【作者】 高山；

【导师】 余保平；

【作者基本信息】 武汉大学 ， 内科学， 2013， 博士

【摘要】 第一部分经直肠内镜超声引导下行细针穿刺活检对盆腔实性占位病变的价值目的经直肠内镜超声引导下行细针穿刺活检(EUS-FNA)取得细胞学或组织学标本,确定盆腔病变的性质,并评价EUS-FNA对盆腔占位病变的安全性。方法选取2009年3月至2012年6月期间在湖北文理学院附属医院52例经B超、CT或MRI检查发现盆腔肿块,其中男37例,女15例,平均年龄51.5岁(35-72)。肿块直径平均6.8cm(2.2～12.5)。其中实性占位性病变42例,均行经直肠EUS-FNA.部分患者穿刺术后通过手术病检或临床随访2月以上验证结果。线阵超声内镜使用日本PENTAX EG-3630U,探头频率5-10MHZ,电子线阵扇扫。主机采用PENTAX3500内镜主机和HITACHI5500。22G穿刺针采用OLYMPUSNA-10J-1、COOK ECHO-1-2,19G穿刺针选用COOK ECHO-19。术前患者或授权代理人签署相关知情同意书,常规清肠。检查时患者取左侧卧位、右侧卧位或平卧位,探头置于直肠扫查盆腔,进镜距肛门约2—20cm,观察盆腔占位大小、形态、位置、回声强度,在内镜超声引导下选择合适穿刺位置,应用彩色多普勒功能探查穿刺路径,注意避开大的血管,选择合适穿刺路径。根据肿块为囊性还是实性,选择不同的穿刺针及负压。穿刺时,使穿刺针头对准肿块中央,通过抬钳器调整方向。观察针尖进入目标内后,拔出针芯,连接负压注射器。采用19G或22G穿刺针。实质性病变穿刺用0ml～10ml负压。每个部位穿刺2-5次,每次反复提插10～30下。如果穿刺物中有较多血性液体、线条样组织较少,则可去除负压反复提插。以穿刺者认为标本量足够为准。在病灶中来回提插数十次,解除负压后拔针。用针芯将抽取物推出至液基细胞学保存液中或玻片上,对有成形组织条,置于10%福尔马林溶液中固定。必要时重复抽吸2-5次。穿刺后观察患者有无腹痛、发热、便血等不良反应。穿刺出组织送病理学及细胞学检查。术后追踪病理学及细胞学结果。住院患者术后给予广谱抗生素预防感染2天。门诊患者术后口服诺氟沙星胶囊或头孢类口服药2天。住院患者术后三天每天随访,了解有无并发症。门诊患者如有腹痛、发热等并发症,随时到医院就诊。到医院取病理检验报告单时到超声内镜室随访。结果全部42例盆腔实性包块患者均接受了细针穿刺活检,经病理学及/或细胞学检查。其中转移腺癌28例,恶性间质瘤3例,炎性肿块3例,淋巴瘤2例,皮样囊肿1例,其它5例。19G和22G穿刺针比较,穿刺物能作免疫组化的比例差异无统计学意义(P>0.05)。术后观察,无一例出现发热、便血等并发症。结论内镜超声引导下细针穿刺活检术是明确盆腔占位病变性质准确的方法。操作简单、安全、创伤小。第二部分经直肠内镜超声引导下行细针穿刺活检对盆腔囊性或囊实性占位病变的诊治价值目的经直肠内镜超声引导下行细针穿刺活检(EUS-FNA)取得细胞学或组织学标本,确定盆腔囊性占位病变的性质,对脓肿行引流术并行抗生素灌洗术,评价EUS-FNA对盆腔囊性占位病变的安全性。方法选取2009年3月至2012年6月期间在湖北文理学院附属医院52例经B超、CT或MRI检查发现盆腔肿块,其中囊性占位性病变10例,均行经直肠EUS-FNA。超声内镜采用日本PENTAX EG-3630U,探头频率5-10MHZ,电子线阵扇扫。PENTAX3500内镜主机和HITACHI5500超声主机。22G穿刺针选用OLYMPUSNA-10J-1、COOK ECHO-1-2,19G穿刺针选用COOK ECHO-19。术前患者或授权代理人签署相关知情同意书,常规清肠。检查时患者取左侧卧位、右侧卧位或平卧位,探头置于直肠扫查盆腔,进镜距肛门约2-20cm,观察盆腔占位大小、形态、位置、回声强度,在内镜超声影像提示下选择合适穿刺位置,应用彩色多普勒功能探查穿刺路径上的血管,注意避开大血管。穿刺时,通过抬钳器调整方向,使穿刺针头对准肿块中央。观察针尖进入目标内,拔出针芯,连接负压注射器。采用19G或22G穿刺针,考虑为脓肿或囊性时用19G穿刺针。穿刺抽液均行涂片细胞学检查,必要时查CEA、细菌培养。各部位穿刺2-5次,每次反复提插10～30下。囊实性病灶穿刺抽囊液1-2次,并穿刺实性部分2-3次。囊液性或脓肿性病变穿刺抽液1-3次。保持负压为5-10ml,在病灶中来回提插数十次,解除负压后拔针。用针芯将抽取物推出至液基细胞学保存液中或玻片上,如有成形组织条,置于10%福尔马林溶液中固定。送病理学及细胞学检查。术后追踪病理学及细胞学结果。穿刺后观察患者有无腹痛、发热、便血等不良反应。住院患者术后给予甲硝唑或替硝哗注射液预防感染2天。门诊患者术后口服诺氟沙星胶囊2天。住院患者术后三天每天随访,了解有无并发症。门诊患者到医院取病理检验报告单时到超声内镜室随访。如有腹痛、发热等并发症,随时到医院就诊。结果全部10例盆腔囊性或囊实性包块患者均接受了细针穿刺活检,经病理学及/或细胞学检查,2例为卵巢浆液性囊腺瘤,直肠周围脓肿8例。2例直肠周围脓肿因脓液粘稠,仅抽出少量脓性液体,其余6例直肠周围脓肿抽出脓液后,注射甲硝唑注射液灌洗数次。其中3例1-2月后复查超声内镜,脓肿消失。结论内镜超声引导下细针穿刺活检术是明确盆腔囊性占位病变性质准确的方法。对脓肿可行灌洗术,使部分患者避免手术。操作简单、安全、创伤小。更多还原

【Abstract】 Part I. The effect of Endoscopic ultrasound guided fine needle aspiration biopsy on pelvic solid lesionsObjectiveEndoscopic ultrasound guided fine needle aspiration biopsy(EUS-FNA) was performed for diagnosis of the pelvic solid lesions and the safety of this method were evaluated.MethodsPatients referred for EUS-FNA of pelvic lesions from March2009to June2012in the Affiliated Hospital of Hubei University of Arts and Science were studied retrospectively. A total of42patients with pelvic solid masses discovered by B-ultrasound, CT or MRI had been referred for EUS-FNA. Some patients verified by surgical pathologic examination or clinical follow-up after2months. EUS-FNA was performed using the curved