35891.0 yuan. The average hospitalization cost of the laparoscopic group was significantly higher than that of the endoscopic group (P 0.05). Conclusion: LWF is effective and safe in the treatment of gastric submucosal tumors. Although the efficacy of EFR is consistent with that of LWR, the safety of EFR is low and should be carried out cautiously.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R735

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