Te maimoatanga endoscopic o ngā pukupuku submucosal o te ara kai: 3 ngā kaupapa matua kua whakarāpopototia i roto i te tuhinga kotahi

Ko ngā pukupuku submucosal (SMT) o te ara kai he whara teitei e ahu mai ana i te muscularis mucosa, submucosa, muscularis propria rānei, ā, tera pea he whara extraluminal. I te whanaketanga o te hangarau hauora, kua uru mārire ngā kōwhiringa maimoatanga pokanga tuku iho ki te wā o te maimoatanga iti rawa te whakaekenga, pērā i te lte pokanga aparoskopi me te pokanga karetao. Heoi, i roto i te mahi haumanu, ka kitea kāore te "pokanga" e pai mō ngā tūroro katoa. I ngā tau tata nei, kua āta arohia te uara o te maimoatanga endoscopic. Kua tukuna te putanga hou o te whakaaetanga a ngā tohunga Hainamana mō te tautuhi me te maimoatanga endoscopic o te SMT. Ka ako poto tēnei tuhinga i ngā mōhiotanga e tika ana.

1. Te āhua o te mate urutā SMTngā mahi auaha

(1) Te auau o te SMHe koretake te T i ngā wāhanga rerekē o te ara nakunaku, ā, ko te puku te wāhi tino noa mō te SMT.

Te auau o ngā momoKāore i te ōrite ngā wāhanga o te ara nakunaku, ā, ko te ara nakunaku o runga te mea e kitea whānuitia ana. O ēnei, e 2/3 kei roto i te puku, ā, whai muri ko te korokoro, te duodenum, me te koroni.

(2) Ngā histopathologicalHe uaua ngā momo SMT, engari ko te nuinga he whara pai, ā, he torutoru noa iho he whara kino.

Kāore he A.SMTngā whara n-pūkahukahu pērā i te kiko repeure ectopic me ngā whara pūkahukahu.

B. I roto i te whara neoplasticKo ngā leiomyomas puku, ngā lipomas, ngā Brucella adenomas, ngā pukupuku pūtau granulosa, ngā schwannomas, me ngā pukupuku glomus he pai te nuinga, ā, he iti iho i te 15% ka puta hei kiko kino.

C. Te stroma o te pukuKo ngā pukupuku l (GIST) me ngā pukupuku neuroendocrine (NET) i roto i te SMT he pukupuku me ētahi pūmanawa kino, engari kei runga tēnei i tōna rahi, tōna tauwāhi me tōna momo.

D. He hononga te wāhi o SMTki te whakarōpūtanga mate pukupuku: a. Ko ngā Leiomyomas he momo mate pukupuku noa o te SMT i roto i te esophagus, e 60% ki te 80% o ngā SMT esophageal, ā, he nui ake te tūponotanga ka puta i ngā wāhanga waenga me raro o te esophagus; b. He uaua ngā momo mate pukupuku o te SMT gastric, me te GIST, te leiomyoKo te ma me te ectopic pancreas te mea tino kitea. I roto i te SMT gastric, ko te GIST te mea tino kitea i roto i te fundus me te tinana o te puku, ko te leiomyoma kei roto i te cardia me te taha o runga o te tinana, ā, ko te pancreas ectopic me te ectopic pancreas te mea tino kitea. He nui ake te kitea o ngā lipomas i roto i te antrum gastric; c. He nui ake te kitea o ngā lipomas me ngā cysts i roto i ngā wāhanga heke me ngā wāhanga pūngāwerewere o te duodenum; d. I roto i te SMT o te ara gastrointestinal o raro, he nui te kitea o ngā lipomas i roto i te koroni, ko ngā NET ia he nui te kitea i roto i te rectum.

(3) Whakamahia te CT me te MRI hei aromatawai, hei rongoā, hei aromatawai hoki i ngā pukupuku. Mō ngā SMT e whakapaetia ana he kino pea, he pukupuku nui rānei (he roa(mēnā he whānui > 2 henimita), ka tūtohutia kia mahia he CT me te MRI.