linear array echoendoscope (PENTAX EG-3630U) and Hitachi EUB5500ultrasound workstation. In all cases19-gauge and22-gauge needles with stylet were utilized (OLYMPUSNA-10J-1or COOK ECHO-1-2, COOK ECHO-19).All patients took the left lateral decubitus position, the right lateral or supine position. The probe was placed in the rectum which observed the the size, shape, location, and echo intensity of pelvic masses. Endoscopic ultrasound images prompted to select the appropriate puncture position and avoid the blood vessels by using color Doppler function. The needle was advanced into the lesion under real time endosonographic visualization and inserted into the mass, with a maximum depth of penetration of50mm. The needle stylet was then removed from the assembly. When the needle tip was seen to lie within the lesion, continuous suction was applied with0ml～10ml negative pressures. At the same time, the needle was moved back and forth within the lesion with3-5mm movements, while observing on the ultrasound console screen. Various parts were punctured2to5times, each repeated lifting and thrusting from10to30. If first suction has too much liquid bleeding subject and less tissue lines, you should not sucked in negative pressure until get enough specimens. Suction was then released, and the needle was withdrawn. The contents of the needle were expressed onto a glass slide or pushed into liquid-based cytology preservative fluid and slide forming tissue strips, if any, were fixed in10%formalin solution. Tissues were examined by pathology and cytology. Repeated puncture2～5times if necessary. Follow up the results of pathology and cytology. Postoperative complications such as abdominal pain, fever, blood in the stool were observed. Hospitalized patients were given metronidazole or tinidazole injection for two days to prevent infection. The outpatients took Norfloxacin capsules two days. Hospitalized patients were followed up after three days. Outpatients were examined when they came to hospital next time for pathological inspection report. If suffered from abdominal pain, fever and other complications, patients should look doctor at any time.ResultsAll patients were performed fine needle biopsy of the pelvic lesions. Among the42solid lesions, cytology and pathology demonstrated malignant tumors in28patients,3cases of malignant stromal tumors,3cases of Inflammatory mass cases,2cases of lymphoma,1case of dermoid cyst,5cases of other. Diagnosis rates of samples for immunohistology remained similar between22gauge and19gauge needles (P>0.05). There were no abdominal pain, fever, bloody stool and other complications after the procedures.ConclusionEUS-guided FNA is minimally invasive, a safe and accurate method for diagnosis of pelvic solid lesions. Part Ⅱ. The effect of Endoscopic ultrasound guided fine needle aspiration biopsy on pelvic cystic lesionsObjective Endoscopic ultrasound guided fine needle aspiration biopsy(EUS-FNA) was performed for diagnosis and treatment of the pelvic cystic