Endoscopique ivura ibibyimba bya subucosal yinzira yigifu: ingingo 3 zingenzi zavuzwe mu ngingo imwe

Ibibyimba bya Submucosal (SMT) byo mu nda ya gastrointestinal ni ibisebe byatewe hejuru biva mu mitsi ya muscularis mucosa, submucosa, cyangwa muscularis propria, kandi birashobora no gukomeretsa bidasanzwe.Hamwe niterambere ryubuhanga bwubuvuzi, uburyo bwo kuvura gakondo bwo kubaga bwagiye buhoro buhoro bwinjira mugihe cyo kuvura byoroheje, nka lkubaga aparoscopique no kubaga robot.Ariko, mubikorwa byubuvuzi, ushobora gusanga "kubaga" bidakwiye abarwayi bose.Mu myaka yashize, agaciro ko kuvura endoskopique kamaze kwitabwaho.Hasohotse verisiyo iheruka y’impuguke z’abashinwa ku bijyanye no gusuzuma no kuvura SMT.Iyi ngingo iziga muri make ubumenyi bujyanye.

1.Icyorezo cy'icyorezoristics

(1) Indwara ya SMT ntaringaniye mubice bitandukanye byigifu, kandi igifu nikibanza gikunze kugaragara kuri SMT.

Indwara ya various ibice byinzira yigifu ntabwo bingana, hamwe ninzira yo hejuru yigifu.Muri ibyo, 2/3 bibaho mu gifu, bigakurikirwa na esofagusi, duodenum, na colon.

(2) HistopathologicaUbwoko bwa SMT buragoye, ariko SMT nyinshi ni ibikomere byiza, kandi bike gusa ni bibi.

A.SMT ikubiyemo oyan-neoplastique ibikomere nka ectopic pancreatic tissue na neoplastique.

B.Mu gice cya neoplastiques, gastrointestinal leiomyoma, lipoma, adenoma ya Brucella, ibibyimba bya selile granulosa, schwannoma, na glomus yibibyimba ahanini ni byiza, kandi munsi ya 15% birashobora kugaragara nka tissue Wige ikibi.

C. Indwara ya gastrointestinalibibyimba (GIST) na neuroendocrine ibibyimba (NET) muri SMT ni ibibyimba bifite ubushobozi bubi, ariko ibi biterwa nubunini bwabyo, aho biherereye n'ubwoko bwayo.

D.Ahantu SMT ifitanye isanoku byiciro by’indwara: a.Leiomyoma ni ubwoko bwa patologiya busanzwe bwa SMT muri esofagusi, bingana na 60% kugeza 80% bya SMTs esofageal, kandi birashoboka cyane ko biboneka mugice cyo hagati no hepfo ya esofagusi;b.Ubwoko bwa pathologiya ya gastricike SMT iragoye, hamwe na GIST, leiomyoma na ectopic pancreas nibisanzwe.Muri gastric SMT, GIST ikunze kuboneka mumafaranga no mumubiri wigifu, leiomyoma ikunze kuba mumutima no mugice cyo hejuru cyumubiri, kandi pancreas ectopique na pancreas ectopique ikunze kugaragara.Lipoma ikunze kugaragara muri antrum gastric;c.Lipoma na cysts bikunze kugaragara mubice bimanuka kandi binini bya duodenum;d.Muri SMT yo mu gice cyo hepfo gastrointestinal, lipoma yiganje muri colon, mugihe NET yiganje muri rectum.

(3) Koresha CT na MRI kugirango ugabanye, kuvura, no gusuzuma ibibyimba.Kuri SMTs zikekwa kuba zishobora kuba mbi cyangwa zifite ibibyimba binini (birebirediameter> cm 2), CT na MRI birasabwa.