He mea nui anō hoki ētahi atu tikanga whakaahua, tae atu ki te CT me te MRI, mō te tautuhi i te SMT. Ka taea e rātou te whakaatu tika i te wāhi i puta ai te pukupuku, te tauira tipu, te rahi o te whara, te āhua, te aroaro, te ngaro rānei o te lobulation, te mātotoru, te ōritetanga, te nui o te whakarei ake, me te āhua rohe, me ētahi atu, ā, ka taea te kimi mēnā me te nui o te matotoru.te whakatuwheratanga o te pakitara o te puku. He mea nui ake, ka taea e ēnei whakamātautau whakaahua te kite mēnā kei te whakaekea ngā hanganga tata o te whara, me te mea kei te horapa te mate ki roto i te peritoneum e karapoti ana, ngā kōpū lymph me ētahi atu okana. Koinei te tikanga matua mō te whakatauranga haumanu, te maimoatanga me te aromatawai i te matapae o ngā pukupuku.

(4)Kāore e tūtohutia te tauira kikoi whakaritea mō ngā SMT pai ka taea te tātaritanga mā te endoscopy tikanga me te EUS, pērā i ngā lipomas, ngā cysts, me te pancreas ectopic.

Mō ngā whara e whakapaetia ana he kino, kāore rānei e taea e te endoscopy tikanga me te EUS te aromatawai i ngā whara pai, kino rānei, ka taea te whakamahi i te EUS-guided fine-deedle aspiration/biopsy (endoscopic ultrasonography guided fine nte tango/koiora i te kiri, te EUS-FNA/FNB), te koiora tapahi mucosal (te koiora āwhina-ki-te-kiri, te MIAB), me ētahi atu. te whakahaere i te koiora hei aromatawai i te mate i mua i te pokanga. I runga i ngā herenga o te EUS-FNA me te pānga o muri mai ki te tango endoscopic, mō te hunga e tika ana mō te pokanga endoscopic, i runga i te whakaaro kia taea te tango katoa i te pukupuku, ka taea te rongoa i ngā waeine me te hangarau maimoatanga endoscopic pakari e te tohunga endoscopist te tango endoscopic tika me te kore e whiwhi i te tautuhi mate i mua i te pokanga.

He tikanga urutomo te tiki tauira mate i mua i te pokanga, ā, ka kino te kiriuhi mucosa, ka piri rānei ki te kiko o raro i te kiriuhi mucosa, ka nui ake te uaua o te pokanga, ā, ka nui ake pea te mōrearea o te toto, te pakaru rānei.te whāngai, me te horapa o te pukupuku. Nō reira, kāore e hiahiatia he koiora i mua i te pokanga. He mea tika, inā koa mō ngā SMT ka taea te tautuhi mā te endoscopy tikanga me te EUS, pērā i ngā lipomas, ngā cysts, me te ectopic pancreas, kāore e hiahiatia he tauira kiko.

2.Maimoatanga endoscopic SMTnt

(1) Ngā mātāpono maimoatanga

Ko ngā whara kāore he horapa ki ngā kōpū lymph, he iti rawa rānei te mōrearea o te horapa ki ngā kōpū lymph, ka taea te tango katoa mā te whakamahi i ngā tikanga endoscopic, ā, he iti hoki te mōrearea o te toenga me te hokinga mai, he pai mō te tango endoscopic mēnā e tika ana te maimoatanga. Mā te tango katoa i te pukupuku ka whakaiti i te toenga o te pukupuku me te mōrearea o te hokinga mai. Ko teMe whai i te mātāpono o te maimoatanga kore-puku i te wā e tangohia ana te pūtau endoscopic, ā, me whakarite kia mau tonu te kounga o te kāpū pukupuku i te wā e tangohia ana.

(2)Ngā Tohu

i. Ngā pukupuku e whakapaetia ana he kino pea i mua i te pokanga, i whakaūtia rānei e te koiora, inā koa ko ērā e whakapaetia ana he mate GIKa taea te tango mā te endoscopic te ST me te aromatawai i mua i te pokanga o te roa o te pukupuku ≤2cm me te iti o te mōrearea o te hokinga mai me te metastasis, me te āheinga o te tango katoa,; mō ngā pukupuku he whānui roa Mō te GIST iti-mōrearea e whakapaetia ana >2cm, mēnā kua tangohia te kōpū lymph, te metastasis tawhiti rānei i te aromatawai i mua i te pokanga, i runga i te whakaaro kia taea te tango katoa i te pukupuku, ka taea te mahi pokanga endoscopic e ngā endoscopists wheako i roto i te wāhanga me te hangarau maimoatanga endoscopic pakari. tango.

ii. Ngā tohu (hei tauira, te toto, te aukati) SMT.

iii. Ngā tūroro e whakapaetia ana he pai ngā pukupuku i mua i te pokanga, e whakaūtia ana rānei e te pathology, engari kāore e taea te tirotiro tonu, te whakanui rānei i ō rātou pukupuku i roto i te wā poto i te wā tirotiro, ā, he hiahia nui tō rātou ki tee mō te maimoatanga endoscopic.