lesions and purulent lesions were lavaged with Metronidazole repeatedly. The safety of this method was evaluated.MethodsPatients referred for EUS-FNA of pelvic lesions from March2009to June2012in the Affiliated Hospital of Hubei University of Arts and Science were studied retrospectively. A total of10patients with pelvic cystic masses discovered by B-ultrasound, CT or MRI had been referred for EUS-FNA. EUS-FNA was performed using the curved linear array echoendoscope (PENTAX EG-3630U) and Hitachi EUB5500ultrasound workstation. In all cases19-gauge and22-gauge needles with stylet were utilized (OLYMPUSNA-10J-1or COOK ECHO-1-2, COOK ECHO-19). All patients took the left lateral decubitus position, the right lateral or supine position. The probe was placed in the rectum which observed the the size, shape, location, and echo intensity of pelvic masses. Endoscopic ultrasound images prompted to select the appropriate puncture position and avoid the blood vessels by using color Doppler function. The needle was advanced into the cystic lesion under real time endosonographic visualization and inserted into the mass. The needle stylet was then removed from the assembly. When the needle tip was seen to lie within the lesion, continuous suction was applied with5ml～10ml negative pressure and repeated2～5times. The pelvic cystic lesions were drained1～2times and then2-3times for solid portions. Purulent lesions were lavaged with Metronidazole repeatedly. Suction was then released, and the needle was withdrawn. The contents of the needle were expressed onto a glass slide or pushed into liquid-based cytology preservative fluid and slide forming tissue strips, if any, were fixed in10%formalin solution. To send pathology and cytology. Follow up the results of pathology and cytology. Postoperative complications such as abdominal pain, fever, blood in the stool were observed. Hospitalized patients were given metronidazole or tinidazole injection for two days to prevent infection. The outpatients took Norfloxacin capsules two days. Hospitalized patients were followed up after three days. Outpatients were examined when they came to hospital next time for pathological inspection report. If suffered from abdominal pain, fever and other complications, patients should look doctor at any time.ResultsAll patients were performed fine needle biopsy of the pelvic lesions. Among the52lesions, there were10cystic lesions. In cystic lesions,2cases of serous cystadenoma, perirectal abscess in8cases.6purulent lesions were lavaged with Metronidazole repeatedly. Amony them, purulent lesions in3cases disappeared after1～2months examined by EUS. During the operation,8cases of perirectal abscess patients have different degree of pain. There were no other complications after the procedures except that one patient suffered from fever.ConclusionEUS-FNA is minimally invasive, a safe and accurate method for diagnosis of pelvic cystic lesions. EUS-FNA can lavage abscess which make some patients avoid operation.更多还原