Ubundi buryo bwo gufata amashusho, harimo CT na MRI, nabwo bufite akamaro kanini mugupima SMT.Barashobora kwerekana mu buryo butaziguye aho ibibyimba bibera, uburyo bwo gukura, ingano yangirika, imiterere, kubaho cyangwa kutabaho kwa lobulation, ubucucike, ubutinganyi, urwego rwo kuzamura, hamwe nimbibi, nibindi, kandi barashobora kumenya niba nubunini bwubuniniening y'urukuta rwa gastrointestinal. Icy'ingenzi cyane, ibi bizamini byerekana amashusho birashobora kumenya niba hari ibitero byubatswe byegeranye na lesion kandi niba hari metastasis muri peritoneum ikikije, lymph node nizindi ngingo.Nuburyo bwibanze bwo gupima amavuriro, kuvura no gusuzuma ibibyimba.

(4) Guhitamo imyenda ntisubirwamoYahinduwe kuri SMTs nziza ishobora gupimwa na endoskopi isanzwe ihujwe na EUS, nka lipoma, cysts, na pancreas ya ectopique.

Kubikomere bikekwa kuba ari bibi cyangwa mugihe endoskopi isanzwe ihujwe na EUS idashobora gusuzuma ibikomere byiza cyangwa bibi, EUS iyobowe na EUS iyobowe neza-inshinge / biopsy irashobora gukoreshwa (ultrasonic endoscopique iyobora neza needle aspiration / biopsy, EUS-FNA / FNB), mucosal incision biopsy (mucosalincision-ifashwa na biopsy, MIAB), nibindi bikora sample ya biopsy kugirango isuzume indwara mbere yo gutangira.Urebye aho EUS-FNA igarukira hamwe n'ingaruka zizakurikiraho ku kwanduza endoskopi, ku bemerewe kubagwa endoskopique, hashingiwe ku kureba niba ikibyimba gishobora guterwa burundu, ibice bifite tekinoroji yo kuvura endoskopi ikuze bishobora kuvurwa n'uburambe Endoskopi ikora endoskopique ikuraho bitabaye ngombwa ko isuzumwa mbere yo gutangira indwara.

Uburyo ubwo aribwo bwose bwo kubona ibimenyetso byindwara mbere yo kubagwa biratera kandi byangiza mucosa cyangwa bigatera gufatira ku ngingo ya subucosal, bityo bikongerera ingorane zo kubagwa kandi byongera ibyago byo kuva amaraso, perfogukwirakwiza, no gukwirakwiza ibibyimba.Kubwibyo, biopsy mbere yo gutangira ntabwo ari ngombwa byanze bikunze.Birakenewe, cyane cyane kuri SMTs zishobora gupimwa na endoskopi isanzwe ifatanije na EUS, nka lipoma, cysts, na pancreas ya ectopique, ntagisabwa icyitegererezo.

2.SMT endoscopic treatment

(1) Amahame yo kuvura

Ibibyimba bidafite lymph node metastasis cyangwa ibyago bike cyane bya lymph node metastasis, birashobora gusubirwamo rwose hakoreshejwe tekinoroji ya endoskopique, kandi bifite ibyago bike byo gusigara no kwisubiramo birakwiriye kwangirika kwa endoskopi niba bikenewe kuvurwa.Kurandura burundu ikibyimba bigabanya ikibyimba gisigaye kandi ibyago byo kongera kubaho.Uwitekaihame ryo kuvura ibibyimba bigomba gukurikizwa mugihe cyo kwanga endoskopique, kandi hagomba kubaho ubusugire bwa capsule yibibyimba mugihe cyo kwanga.

(2) Ibyerekana

i.Ibibyimba bifite ubushobozi bubi bikekwa no kwisuzumisha mbere cyangwa byemejwe na biopsy patology, cyane cyane abakekwaho GIST hamwe nisuzuma ryibanze ryikibyimba gifite uburebure bwa cm2cm hamwe ningaruka nke zo kongera kubaho na metastasis, kandi hamwe nibishobora kuzura burundu, birashobora guterwa endoskopi;ku bibyimba bifite diameter ndende Kubakekwaho kuba bafite ibyago bike GIST> 2cm, niba lymph node cyangwa metastasis ya kure itarigeze isuzumwa mbere yo gutangira, hashingiwe ku kwemeza ko ikibyimba gishobora kuvaho burundu, kubaga endoskopique bishobora gukorwa na endoskopi babimenyereye muri igice gifite tekinoroji yo kuvura endoskopi.kwanga.

