Uburyo bwo kuvura ibibyimba byo mu nzira y'igogora hakoreshejwe endoscope: Ingingo 3 z'ingenzi zikubiye mu ngingo imwe

Ibibyimba byo mu gifu (SMT) ni ibibyimba byinshi bikomoka ku mucosa w’imitsi, submucosa, cyangwa muscularis propria, kandi bishobora no kuba ibibyimba byo hanze y’urumuri. Bitewe n’iterambere ry’ikoranabuhanga mu buvuzi, uburyo gakondo bwo kuvura bwagiye bwinjira buhoro buhoro mu gihe cyo kuvura mu buryo budakunze kugaragara, nka lKubaga indwara ya aparoscopic no kubaga robots. Ariko, mu buvuzi, byagaragaye ko "kubaga" bidakwiye abarwayi bose. Mu myaka ya vuba aha, agaciro ko kuvura indwara ya endoscopic kagiye kitabwaho buhoro buhoro. Verisiyo iheruka y’impuguke z’Abashinwa ku bijyanye no gusuzuma no kuvura SMT yasohotse. Iyi nkuru iziga muri make ubumenyi bujyanye nayo.

1. Indwara ya SMT igaragaraimiyoborere

(1) Ikwirakwira rya SMT ntabwo ingana mu bice bitandukanye by'inzira y'igogora, kandi igifu niho hakunze kugaragara SMT.

Ikwirakwira ry'indwara zitandukanyeIbice by'inzira y'igogora ntibingana, aho igice cyo hejuru cy'igogora ari cyo gikunze kugaragara cyane. Muri ibi, 2/3 biba mu gifu, hagakurikiraho umwobo, duodenum, n'amara.

(2) Isuzuma ry'imiterere y'ibinyabuzimaUbwoko bwa SMT buragoye, ariko SMT nyinshi ni ibisebe bidapfa kwangirika, kandi bike gusa ni bibi.

A.SMT irimo ntaibisebe bya n-neoplastic nk'ibisebe bya pancreas byo hanze y'uruhu n'ibisebe bya neoplastic.

B.Muri ikibyimba cya neoplastics, leiomyoma zo mu gifu, lipoma, adenoma za Brucella, tumors za granulosa cell, schwannomas, na glomus tumors akenshi ni nziza, kandi munsi ya 15% bishobora kugaragara nk'ingingo.

C. Stroma yo mu gifuIbibyimba (GIST) na kanseri y’ubwonko (NET) muri SMT ni ibibyimba bifite ubushobozi bwo kwangiza, ariko ibi biterwa n’ingano yabyo, aho biherereye n’ubwoko bwabyo.

D. Aho SMT iherereye birafitanye isanoku cyiciro cy’indwara: a. Leiomyoma ni ubwoko busanzwe bwa SMT mu muhogo, bungana na 60% kugeza kuri 80% bya SMT mu muhogo, kandi bukunze kugaragara mu bice byo hagati n’ibyo hasi by’umuhogo; b. Ubwoko bw’indwara za SMT mu gifu buragoye cyane, hamwe na GIST, leiomyoma na pancreas yo mu nda ni byo bikunze kugaragara cyane. Muri SMT yo mu nda, GIST ikunze kuboneka mu gice cy'umugongo n'umubiri w'igifu, leiomyoma ikunze kugaragara mu mutima no mu gice cyo hejuru cy'umubiri, naho pancreas yo mu nda n'pancreas yo mu nda ni byo bikunze kugaragara cyane. Lipoma zikunze kugaragara cyane mu gice cy'igifu; c. Lipoma na cysts zikunze kugaragara cyane mu bice bimanuka n'ibinini bya duodenum; d. Muri SMT yo hasi mu nzira y'igifu, lipoma zikunze kugaragara mu mara, mu gihe NET zikunze kugaragara mu gice cy'umura.

(3) Koresha CT na MRI kugira ngo umenye ibibyimba, uvure, kandi upime. Ku ndwara za SMT zikekwaho kuba zishobora kuba mbi cyangwa zifite ibibyimba binini (birebire).umurambararo > cm 2), CT na MRI ni byo byiza.

Ubundi buryo bwo gufata amashusho, harimo CT na MRI, nabwo bufite akamaro kanini mu gusuzuma SMT. Bushobora kwerekana neza aho ikibyimba cyabereye, imiterere y'igisebe, ingano y'igisebe, imiterere, kuba cyangwa kutagira aho kigaragara, ubwinshi bw'ibisebe, uburinganire, ingano y'ubwiyongere, n'imiterere y'umupaka, nibindi, kandi bushobora kumenya niba n'ingano y'ubunini bw'ibisebe.gucika k'urukuta rw'igifu. Icy'ingenzi kurushaho, ibi bipimo by'amashusho bishobora kugaragaza niba hari imiterere yegereye ikibyimba ndetse niba hari metastasis mu gice kiyikikije, node za lymph n'izindi ngingo. Ni bwo buryo bw'ingenzi bwo gupima, kuvura no gusuzuma ubwiyongere bw'ibibyimba.

