【作者】 李文捷；

【导师】 李延青；

【作者基本信息】 山东大学 ， 内科学， 2011， 博士

【摘要】 研究背景和目的研究背景：胃肠道间质瘤是消化道最常见的间叶源性肿瘤,由胃肠道间叶组织发生,且具有多向分化及恶变潜能的一种肿瘤。由于其起源于粘膜下层,普通内镜诊断较为困难,且难以与其它消化道粘膜下病变相鉴别。超声内镜的运用为间质瘤的诊断开辟了新的途径。超声内镜下不但可以依据超声影像判断间质瘤的起源层次、大小、浸润的深度、有无邻近脏器及淋巴结转移,有助于判断间质瘤内镜下治疗的可行性及风险,而且还可以在超声内镜引导下行细针穿刺抽取细胞学检查以明确诊断。手术切除是间质瘤的主要治疗手段,但传统的开腹手术和腹腔镜手术创伤大,病人痛苦大,花费较高。近年来随着内镜器械的发展和内镜技术的成熟,内镜下粘膜切除术(EMR)、内镜粘膜下剥离术(ESD)等微创治疗在临床获得越来越广泛的应用。不仅可以完整切除粘膜下病变,同时还可提供完整的病理诊断资料,病人创伤小、恢复快,具有与外科手术相同的治疗效果。本研究通过对胃间质瘤的超声内镜检查及EMR、ESD等治疗,探讨胃间质瘤的超声内镜诊断价值及内镜微创治疗的可行性、疗效和安全性。研究方法：1、收集2004年5月至2010年5月间山东大学齐鲁医院胃镜检查提示上消化道粘膜下隆起性病变者1163例行超声内镜检查,共检出胃间质瘤160例,其中男性89例,女71例；年龄(35-78)岁,平均年龄56岁；101例异位胰腺,其中男57例,女44例；年龄(15—72)岁,平均43岁；12例脂肪瘤,其中男8例,女4例,年龄(27-65)岁,平均年龄47岁。2、应用超声内镜观察间质瘤的起源层次、大小、形态、内部回声及浸润深度,并与异位胰腺、脂肪瘤等粘膜下病变相鉴别。3.选择26例来源于粘膜肌层和/或固有肌层、直径<2cm的胃间质瘤行内镜下微创治疗(ESD、EMR等)。术后随诊。结果：1.胃间质瘤多位于胃体(46.8%)和胃底(26.2%),大小为28.7±14.8mm,明显大于异位胰腺和脂肪瘤,P<0.05.胃间质瘤多起源于胃壁第四层(固有肌层)(53.1%)；边缘光滑(64%)；内部回声均质(74,7%),主要表现为低回声和中等回声(55.3%,42.5%)。异位胰腺和脂肪瘤多起源于第三层(粘膜下层)(69.3%,75%)。异位胰腺边缘不规则(75.2%)、内部回声不均质,以中等回声为主(63.4%)。脂肪瘤主要表现为高回声(83.3%),内部回声均质(83.3%)。2.26例胃间质瘤根据不同超声内镜下特点分别给予高频电切3例(11.5%),套扎+电切10例(38.5%),ESD13例(50%)。所有病例均完整切除。只有1例发生穿孔转外科手术；1例发生出血,给予止铗血止血。所有患者术后随访3到12个月,创面愈合,均无复发。结论：1.超声内镜下胃间质瘤主要位于胃体胃底部,多来源于固有肌层,边缘光滑,内部回声均质,为中等偏低回声。在起源、部位、大小、内部回声方面与脂肪瘤、异位胰腺有明显区别。因而超声内镜检查对于胃间质瘤的诊断具有重要意义。2、对于起源于肌层、直径小于2cm的胃部间质瘤,内镜下微创治疗安全、疗效高,病人花费低。超声内镜检查对间质瘤内镜微创治疗方式的选择具有重要的指导价值。更多还原

【Abstract】 Backgrounds and aims:Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. They are submucosal lesion covered by the normal mucosa. The histological diagnosis is usually difficult when tissue speciemens are obtained using a standard forcep biopsy through the conventional endoscopy. The ability of endoscopic ultrasonography (EUS) to clearly demonstrate the gastric wall and its layers makes it a great tool for the clinician to make the differential diagnosis of "real" submucosal lesions. Moreover, it can also assist in their exact pathologic diagnosis by EUS-guided fine needle aspiration (EUS-FNA). Because of the potential malignant features of GISTs, surgical resection was the main treatment in the past time. With the progression of the endoscopy instruments and endoscpic operation, importantly, under the guidance of the EUS, GISTs can be removed by appropriate endoscopic treatment such as endoscopic mucosa resection (EMR), endoscopic sunmucosal dissection (ESD) without severe complications. In this study, we evaluate the role of EUS in the diagnosis and differentiation of gastric gastrointestinal stromal tumor. And also evaluate the feasibility, curative effect and safety of endoscopic treatment.Methods: 1. A total of 1163 consecutive patients with submucosal lesions in upper gastrointestinal tract found by conventional endoscope were included in EUS examination during the period from May 2004 to May 2010 in Qilu Hospital of Shandong University, China. There were 160 (13.7%) gastric stromal tumor composed of 89 males and 71 females, and aged from35 to 78 years, with a mean of 56 years.101 ectopic pancreases (8.6%) including 57 males and 44 females aged from 15 years to 72 years (mean 43 years).12 lipoma(1.0%),8 males and 4 females, aged from 27 years to 65 years, their mean age was 47 years.2. EUS examination was used to observe the location, size, layers of origin and the internal echo pattern of the stromal tumors. And furthermore differentiate from lipoma and ectopic pancrease.3.26 gastric stromal tumors with the diameter smaller than 2cm and muscularis layer origin underwent different kinds of endoscopic treanment according to the EUS findings.Results:1. Gastric stromal tumors were predominantly located in the body (46.8%) which usually originated from the fourth layer (53.1%). Gastric stromal tumors were larger than ectopic pancreas or lipomas (28.7±14.8mm vs 11.5±5.6mm or 1.34±0.38mm, p<0.05) with smooth margin (64%) and homogeneous hypoechoic (55.3%) or intermediate internal echo (42.5%). While the ectopic pancreas and lipoma mainly originated from the third layer (69.3%,75%). Lipoma shows hyperechoic (83.3%). Ectopic pancreas predominately shows intermediate inner echo (63.4%) with irregular maigin (75.2%).2. Based on EUS images, we treated 26 GISTs by different endoscopic therapies, including snare electrosection, endoloop and ESD. Complete resection of the lesions was achieved in all cases. Only two patients suffered from bleeding or resection-related perforation. All wounds were closed up nicely and no recurrence was found in the follow-up after 12 months.Conclusions: 1. Gastric stromal tumors mainly located in the body or fundus with smooth margin and homogeneous hypoechoic or intermediate inner echo. It predominately originated from the musculrus propria. Gastric stromal tumors are quite different from ectopic pancreas and lipoma on the respect of location, size, origin and inner echo pattern. So the EUS is of great value in diagnosing stromal tumors.2. Preoperative EUS examination is important for choosing the type of endoscopic therapy for stromal tumors. By which the lesions can be treated safely and effectively.更多还原