ii.Ibimenyetso (urugero, kuva amaraso, inzitizi) SMT.

iii.Abarwayi bakekwa ko ibibyimba byabo ari byiza mugupima mbere yo gutangira cyangwa byemejwe na patologiya, ariko ntibishobora gukurikiranwa buri gihe cyangwa ibibyimba byiyongera mugihe gito mugihe cyo kubikurikirana kandi bafite icyifuzo gikomeye.e kuvura endoskopi.

(3) Kwivuguruza

i.Menya ibikomere mfiteuburyohe kuri lymph node cyangwa imbuga za kure.

ii.Kuri SMT zimwe na lymph isobanutsenodecyangwa metastasis ya kure, biopsy nyinshi irasabwa kubona patologiya, ishobora gufatwa nkikigereranyo cyo kwanduza.

iii.Nyuma yo gutangira birambuyegusuzuma, hemejwe ko imiterere rusange imeze nabi kandi kubaga endoskopi ntibishoboka.

Indwara nziza nka lipoma na pancreas ya ectopique muri rusange ntabwo itera ibimenyetso nkububabare, kuva amaraso, no guhagarika.Iyo S.MT igaragara nkisuri, ibisebe, cyangwa kwiyongera byihuse mugihe gito, amahirwe yo kuba ibisebe bibi ariyongera.

(4) Guhitamo uburyo bwo kwangad

Endoscopic umutego wo kwanga: KuriSMT isa naho itagaragara, isohoka mu cyuho nkuko byagenwe n'ibizamini bya EUS na CT mbere yo gutangira, kandi birashobora gukurwaho icyarimwe icyarimwe n'umutego, umutego wa endoscopique urashobora gukoreshwa.

Ubushakashatsi bwakozwe mu gihugu no mu mahanga bwemeje ko butekanye kandi bukora neza muri SMT yo hejuru <2cm, ifite ibyago byo kuva amaraso 4% kugeza 13% hamwe no gutoboraibyago bya 2% kugeza 70%.

Ubucukuzi bwa Endoscopic subucosal, ESE: Kuri SMTs ifite diameter ndende cm cm2 cyangwa niba ibizamini byo gufata amashusho mbere yo gutangira nka EUS na CT byemeza thku kibyimba kiva mu cyuho, ESE birashoboka ko endoskopique yorohereza SMTs zikomeye.

ESE ikurikiza ingeso ya tekinike yaendoscopic subucosal dissection (ESD) hamwe na endoscopic mucosal resection, kandi mubisanzwe ikoresha uruziga "flip-top" ruzengurutse ikibyimba kugirango ikureho mucosa itwikiriye SMT kandi igaragaze neza ikibyimba., kugirango ugere ku ntego yo kubungabunga ubusugire bwikibyimba, kunoza ubukana bwokubaga, no kugabanya ingorane zidasanzwe.Kubibyimba cm1.5 cm, igipimo cyuzuye cyo kwanga 100% kirashobora kugerwaho.

Submucosal Tunneling Endoscopic Igisubizoion uburyo bwo kuvura.

STER ni tekinolojiya mishya yatunganijwe ishingiye kuri peroral endoscopic esophageal sphincterotomy (POEM) kandi ni iyagurwa rya tekinoroji ya ESDnologiya.Igipimo cy’ibisubizo bya STER yo kuvura SMT kigera kuri 84.9% kugeza kuri 97.59%.

Endoskopi Yuzuye-Ubuniniion, EFTR: Irashobora gukoreshwa kuri SMT aho bigoye gushiraho umuyoboro cyangwa aho diameter ntarengwa ya transvers ya tumeri ifite cm 3.5,5 kandi idakwiriye STER.Niba ikibyimba kigaragaye munsi yumutuku cyangwa kigakura hanze yumwobo, kandi ikibyimba ugasanga gifatanye cyane na serosa mugihe cyo kubagwa kandi ntigishobora gutandukana, kirashobora gukoreshwa.EFTR ikora endoskopi ivura.