(4) Gufata ingero z'uturemangingo ntibisubirwamobyakorewe ku miti igabanya ubukana bw'amaraso mu mubiri ishobora gupimwa hakoreshejwe endoskopi isanzwe ihujwe na EUS, nka lipoma, cysts, na pancreas yo mu nda.

Ku bisebe bikekwaho kuba bibi cyangwa iyo endoskopi isanzwe ihujwe na EUS idashobora gusuzuma ibisebe bidakomeye cyangwa bibi, EUS-guided fine-induced aspiration/biopsy irashobora gukoreshwa (endoskopiya ya ultrasonography iyobowe neza nGupima/gupima ibinure, EUS-FNA/FNB), gupima mucosal incision biopsy (gupima mucosalinciation-assisted biopsy, MIAB), nibindi. Gukora isuzuma rya biopsy mbere yo kubagwa. Bitewe n'imbogamizi za EUS-FNA n'ingaruka zikurikiraho ku gupima endoscopic resection, ku bantu bemerewe kubagwa endoscopic, hashingiwe ku kwemeza ko ikibyimba gishobora gukurwamo burundu, ibikoresho bifite ikoranabuhanga ryo kuvura endoscopic rikuze bishobora kuvurwa n'inararibonye. Umuganga w'indwara zo mu nda akora endoscopic resection atabanje kubona isuzuma ry'indwara mbere yo kubagwa.

Uburyo ubwo aribwo bwose bwo kubona ingero z’indwara mbere yo kubagwa burabangamira kandi buzangiza uturemangingo tw’amaraso cyangwa bugatera gufatana n’uturemangingo tw’umubiri, bityo byongera ingorane zo kubagwa ndetse bishobora no kongera ibyago byo kuva amaraso, imikorereKugabanya ibibyimba no gukwirakwiza ikibyimba. Kubwibyo, biopsy mbere yo kubagwa si ngombwa cyane. Ni ngombwa, cyane cyane ku ndwara zo mu bwoko bwa SMT zishobora gupimwa hakoreshejwe endoskopi isanzwe ihujwe na EUS, nka lipomas, cysts, na pancreas yo mu nda, nta gupima ingirabuzima fatizo bikenewe.

2.Ubuvuzi bwa SMT endoscopicnt

(1) Amahame ngenderwaho mu kuvura

Ibisebe bidafite udukoko twa lymph node cyangwa ibyago bike cyane byo kugabanuka kw'udukoko twa lymph node, bishobora gukurwamo burundu hakoreshejwe uburyo bwo gupima, kandi bifite ibyago bike byo kugabanuka no kugaruka ni byiza gucibwamo udukoko twa lymph node mu gihe bibaye ngombwa. Gukuraho burundu ikibyimba bigabanya ibibyimba bisigaye n'ibyago byo kugaruka.Ihame ryo kuvura nta kibyimba rigomba gukurikizwa mu gihe cyo kubaga endoscopic, kandi hagakurikizwa ubusugire bw'agapfukamunwa k'ikibyimba mu gihe cyo kubaga.

(2) Ibimenyetso

i. Ibibyimba bishobora kwangiza bikekwaho isuzuma mbere yo kubagwa cyangwa byemejwe n'indwara ya biopsy, cyane cyane ibikekwaho indwara ya GIST mbere yo kubagwa hagasuzumwa uburebure bwa ≤2cm mbere yo kubagwa kandi hatari ibyago byinshi byo kongera kugaragara no kwangirika kw'uturemangingo, kandi hakabaho amahirwe yo gucibwa burundu, ishobora gucibwa hakoreshejwe endoscope; ku turemangingo dufite umurambararo muremure. Ku bibyimba bikekwa ko bifite ibyago bike >2cm, niba urugingo rwa lymph cyangwa metastasis iri kure bitarasuzumwe mbere yo kubagwa, hashingiwe ku kwemeza ko ikibyimba gishobora gukurwamo burundu, kubagwa hakoreshejwe endoscope bishobora gukorwa n'abahanga mu by'ubuvuzi bw'indwara zo mu nda mu cyumba gifite ikoranabuhanga ryo kuvura indwara zo mu nda.

ii. Ibimenyetso (urugero, kuva amaraso, kuziba kw'imitsi) SMT.

iii.Abarwayi bakekwaho ko ibibyimba byabo ari bibi binyuze mu isuzuma rya mbere yo kubagwa cyangwa byemejwe n'indwara, ariko ntibashobora gukurikiranwa buri gihe cyangwa ibibyimba byabo bikiyongera mu gihe gito mu gihe cyo gukurikirana kandi bafite icyifuzo gikomeye cyo kubyihanganira.e yo kuvura indwara ya endoskopi.