(3) Ngā Āraitanga

i. Tāutuhia ngā whara e pā ana ki ahauka tukuna ki ngā kōpū lymph, ki ngā wāhi tawhiti rānei.

ii. Mō ētahi SMT me te lymph māramanodemēnā he metastasis tawhiti rānei, me hiahiatia he koiora rahi hei tiki i te pathology, ka taea te kī he ārai whanaunga tēnei.

iii. I muri i te mahi taipitopito i mua i te pokangai muri i te aromatawai, ka whakatauhia he kino te āhua whānui, ā, kāore e taea te pokanga endoscopic.

Ko ngā whara pai pēnei i te lipoma me te pancreas ectopic, kāore e puta he tohu pēnei i te mamae, te toto, me te aukati. Ina SKa puta te MT hei horo, he mate puku, he tere rānei te piki haere i roto i te wā poto, ka piki ake te tūponotanga he whara kino.

(4) Kōwhiringa o te tikanga tangod

Te tango i te mahanga endoscopic: MōMēnā he āhua papaku te SMT, ka puta ki roto i te kōhao e ai ki ngā whakamātautau EUS me te CT i mua i te pokanga, ka taea te tango katoa i te wā kotahi mā te whakamahi i te mahanga endoscopic.

Kua whakaūtia e ngā rangahau ā-roto me tāwāhi he haumaru, he whai hua hoki i roto i te SMT papaku <2cm, me te mōrearea toto o te 4% ki te 13% me te poka.te mōrearea o te 2% ki te 70%.

Keritanga endoscopic submucosal, ESE: Mō ngā SMT he whānui roa ≥2 cm, mēnā rānei ka whakaūtia e ngā whakamātautau whakaahua i mua i te pokanga pērā i te EUS me te CTIna puta te puku ki roto i te kōhao, ka taea te tango i ngā SMT tino nui mā te whakamahi i te ESE.

E whai ana a ESE i ngā tikanga hangarau ote tango i te kiriuhi raro i te mucosal endoscopic (ESD) me te tango i te mucosal endoscopic, ā, ka whakamahia he tapahi porohita "flip-top" huri noa i te pukupuku hei tango i te mucosa e hipoki ana i te SMT me te whakaatu katoa i te pukupuku. , kia tutuki ai te kaupapa o te tiaki i te pono o te pukupuku, te whakapai ake i te kaha o te pokanga, me te whakaiti i ngā raruraru i te wā o te pokanga. Mō ngā pukupuku ≤1.5 cm, ka taea te whakatutuki i te tere tango katoa o te 100%.

Te Tātaritanga Endoscopic Tunneling Submucosalkatote, STER: Mō te SMT e ahu mai ana i te muscularis propria i roto i te esophagus, te hilum, te piko iti o te tinana puku, te antrum puku me te rectum, he ngāwari ki te whakatū kauhanga, ā, ko te diameter whakawhiti he ≤ 3.5 cm, ko te STER te tikanga maimoatanga pai ake.

He hangarau hou te STER i whakawhanakehia i runga i te peroral endoscopic esophageal sphincterotomy (POEM) ā, he toronga atu i te hangarau ESD.te nology. Ko te tere tango whānui o te STER mō te maimoatanga SMT ka eke ki te 84.9% ki te 97.59%.

Te tango i te matotoru katoa o te endoscopickatote, EFTR: Ka taea te whakamahi mō te SMT ina he uaua ki te whakatū i tētahi kauhanga, ina rānei ko te diameter whakawhiti mōrahi o te puku he ≥3.5 cm, ā, kāore e tika mō te STER. Mena ka puta te puku i raro i te kiriuhi papura, ka tipu rānei i waho o te kōhao, ā, ka kitea he piri tonu te puku ki te paparanga serosa i te wā o te pokanga, ā, kāore e taea te wehe, ka taea te whakamahi. Ka mahi te EFTR i te maimoatanga endoscopic.