Gutunganya neza gutoboraurubuga nyuma ya EFTR nurufunguzo rwo gutsinda kwa EFTR.Kugirango dusuzume neza ibyago byo kongera kubyimba no kugabanya ibyago byo gukwirakwiza ibibyimba, ntibisabwa guca no kuvanaho ikibyimba cyakuwe mugihe cya EFTR.Niba ari ngombwa kuvanaho ikibyimba mo ibice, gutobora bigomba kubanza gusanwa kugirango bigabanye ibyago byo gutera ibibyimba no gukwirakwira.Bumwe muburyo bwo kudoda burimo: sipure yicyuma, guswera-clip suture, tekinike ya patch suture, uburyo bwa "sumse sum suture" uburyo bwumugozi wa nylon uhujwe na clip clip, sisitemu yo gufunga ibyuma bya rake (hejuru ya clip, OTSC) OverStitch suture nibindi tekinolojiya mishya yo gusana ibikomere byo munda no guhangana no kuva amaraso, nibindi.

(5) Ingorane nyuma yo kubagwa

Kuva amaraso munda: Amaraso atera hemoglobine yumurwayi kugabanuka kuri g / L.
Kugira ngo wirinde kuva amaraso menshi mu mikorere,inshinge zihagije zigomba gukorwa mugihe cyo kubaga kwerekana imiyoboro minini yamaraso no koroshya amashanyarazi guhagarika amaraso.Amaraso ava munda ashobora kuvurwa akoresheje ibyuma bitandukanye byo gutemagura, imbaraga za hemostatike cyangwa clips zicyuma, hamwe na hemostasis yo kwirinda imiyoboro y'amaraso yagaragaye iboneka mugihe cyo gutandukana.

Kuva amaraso nyuma yo kubagwa: Amaraso nyuma yo kubagwa agaragaza nko kuruka amaraso, melena, cyangwa amaraso mu ntebe.Mugihe gikomeye, ihungabana rya hemorhagie rishobora kubaho.Ahanini bibaho mugihe cyicyumweru 1 nyuma yo kubagwa, ariko birashobora no kubaho ibyumweru 2 kugeza kuri 4 nyuma yo kubagwa.

Kuva amaraso nyuma yo kuvurwa akenshi bifitanye isanoibintu nko kugenzura umuvuduko ukabije wamaraso nyuma yo kubagwa no kwangirika kwimiyoboro yamaraso isigaye na acide gastric.Byongeye kandi, kuva amaraso nyuma yo kubagwa nabyo bifitanye isano n’aho iyo ndwara ibereye, kandi bikunze kugaragara muri antrum gastric na rectum nkeya.

Gutinda gutobora: Mubisanzwe bigaragarira nko kwaguka mu nda, ububabare bukabije bwo munda, ibimenyetso bya peritonite, umuriro, hamwe no gusuzuma amashusho byerekana kwirundanya gaze cyangwa kwiyongera kwa gaze ugereranije na mbere.

Bifitanye isano ahanini nimpamvu nko kudoda ibikomere nabi, amashanyarazi menshi, kubyuka kare cyane kugirango azenguruke, kurya ugutwi cyane, kugenzura isukari mu maraso, no guturika ibikomere na acide gastric.a.Niba igikomere ari kinini cyangwa cyimbitse cyangwa igikomere gifite fisimpinduka zisa neza, igihe cyo kuruhuka cyo kuryama nigihe cyo kwiyiriza bigomba kwagurwa muburyo bukwiye kandi decompression gastrointestinal igomba gukorwa nyuma yo kubagwa (abarwayi nyuma yo kubagwa inzira yo hepfo ya gastrointestinal bagomba kugira imiyoboro y'amazi);b.Abarwayi ba diyabete bagomba kugenzura neza isukari yabo mu maraso;abafite udusimba duto hamwe n'indwara zoroheje zo mu nda no mu nda bagomba guhabwa imiti nko kwiyiriza ubusa, kurwanya indwara, no guhagarika aside;c.Kubafite effusion, amazi yo mu gatuza afunze hamwe no gutobora mu nda birashobora gukorwa Ibijumba bigomba gushyirwaho kugirango bikomeze gutemba neza;d.Niba ubwandu budashobora kwerekanwa nyuma yubuvuzi bwa conservateur cyangwa buhujwe nubwandu bukabije bwa thoracoabdominal, laparoskopi yo kubaga igomba gukorwa vuba bishoboka, kandi hagomba gukorwa gusana no gutobora no gukuramo inda.