(3) Ibibujijwe

i. Kumenya ibikomere binteyebiryoshye ku nsoro za lymph cyangwa ahantu ha kure.

ii. Kuri SMT zimwe na zimwe zifite lymph isobanutse nezanodecyangwa kure, hakenewe biopsy kugira ngo haboneke uburwayi, ibyo bikaba bishobora gufatwa nk'aho ari ikibazo kidakwiye.

iii. Nyuma yo kubagwa mu buryo burambuyeisuzuma, byemezwa ko indwara muri rusange ari mbi kandi ko kubagwa mu buryo bwa endoscopic bidashoboka.

Ibisebe bidafite ingaruka mbi nka lipoma na pancreas yo mu nda muri rusange ntibitera ibimenyetso nko kubabara, kuva amaraso, no kuziba. Iyo SMT igaragara nk'isuri, ibisebe, cyangwa yiyongera vuba mu gihe gito, amahirwe yo kuba igisebe kibi ariyongera.

(4) Guhitamo uburyo bwo gukatad

Gukuraho umutego wo mu ruhu: Ku bijyanye no gukata umutego wo mu ruhuSMT igaragara hejuru cyane, isohoka mu mwobo nk'uko byemejwe n'ibizamini bya EUS na CT mbere yo kubagwa, kandi ishobora gukurwamo burundu icyarimwe hakoreshejwe umutego, gucibwamo umutego hakoreshejwe endoscopic bishobora gukoreshwa.

Ubushakashatsi bwo mu gihugu no mu mahanga bwemeje ko ari byiza kandi ko bigira ingaruka ku ndwara ya SMT iri hejuru ya cm 2, ikaba ishobora kuva amaraso kuva kuri 4% kugeza kuri 13% no gutobora.ibyago biri hagati ya 2% na 70%.

Gucukura mu gice cy'umuyoboro wa endoscopic, ESE: Ku bipimo bya SMT bifite umurambararo muremure wa ≥2 cm cyangwa niba ibizamini byo gufata amashusho mbere yo kubagwa nka EUS na CT byemeza koIyo ikibyimba kigeze mu mwobo, ESE irashoboka mu gukata amaboko ya SMTs zikomeye.

ESE ikurikiza imico ya tekiniki yaGukuraho mucosal submucosal (ESD) no gukata mucosal endoscopic, kandi buri gihe hakoreshejwe "flip-top" incision izengurutse ikibyimba kugira ngo ukureho mucosal itwikiriye SMT no kwerekana neza ikibyimba. , kugira ngo tugere ku ntego yo kubungabunga ubusugire bwa kibyimba, kunoza ubwinshi bw'indwara zo kubaga, no kugabanya ingorane mu gihe cyo kubaga. Ku bibyimba ≤1.5 cm, igipimo cyuzuye cyo gukata 100% gishobora kugerwaho.

Udukoko two mu bwoko bwa Submucosal Tunneling Endoscopic ReseptIon, STER: Kuri SMT ikomoka ku mitsi yo mu gifu, hilum, kugorama guke k'umubiri w'igifu, antrum y'igifu n'iy'umura, byoroshye gushyiraho inzira, kandi umurambararo w'igifu uri hejuru ya cm 3.5, STER ishobora kuba uburyo bwiza bwo kuvura.

STER ni ikoranabuhanga rishya ryakozwe hashingiwe ku gupima umuhogo mu kanwa (POEM) kandi ni inyongera y'ikoranabuhanga rya ESD.ikoranabuhanga. Igipimo cyo gucibwa kwa STER mu buryo bwo kuvura SMT kigera kuri 84.9% kigera kuri 97.59%.

Endoscopic Full-ubugari Resection, EFTR: Ishobora gukoreshwa kuri SMT aho bigoye gushyiraho umuyoboro cyangwa aho umurambararo ntarengwa w'ikibyimba uri ≥3.5 cm kandi ntabwo ikwiriye STER. Iyo ikibyimba kivuye munsi y'urukiramende rw'umuhengeri cyangwa gikurira hanze y'igice cy'umwobo, maze ikibyimba kikagaragara ko gifashe neza ku gice cya serosa mu gihe cyo kubagwa kandi kidashobora gutandukana, gishobora gukoreshwa. EFTR ikora ubuvuzi bwa endoscopic.