Te tuitui tika o te pokaKo te wāhi i muri i te EFTR te kī ki te angitu o te EFTR. Hei aromatawai tika i te mōrearea o te hokinga mai o te pukupuku me te whakaiti i te mōrearea o te horapa o te pukupuku, kāore i te tūtohutia kia tapahia, kia tangohia rānei te tauira pukupuku kua tangohia i te wā o te EFTR. Mena me tango te pukupuku kia porotaka, me whakatika tuatahi te poka kia whakaitihia ai te mōrearea o te purapura me te horapa o te pukupuku. Ko ētahi tikanga tuitui ko: te tuitui topenga whakarewa, te tuitui topenga momi, te tikanga tuitui papaki omental, te tikanga "tuitui putea putea" o te taura nairona i honoa ki te topenga whakarewa, te pūnaha kati topenga whakarewa rake (topi tirotiro i runga i te whānuitanga, OTSC) te tuitui OverStitch me ētahi atu hangarau hou hei whakatika i ngā whara o te puku me te rongoā i te toto, me ētahi atu.

(5) Ngā raruraru i muri i te pokanga

Te toto i roto i te pokanga: He toto e heke ai te hemoglobin o te tūroro neke atu i te 20 g/L.
Hei ārai i te toto nui i te wā e pokanga ana,Me werohia kia rawaka te werohanga o raro i te kiriuhi i te wā o te pokanga hei whakaatu i ngā oko toto nunui ake, hei whakahaere hoki i te electrocoagulation hei aukati i te toto. Ka taea te rongoā i te toto i te wā o te pokanga mā te whakamahi i ngā maripi tapahi, ngā forcep hemostatic, ngā topenga whakarewa rānei, me te hemostasis ārai i ngā oko toto kua kitea i te wā o te mahi wehe.

Te toto i muri i te pokanga: Ka puta te toto i muri i te pokanga mā te ruaki toto, te melena, te toto rānei i roto i te tūtae. I ngā wā tino kino, ka puta pea te ohorere toto. I te nuinga o te wā ka puta i roto i te kotahi wiki i muri i te pokanga, engari ka taea hoki te puta i roto i te 2 ki te 4 wiki i muri i te pokanga.

He maha ngā wā ka hono te toto i muri i te pokanga kingā āhuatanga pēnei i te koretake o te whakahaere i te toto toto i muri i te pokanga me te waikura o ngā oko toto e toe ana i te waikawa o te puku. Hei tāpiri, e pā ana hoki te toto i muri i te pokanga ki te wāhi o te mate, ā, he nui ake te kitea i roto i te antrum puku me te rectum o raro.

Te whakaroa o te poka: Ko te tikanga ka puta mai ko te pupuhi o te puku, te mamae o te puku, ngā tohu o te peritonitis, te kirika, ā, e whakaatu ana te tirotiro whakaahua i te kohikohinga hau, te pikinga ake rānei o te kohikohinga hau i tērā o mua.

Ko te nuinga o te wā e pā ana ki ngā āhuatanga pēnei i te koretake o te tuitui o ngā patunga, te nui rawa o te electrocoagulation, te ara wawe rawa ki te neke haere, te kai nui rawa, te koretake o te whakahaere i te huka toto, me te mimiti o ngā patunga e te waikawa o te puku. a. Mena he nui, he hohonu rānei te patunga, he māhanga rānei kei te patungaMēnā he rite ki ngā panonitanga tino tika, me whakaroa te wā okiokinga moenga me te wā nohopuku, ā, me mahi te whakaiti i te pēhanga o te puku i muri i te pokanga (me tango wai i te awaawa o raro o te puku mō ngā tūroro whai muri i te pokanga o te ara puku o raro); b. Me tino whakahaere te hunga mate huka i ō rātou huka toto; ko te hunga he iti ngā poka me ngā mate ngawari o te uma me te puku me whiwhi maimoatanga pēnei i te nohopuku, te ārai mate, me te pehi waikawa; c. Mō te hunga he rerenga wai, ka taea te mahi i te tango wai katia o te uma me te poka i te puku. Me whakatakoto he ngongo hei pupuri i te rerenga wai maeneene; d. Mēnā kāore e taea te kimi i te mate i muri i te maimoatanga matawhānui, i te honoa rānei ki te mate kino o te thoracoabdominal, me mahi te laparoscopy pokanga i te wā e taea ai, ā, me mahi te whakatika i te poka me te tango wai i te puku.