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

Intraoperative subcutaneous emphysema (yerekanwe nka emphysema mumaso, ijosi, urukuta rwigituza, na scrotum) hamwe na pneumophysema ya mediastinal (subuzima bwiza bwa epiglottis burashobora kuboneka mugihe cya gastroscopi) mubisanzwe ntibisaba ubuvuzi bwihariye, kandi emphysema izakemura wenyine.

Pneumothorax ikabije during kubaga [umuvuduko wumuyaga urenga mmHg 20 mugihe cyo kubagwa

.inage.

Ku barwayi bafite pneumoperitoneum igaragara mugihe cyo kubaga, koresha urushinge rwa pneumoperitoneum kugirango utobore ingingo ya McFarlandmu nda yo hepfo iburyo kugirango uhindure umwuka, hanyuma usige urushinge rwacumita kugeza aho ibikorwa birangiye, hanyuma ubikureho nyuma yo kwemeza ko nta gaze igaragara isohoka.

Fistula ya Gastrointestinal: Amazi yo mu gifu aterwa no kubaga endoskopique atembera mu gituza cyangwa mu nda yo mu nda binyuze mu kumeneka.
Esophageal mediastinal fistula na fistula esophagothoracic irasanzwe.Iyo fistula imaze kubaho, kora igituza gifunze kugirango ukomezemumazi meza kandi atanga infashanyo ihagije.Nibiba ngombwa, ibyuma byuma nibikoresho bitandukanye byo gufunga birashobora gukoreshwa, cyangwa igifuniko cyuzuye gishobora gukoreshwa.Stent nubundi buryo bukoreshwa muguhagarikafistula.Imanza zikomeye zisaba gutabarwa byihuse.

3.Gucunga ibikorwa (follow-up)

(1) Ibikomere byiza:Indwara suggests ko ibikomere byiza nka lipoma na leiomyoma bidasaba gukurikiranwa buri gihe.

(2) SMT idafite ububiubushobozi bw'ikimonyo:Kurugero, urukiramende rwa NET 2cm, hamwe na GIST yo hagati kandi ishobora guteza ibyago byinshi, hagomba gukorwa igenamigambi ryuzuye kandi hagomba gusuzumwa ubundi buryo bwo kuvura (kubaga, chemoradiotherapi, kuvura intego).kuvura).Gutegura gahunda bigomba gushingira ku nama zinyuranye kandi buri muntu ku giti cye.

(3) Ubushobozi buke bwa SMT:Kurugero, GIST ifite ibyago bike igomba gusuzumwa na EUS cyangwa gushushanya buri mezi 6 kugeza 12 nyuma yo kuvurwa, hanyuma ikavurwa ukurikije amabwiriza yubuvuzi.

(4) SMT ifite ubushobozi buciriritse kandi bukabije:Niba indwara ya nyuma yubuvuzi yemeje ubwoko bwa 3 gastric NET, NET yibara ifite uburebure> 2cm, hamwe na GIST yo hagati kandi ishobora guteza ibyago byinshi, hagomba gukorwa igiteranyo cyuzuye kandi hakongerwaho uburyo bwo kuvura (kubaga, chemoradiotherapie, kuvura intego).kuvura).Gutegura gahunda bigomba gushingira[hafi yacu 0118.docx] kugisha inama zitandukanye kandi muburyo bwihariye.