Gufata neza icyuho cy'aho imbobo iherereyeAhantu nyuma ya EFTR ni ingenzi kugira ngo EFTR igere ku ntego. Kugira ngo hasuzumwe neza ibyago byo kongera kugaragara kwa kanseri no kugabanya ibyago byo gukwirakwira kwa kanseri, ntibyemewe gukata no gukuraho icyitegererezo cy’ikibyimba cyakuweho mu gihe cya EFTR. Niba bibaye ngombwa gukuraho ikibyimba mo ibice, icyuho kigomba gusanwa mbere kugira ngo kigabanye ibyago byo gutera no gukwirakwira kwa kanseri. Bumwe mu buryo bwo gukurura harimo: gukurura icyuma, gukurura icyuma, uburyo bwo gukurura icyuma, "purse bag suture" hakoreshejwe umugozi wa nylon uhujwe na icyuma, uburyo bwo gufunga icyuma (over the scope clip, OTSC) gukurura icyuma cya OverStitch n'ubundi buryo bushya bwo gusana imvune zo mu gifu no guhangana n'amaraso, nibindi.

(5) Ingorane nyuma yo kubagwa

Kuva amaraso mu gihe cyo kubagwa: Kuva amaraso bituma hemoglobin y'umurwayi igabanukaho garama zirenga 20/L.
Kugira ngo hirindwe kuva amaraso menshi mu gihe cyo kubagwa,Gutera amaraso mu gice cy’umura (submucosal injection) bihagije bigomba gukorwa mu gihe cyo kubaga kugira ngo imiyoboro minini y’amaraso igaragare kandi byorohereze electrocoagulation kugira ngo amaraso ahagarike kuva. Kuva amaraso mu gihe cyo kubaga bishobora kuvurwa hakoreshejwe ibyuma bitandukanye byo gukata, ibyuma bikingira amaraso cyangwa ibice by’icyuma, hamwe no gukumira kuva amaraso mu gihe cyo kuyacamo ibice.

Kuva amaraso nyuma yo kubagwa: Kuva amaraso nyuma yo kubagwa bigaragazwa no kuruka amaraso, melena, cyangwa amaraso mu mwanda. Mu bihe bikomeye, gushoka kw'amaraso bishobora kubaho. Akenshi bibaho mu cyumweru kimwe nyuma yo kubagwa, ariko bishobora no kubaho mu byumweru 2 kugeza kuri 4 nyuma yo kubagwa.

Kuva amaraso nyuma yo kubagwa bikunze kujyana noibintu nko kudakora neza mu kugenzura umuvuduko w'amaraso nyuma yo kubagwa no kwangirika kw'imitsi isigaye y'amaraso bitewe na aside yo mu gifu. Byongeye kandi, kuva amaraso nyuma yo kubagwa bifitanye isano n'aho indwara iherereye, kandi bikunze kugaragara cyane mu gice cy'igifu n'aho uturemangingo turi hasi.

Gutinda gutobora: Akenshi bigaragazwa no kubyimba inda, kubabara mu nda birushaho kwiyongera, ibimenyetso bya peritonitis, umuriro, no gusuzuma amashusho bigaragaza imyuka yiyongera cyangwa kwiyongera k'imyuka ugereranije na mbere.

Biterwa ahanini n'ibintu nko kudakora neza kw'ibikomere, gukoresha amashanyarazi menshi mu gufungana kw'inyama, kubyuka kare cyane kugira ngo umuntu atagenda, kurya cyane, kudakoresha isukari mu maraso, no kwangirika kw'ibikomere bitewe na aside yo mu gifu. a. Niba igikomere ari kinini cyangwa kiri hejuru cyangwa igikomere gifite fisImpinduka zigaragara, igihe cyo kuryama n'igihe cyo kwiyiriza ubusa bigomba kongerwa uko bikwiye kandi igogora ry'igifu rigakorwa nyuma yo kubagwa (abarwayi nyuma yo kubagwa igice cyo hasi cy'igifu bagomba gusohoka mu miyoboro y'ikibuno); b. Abarwayi ba diyabete bagomba kugenzura cyane isukari mu maraso yabo; abafite ibibazo bito n'indwara zo mu gituza n'iz'inda bagomba guhabwa imiti nko kwiyiriza ubusa, kurwanya kwandura, no kugabanya aside; c. Ku bafite ikibazo cyo gusohora amazi mu gituza, gufunga amazi mu gituza no gutobora inda bishobora gukorwa. Imiyoboro igomba gushyirwaho kugira ngo amazi akomeze kuba meza; d. Niba indwara idashobora kugaragara aho iri nyuma yo kuvurwa mu buryo burambye cyangwa ivanze n'indwara ikomeye yo mu gifu, kubagwa laparoscopy bigomba gukorwa vuba bishoboka, kandi gusana icyuho no gusohora amazi mu nda bigomba gukorwa.