Ngā raruraru e pā ana ki te hau: Tae atu ki te kiri rarote emphysema puku, te pneumomediastinum, te pneumothorax me te pneumoperitoneum.

Te emphysema kiri raro i te kiri i te wā o te pokanga (e whakaatuhia ana hei emphysema i te mata, te kaki, te pakitara o te uma, me te scrotum) me te pneumophysema mediastinal (s(((mēnā ka kitea te pupuhi o te epiglottis i te wā o te gastroscopy) kāore e hiahiatia he maimoatanga motuhake, ā, ka memeha noa te emphysema.)

Ka puta te pneumothorax kinoi te wā pokanga [neke atu te pēhanga o te ara manawa i te 20 mmHg i te wā pokanga

(1mmHg=0.133kPa), SpO2<90%, i whakaūtia e te hihi-X o te uma i te taha o te moenga], ka taea tonu te mahi pokanga i muri i te tango i te uma kua katitau

Mō ngā tūroro he kitea te pneumoperitoneum i te wā o te pokanga, whakamahia he ngira pneumoperitoneum hei wero i te pūwāhi McFarland.ki te puku matau o raro hei whakaiti i te hau, ka waiho te ngira werohanga kia mau tonu tae noa ki te mutunga o te pokanga, kātahi ka tangohia i muri i te whakaū kāore he hau e kitea ana e tukuna ana.

Te fistula puku: Ka rere te wai nakunaku i puta mai i te pokanga endoscopic ki roto i te uma, i te kōhao puku rānei mā te turuturu.
He mea noa ngā fistula mediastinal esophageal me ngā fistula esophagothoracic. Kia puta he fistula, me mahi he rerenga wai i roto i te uma kia mau tonu ai te rere.kia maeneene te rerenga wai, kia pai ai te tautoko kai. Mēnā e tika ana, ka taea te whakamahi i ngā topenga whakarewa me ngā momo taputapu kati, ka taea rānei te hangarua te uhi katoa. Ka whakamahia ngā stent me ētahi atu tikanga hei aukati i tefistula. Ko ngā take kino me tere te pokanga.

3. Te whakahaere i muri i te pokanga (fwhai muri)

(1) Ngā whara pai:Ngā mate pāweraE kī ana kāore e hiahiatia he tirotiro auau mō ngā whara pai pēnei i te lipoma me te leiomyoma.

(2) SMT kāore he kinopūmanawa pōpokorua:Hei tauira, ko ngā NET rectal 2cm, me te GIST mōrearea-waenga me te mōrearea-tiketike, me whakahaere te wāhanga katoa, ā, me tino whai whakaaro ki ngā maimoatanga tāpiri (pokanga, chemoradiotherapy, rongoā arotahi). Me hangai te whakatakotoranga o te mahere ki runga i te whakawhitiwhiti kōrero maha-mātauranga, me te kaupapa takitahi.

(3) Te iti o te pūmanawa kino SMT:Hei tauira, me aromatawai te GIST iti-morearea mā te EUS, te whakaahua rānei i ia 6 ki te 12 marama i muri i te maimoatanga, kātahi ka rongoatia kia rite ki ngā tohutohu haumanu.

(4) SMT me te kaha kino waenga me te kaha nui:Mena ka whakaūtia e te mate muri i te pokanga te momo NET puku 3, te NET colorectal me te roa >2cm, me te GIST mōrearea-waenga me te mōrearea-tiketike, me mahi te whakatau i te wāhanga katoa, ā, me tino whakaarohia ngā maimoatanga tāpiri (pokanga, chemoradiotherapy, rongoā arotahi). Me hangai te whakatakotoranga o te mahere ki runga i[mō mātou 0118.docx]te whakawhitiwhiti kōrero maha-mātauranga, ā, i runga i te kaupapa takitahi.