食管、胃黏膜下腫瘤內(nèi)鏡規(guī)范化治療研究
發(fā)布時間：2018-09-04 11:39
【摘要】：第一部分:819例上消化道黏膜下病變流行特點分析目的:了解青海地區(qū)上消化道黏膜下病變的流行特點。方法:回顧性分析近年來在青海省人民醫(yī)院內(nèi)鏡檢出黏膜下病變一般生物學特點。結(jié)果:共完成超聲內(nèi)鏡檢查1926例,共檢出黏膜下病變819例,黏膜下病變占超聲內(nèi)鏡檢查例數(shù)的42.5%;男女分別為424、395例;其中檢出食管、胃、十二指腸黏膜下病變分別為321、395、103例。其中SMT506例,非SMT313例,二者比例為1.617:1。檢出間質(zhì)瘤320例,男女之比為1:1.19,年齡25-85歲,胃間質(zhì)瘤占上消化道間質(zhì)瘤62.8%,胃是上消化道間質(zhì)瘤好發(fā)器官;胃底與胃體是胃間質(zhì)瘤好發(fā)部位,占胃間質(zhì)瘤的71.1%;食道間質(zhì)瘤多來源于黏膜肌層而胃間質(zhì)瘤多起源于固有肌層。檢出平滑肌瘤123例,男女之比1.16:1,發(fā)病年齡15-82歲;食道為上消化道平滑肌瘤好發(fā)部位,占77.24%;食道平滑肌瘤多來源于肌層而胃平滑肌瘤多起源于固有肌層。檢出脂肪瘤55例,男女之比1.62:1,年齡25-81歲,胃為上消化道脂肪瘤好發(fā)器官,占63.64%;胃竇為胃脂肪瘤好發(fā)部位,占胃脂肪瘤的80%;脂肪瘤絕大多數(shù)起源于黏膜下層,占93.36%。檢出異位胰腺125例,男女之比為1:1.08,年齡17-79歲,分布于胃和十二指腸,胃為上消化道異位胰腺好發(fā)器官,占86.4%,胃竇是胃異位胰腺的好發(fā)部位,占63.9%,異位胰腺全部起源于黏膜下層。檢出囊腫160例,男女比例為1.5:1,年齡23-84歲,食管、十二指腸是上消化道囊腫好發(fā)部位,占86.9%,囊腫絕大多數(shù)起源于黏膜下層,占98.1%。結(jié)論:青海地區(qū)上消化道胃黏膜下病變流行特點與國內(nèi)外報道并不完全一致,了解本地區(qū)不同性質(zhì)病變特點有助于內(nèi)鏡醫(yī)師提高對粘膜下病變的認識。第二部分:內(nèi)鏡下切除食管黏膜下腫瘤有效性、安全性評價目的:評價內(nèi)鏡下治療食管黏膜下腫瘤的有效性及安全性。方法:使用EMR、ESE、STER術(shù)式分別切除食管黏膜下腫瘤38例,分析不同術(shù)式治療后,腫瘤切除率、患者并發(fā)癥的發(fā)生率、患者住院時間、手術(shù)耗時、術(shù)后禁食時間及住院費用。結(jié)果:38例食管黏膜下腫瘤均被完整切除,成功率為100%,其中EMR切除13例、ESE切除20例、STER切除5例;EMR術(shù)中出血率為30.8%,ESE、STER術(shù)中出血率為100%,術(shù)中出血均可用熱活檢鉗電凝止血;術(shù)后發(fā)生并發(fā)癥7例,并發(fā)癥發(fā)生率為18.4%,分別為創(chuàng)面出血1例、穿孔后食管胸腔瘺1例、皮下及縱膈氣腫3例、感染2例;EMR術(shù)式平均耗時、患者住院費用明顯低于ESE、STER組;并發(fā)癥的發(fā)生與腫瘤大小有關(guān),并發(fā)癥發(fā)生后,患者禁食時間、住院時間、住院費用均明顯高于未發(fā)生并發(fā)癥者。結(jié)論:開展食管黏膜下腫瘤內(nèi)鏡下治療術(shù)是安全、有效的。第三部分:ESE、EFR術(shù)式切除胃黏膜下腫瘤對比研究目的:評價內(nèi)鏡下治療胃黏膜下腫瘤的有效性及安全性。方法:納入胃黏膜下腫瘤患者57例并行ESE、EFR術(shù)式切除治療,分析不同術(shù)式腫瘤切除率、患者并發(fā)癥的發(fā)生率、手術(shù)耗時、術(shù)中出血量、術(shù)后住院天數(shù)及住院費用。