内镜超声对上消化道黏膜下肿瘤的诊治价值

The value of endoscopic ultrasonography in the diagnosis and treatment of submucosal tumors in the upper gastrointestinal tract

摘要:

目的 探讨内镜超声（EUS）对指导内镜下上消化道黏膜下肿瘤的诊治价值。方法 对怀疑上消化道黏膜下肿瘤的患者共110例，内镜治疗前行内镜超声评估。根据黏膜下肿瘤的大小、起源及内部回声决定治疗方案。内镜治疗包括内镜下黏膜剥离术（ESD），内镜下黏膜挖除术（ESE），内镜下全层切除术（EFR）及双镜联合治疗。术后标本行病理学检查。结果 经内镜超声检查，35例起源于黏膜肌层，9例起源于黏膜下层，均为腔内型，超声测量大小0.3～2.0 cm，平均大小0.88 cm，采用ESD治疗；42例起源于固有肌层，12例起源于黏膜下层，均为腔内型，超声测量大小0.5～3.0 cm，平均大小1.1 cm，采用ESE治疗；8例起源于固有肌层并呈腔内腔外型生长，超声测量大小0.8～2.5 cm，平均大小1.78 cm，采用EFR治疗；4例起源于固有肌层且超声测量大小>3 cm，采用双镜联合治疗。术中穿孔13例，其中8例为EFR治疗的主动性穿孔，4例为双镜联合治疗病灶较大的穿孔，1例为ESE的小穿孔，除1例4.7 cm的病灶经双镜联合治疗后穿孔创面较大而中转外科手术治疗，其余穿孔均由金属夹封闭抑或联合组织胶喷洒。术后无迟发性出血及穿孔。EUS检查对黏膜下肿瘤的定位及定性准确率分别达98.3%和95.5%。结论 内镜超声能够对上消化道黏膜下肿瘤的起源和性质进行诊断，对黏膜下肿瘤治疗方案的选择具有重要的指导意义。

Abstract:

【Objective】 To evaluate the endoscopic ultrasonography (EUS) in the diagnosis and treatment of submucosal tumors (SMT) in the upper gastrointestinal (GI) tract. 【Methods】 110 patients with suspicion of upper GI SMT received EUS before the endoscopic treatment. The endoscopic treatment, including endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFR) and laparoscopic and endoscopic cooperative surgery (LECS), was decided according to the size, the deriving layer and internal echo of the lesion. Histological analysis was performed on all the obtained specimens. 【Results】 According to inspection results of EUS, ESD was performed on 44 cases (Mean size 0.88 cm in diameter), including 35 cases deriving from muscularis mucosa and 9 cases deriving from submucosa; ESE was performed on 54 cases (Mean size 1.1 cm in diameter), including 42 cases derived from muscularis propria and 12 cases derived from submucosa; 8 cases(mean size 1.78 cm in diameter) were performed with EFR originating from muscularis propria and involved the serosa; LECS was employed on 4 cases originating from muscularis propria with bigger size (>3.0 cm in diameter). 13 cases experienced perforation, among which, 6 underwent EFR with intentional perforation; 1 case underwent ESE with unexpected small perforation; and 4 cases underwent LECS with bigger perforation. All the perforations were sealed by metal clips, and only 1 patient treated by LECS converted to open surgery. Postoperative complications were not observed in any patient in the later follow-up. The coincidence rate of EUS for preoperative localization and the judgment of lesion characteristics was 98.3% and 95.5%, respectively. 【Conclusion】 EUS is an accurate means of evaluating and diagnosing the origination and lesion characters of the upper GI SMT. EUS plays a significant role in selecting therapeutic strategies for submucosal lesions.