本文選題：內(nèi)鏡全層切除術(shù) + 胃固有肌層腫瘤�。� 參考：《山東大學(xué)》2017年碩士論文

【摘要】：研究背景最近幾十年,隨著內(nèi)鏡操作水平和人們健康意識的提高,胃粘膜下腫瘤(submucosal tumors,SMT)的檢出率越來越高,其多種內(nèi)鏡切除方式也得到迅猛展開。通常情況下,小于2cm的粘膜下腫瘤無癥狀,患者常因其他不適或體檢時于胃鏡或影像學(xué)檢查中偶然發(fā)現(xiàn)。而病變較大、惡性程度較高的粘膜下腫瘤可能會引起出血,腹痛、腹脹甚至腹部包塊及體重下降等臨床癥狀。胃腸道粘膜下腫瘤主要分為四類—具有潛在惡性的間質(zhì)瘤、平滑肌來源的平滑肌瘤和平滑肌肉瘤、神經(jīng)源性腫瘤如神經(jīng)鞘瘤和神經(jīng)纖維瘤、血管源性腫瘤如血管瘤和淋巴管瘤等。其中,間質(zhì)瘤是胃腸道間質(zhì)來源的具有潛在惡性的腫瘤,起源于Cajal間充質(zhì)細(xì)胞,由突變的c-kit基因或血小板源性生長因子受體α(PDGFRA)驅(qū)動,組織學(xué)上多見束狀或彌漫排列的梭形細(xì)胞和上皮樣細(xì)胞等,免疫組織化學(xué)檢測常常顯示為CD117或DOG-1陽性。間質(zhì)瘤基于其復(fù)發(fā)和轉(zhuǎn)移的潛力可分為極低危險度、低危險度、中危險度和高危險度。傳統(tǒng)的治療方式為外科手術(shù)切除胃粘膜下腫瘤,主要包括開腹手術(shù)和腹腔鏡手術(shù)。開腹手術(shù)可以在直視下直接切除腫瘤,做到完整切除,減少復(fù)發(fā)和轉(zhuǎn)移的風(fēng)險,且不受腫瘤位置、大小、浸潤深度的影響。但是,開腹手術(shù)創(chuàng)傷大,并發(fā)癥發(fā)生率高,恢復(fù)時間長,顯著損害了患者術(shù)后的生活質(zhì)量。腹腔鏡手術(shù)相對于開腹手術(shù)來說,微創(chuàng)、恢復(fù)時間短,并且安全、有效、術(shù)式的選擇也更加靈活,這些優(yōu)點(diǎn)使其得到廣泛應(yīng)用。然而,當(dāng)腫瘤較小且向管腔內(nèi)生長時,難以確定腫瘤的精確位置,尤其是腫瘤位于胃后壁和胃小彎時,手術(shù)時易導(dǎo)致胃壁的不完整切除或過度切除,從而導(dǎo)致術(shù)后胃畸形。追求更微創(chuàng)的內(nèi)鏡治療方法是人們的迫切要求。隨著微創(chuàng)觀念的深入,內(nèi)鏡粘膜下剝離術(shù)(endoscopic submucosal dissection,ESD)等內(nèi)鏡技術(shù)的成熟和發(fā)展,醫(yī)療技術(shù)及器械的不斷更新,以及修補(bǔ)消化道穿孔技術(shù)的應(yīng)用并取得顯著療效,內(nèi)鏡全層切除術(shù)(Endoscopic full-thickness resection,EFTR)應(yīng)運(yùn)而生。內(nèi)鏡全層切除術(shù)對于切除起源于固有肌層的消化道SMT并提供準(zhǔn)確的病理診斷,具有較好的效果,已經(jīng)成為起源于固有肌層消化道SMT的治療選擇之一。研究目的探討內(nèi)鏡全層切除術(shù)(Endoscopic full-thickness resection,EFTR)治療起源于胃固有肌層腫瘤的療效、方法、可行性及安全性。研究方法選取24例自2014年12月至2016年12月于山東大學(xué)齊魯醫(yī)院消化科一病房行EFTR治療的胃固有肌層腫瘤的患者,收集臨床資料,評價腫瘤切除率、并發(fā)癥發(fā)生及腫瘤復(fù)發(fā)情況�；颊呔谛g(shù)前行超聲內(nèi)鏡(EUS)檢查明確瘤體來源于胃固有肌層,且無遠(yuǎn)處轉(zhuǎn)移。EFTR步驟:①確定腫瘤位置,標(biāo)記病灶邊緣,粘膜下注射,預(yù)切開腫瘤表面粘膜層和粘膜下層,顯露腫瘤;②沿腫瘤周圍分離固有肌層;③沿腫瘤邊緣切開漿膜層,造成"主動"穿孔;④胃鏡直視下完整切除腫瘤;⑤胃鏡直視下自創(chuàng)面一側(cè)向另一側(cè)完整對縫創(chuàng)面。研究結(jié)果24例胃固有肌層腫瘤患者中,男性9例,女性15例,平均年齡59.75±10.83歲。腫瘤位于胃底者15例,胃體者7例,胃竇者2例。腫瘤平均大小1.56±0.86cm,平均手術(shù)時間為95.83±44.37min,患者平均住院時間10.2±2.50d,平均住院花費(fèi)33719.97元。24例固有肌層腫瘤患者均經(jīng)EFTR完整切除腫瘤,完整切除率為100%,無術(shù)中大出血、術(shù)后遲發(fā)性出血、腹膜炎、腹腔膿腫等并發(fā)癥。術(shù)后病理結(jié)果顯示間質(zhì)瘤18例(極低危險度13例,低危險度5例),平滑肌瘤3例,神經(jīng)鞘瘤2例,叢狀纖維粘液瘤1例。對24例患者進(jìn)行術(shù)后隨訪,隨訪時間為3～23個月,其間未發(fā)現(xiàn)復(fù)發(fā)或轉(zhuǎn)移。結(jié)論內(nèi)鏡全層切除術(shù)(EFTR)是治療胃固有肌層腫瘤的一種安全、有效的微創(chuàng)方法,具有突出的臨床應(yīng)用價值。
[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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R735.2

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