結(jié)果:57例胃黏膜下腫瘤內(nèi)鏡下完整切除56例,失敗1例,成功率為98.2%,術(shù)后總發(fā)生并發(fā)癥6例,并發(fā)癥發(fā)生率為10.7%;其中ESE切除44例,發(fā)生并發(fā)癥1例,并發(fā)癥發(fā)生率為2.3%,EFR切除12例,發(fā)生并發(fā)癥5例,并發(fā)癥發(fā)生率為41.7%,EFR術(shù)式并發(fā)癥發(fā)生率明顯高于ESE術(shù)式,兩種手術(shù)方式并發(fā)癥發(fā)生率有統(tǒng)計學差異(P0.05);ESE術(shù)式平均耗時45.2min,EFR平均耗時65.8min,兩種手術(shù)方式耗時時間有統(tǒng)計學差異(P0.05);ESE平均出血23.6ml,EFR平均出血56.1ml,兩種術(shù)式平均術(shù)中出血差異有統(tǒng)計學意義(P0.05);ESE和EFR術(shù)式在術(shù)后住院時間、住院總費用方面無差異(P0.05);有并發(fā)癥組腫瘤大小平均28mm,明顯大于無并發(fā)癥組12.58mm,差異有統(tǒng)計學意義(P0.05);有并發(fā)癥組手術(shù)平均耗時66.7min,明顯大于無并發(fā)癥組45.6min,差異有統(tǒng)計學意義(P0.05);有并發(fā)癥組患者平均住院費用RMB 31940.8元,大于無并發(fā)癥組的RMB 22510.8元,差異有統(tǒng)計學意義(P0.05)。結(jié)論:ESE是切除胃黏膜下腫瘤安全、有效的內(nèi)鏡治療手段,EFR切除雖然有效,但對術(shù)者技術(shù)要求高、并發(fā)癥發(fā)生率高,需要謹慎開展。第四部分:內(nèi)鏡與腹腔鏡切除胃黏膜下腫瘤對比研究目的:評價無腹腔鏡輔助的內(nèi)鏡消化道壁全層切除術(shù)與腹腔鏡楔形切除術(shù)治療胃黏膜下腫瘤的有效性及安全性。方法:納入胃黏膜下腫瘤23例,分為內(nèi)鏡組與腹腔鏡組,內(nèi)鏡組利用無腹腔鏡輔助的內(nèi)鏡消化道壁全層切除術(shù)(EFR)切除病變13例,腹腔鏡組利用楔形切除術(shù)(LWR)切除病變10例,分析不同術(shù)式治療后,腫瘤切除率、患者并發(fā)癥的發(fā)生率、手術(shù)耗時、術(shù)中出血量、患者術(shù)后住院時間及住院費用。結(jié)果:內(nèi)鏡組納入13例患者,EFR成功切除12例,失敗1例,手術(shù)成功率為92.3%;腹腔鏡成功切除10例,無切除失敗病例,成功率為100%;術(shù)后內(nèi)鏡組發(fā)生并發(fā)癥5例,并發(fā)癥發(fā)生率為41.7%%,腹腔鏡組發(fā)生并發(fā)癥1例,并發(fā)癥發(fā)生率為10.0%,兩組之間并發(fā)癥發(fā)生率無統(tǒng)計學差異(P0.05);內(nèi)鏡組手術(shù)平均耗時65.8min,腹腔鏡組平均耗時139.5min,兩組平均手術(shù)耗時有統(tǒng)計學差異(P0.05);內(nèi)鏡組術(shù)后平均住院7.0天,腹腔鏡組平均10.7天,腹腔鏡組住院時間長于內(nèi)鏡組,兩組總住院時間有統(tǒng)計學差異(P0.05);內(nèi)鏡組平均住院費用RMB 24970.7元,腹腔鏡組RMB 35891.0元,腹腔鏡組住院費用明顯高于內(nèi)鏡組,兩組平均住院費用差異有統(tǒng)計學意義(P0.05)。內(nèi)鏡組與腹腔鏡組在手術(shù)成功率、并發(fā)癥發(fā)生率及術(shù)中出血量方面無統(tǒng)計學差異(P0.05)。結(jié)論:LWF在治療胃黏膜下腫瘤有較好的有效性和安全性,EFR雖然與LWR有效性一致,但EFR術(shù)式安全性較低,臨床中應(yīng)謹慎開展。
[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.
【學位授予單位】：蘇州大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R735
本文編號：2221984
[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.
【學位授予單位】：蘇州大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R735
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9 鐘蕓詩;時強;姚禮慶;周平紅;徐美東;陳巍峰;李全林;蔡賢黎;王萍;;內(nèi)鏡黏膜下挖除術(shù)治療食管固有肌層腫瘤[J];中華消化內(nèi)鏡雜志;2011年10期
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