Ingorane ziterwa na gaze: Harimo subcutaneous emphysema, pneumomediastinum, pneumothorax na pneumoperitoneum.

Gutera imphysema munsi y'umubiri mu gihe cyo kubagwa (bigaragazwa nka emphysema mu maso, mu ijosi, mu gituza no mu isaho) hamwe na pneumophysema yo hagati mu gituza (sGuturika kwa epiglottis bishobora kuboneka mu gihe cyo gupima gastroscopy) ubusanzwe ntibisaba ubuvuzi bwihariye, kandi emphysema muri rusange izakira ubwayo.

Pneumothorax ikomeye ibaho dkubagwa [umuvuduko w'umwuka urenga 20 mmHg mu gihe cyo kubagwa

(1mmHg=0.133kPa), SpO2<90%, byemejwe na X-ray y’igituza cyihutirwa], kubagwa bishobora gukomeza nyuma yo gufungwa kw’igituza.kugabanuka k'imyaka.

Ku barwayi bafite pneumoperitoneum igaragara mu gihe cyo kubagwa, koresha urushinge rwa pneumoperitoneum kugira ngo utobore agace ka McFarland.mu nda yo hasi y'iburyo kugira ngo umwuka ufunguke, hanyuma ureke urushinge rwo gutobora mu mwanya warwo kugeza igihe igikorwa kirangiye, hanyuma uruvaneho nyuma yo kwemeza ko nta mwuka ugaragara usohoka.

Fistula yo mu gifu: Amazi yo mu gifu aterwa no kubagwa hakoreshejwe endoscope atembera mu gituza cyangwa mu nda binyuze mu gusohoka kw'amazi.
Fistula yo mu nda yo mu gituza na fistula yo mu gituza ni ibisanzwe. Iyo fistula ibaye, shyira amazi mu gituza mu mwanya ufunze kugira ngo ukomeze kuyikoresha.mu mazi meza kandi hagatangwa inkunga ihagije y'imirire. Iyo bibaye ngombwa, hashobora gukoreshwa ibyuma bifunga n'ibikoresho bitandukanye, cyangwa igipfundikizo cyose gishobora kongera gukoreshwa. Amasasu n'ubundi buryo bikoreshwa mu kuzibaFistula. Indwara zikomeye zisaba kubagwa vuba.

3. Gucunga nyuma yo kubagwa (fgukurikira

(1) Ibisebe bitameze neza:Pathologyigaragaza ko ibisebe bidasaba gukurikiranwa buri gihe nk'ibisebe bya lipoma na leiomyoma.

(2) SMT idafite ubugomeubushobozi bw'inyenzi:Urugero, hagomba gukorwa ibizamini bya 'rectal NETs' bya 2cm, na 'GIST' iri hagati n'iy'ibyago byinshi, hagomba gukorwa ibizamini byose kandi hagatekerezwa cyane ku buvuzi bw'inyongera (kubaga, ubuvuzi bushingiye ku maradiyo, ubuvuzi bushingiye ku ntego). Uburyo bwo gutegura gahunda bugomba gushingira ku nama z'abantu benshi kandi ku muntu ku giti cye.

(3) SMT ifite ubushobozi buke bwo kwandura kanseri:Urugero, GIST ifite ibyago bike igomba gusuzumwa na EUS cyangwa ifatwa amashusho buri mezi 6 kugeza kuri 12 nyuma yo kuvurwa, hanyuma ikavurwa hakurikijwe amabwiriza y’ubuvuzi.

(4) SMT ifite ubushobozi bwo kwandura kanseri buri hagati n'ubunini:Niba indwara nyuma yo kubagwa yemeje ko NET yo mu gifu yo mu bwoko bwa 3, NET yo mu mara ifite uburebure bwa >2cm, kandi ifite ibyago biri hagati na hejuru, hagomba gukorwa isuzuma ryuzuye kandi hagatekerezwa cyane ku kuvura (kubaga, ubuvuzi bushingiye ku maraso, ubuvuzi bushingiye ku buryo bwimbitse). Uburyo bwo gutegura gahunda bugomba gushingira ku[ku bijyanye natwe 0118.docx] inama ku nzego zitandukanye kandi ku giti cyazo.