食管黏膜下肿瘤的内镜下诊断与治疗
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摘要
目的基于食管黏膜下肿瘤(SMTs)内镜检查及治疗手段,分析食管SMTs的临床病理学特征,同时评价食管SMTs内镜下诊治的安全性、经济性和有效性。方法选择2012年1月-2017年12月新疆医科大学第一附属医院收治的98例食管SMTs患者,并同时完善普通胃镜和超声内镜(EUS)检查,所有患者均接受内镜下治疗,所有切除的肿瘤均行病理学检查。结果共98例患者。其中,女55例(56.12%),男43例(43.88%)。肿瘤位于食管上段27例(27.55%),中段28例(28.57%),下段43例(43.88%),56例病例行内镜黏膜下剥离术(ESD),25例行内镜黏膜下肿瘤挖除术(ESE),12例行内镜黏膜下隧道肿瘤切除术(STER),另3例行电凝电切除术,1例孤立性纤维性肿瘤因术中发现肿瘤基底部深转为外科手术,另1例平滑肌瘤因肿瘤体积太大致内镜操作困难,中途转胸腔镜下治疗。1例神经鞘瘤,ESD术后出现气胸、胸腔积液、术后瘘及食管狭窄等并发症,1例胸腔镜下行肿瘤摘除术的平滑肌瘤,术后发生气胸和胸腔积液,另外2例出现纵隔气肿和皮下气肿,均于术后2或3 d自行好转。病理学检查及免疫组化结果证实,最常见的食管SMTs为平滑肌瘤,共90例,占所有病例91.84%。结论食管SMTs以女性多见,好发于中下段食管,病理以平滑肌瘤最为常见;应用EUS技术能够对病变性质及组织学来源进行较准确的评估;内镜下治疗食管SMTs不仅能提供完整的病理学资料,而且有效安全。
Objectives To analyze the clinical and pathological characteristics of esophageal submucosal tumors(ESMTs), and evaluate the safety, economy and ef?cacy of endoscopic diagnosis and therapy for ESMTs, on account of endoscopic technique. Methods 98 patients with ESMTs were selected from January 2012 to December 2017 by endoscopy and ultrasonography; they were all treated by endoscopic therapy and pathological examination was took in all removed tumors. Result In 98 cases, 55 cases are female patients, accounting for 56.12%; the tumors located at the upper third of the esophagus accounted for 27.55%(27/98), at the middle esophagus for 28.57%(28/98),at the lower esophagus for 43.88%(43/98). 56 cases were treated by endoscopic submucosal dissection, 25 by endoscopic submucosal excavation, 12 by submucosal tunneling endoscopic resection, 3 by endoscopic polypectomy,and the rest 2 were changed to surgical treatment or thoracoscopic surgery because one solitary ?brous tumor was found the basilar part was too deep during the operation and another tumor was found to be too big and dif?cult to dissect by endoscopy; 1 schwannoma occurred post operative pleural effusion, pneumothorax, ?stula and stenosis,1 leiomyoma treated by thoracoscopy occurred pleural effusion, pneumothorax, another 2 occurred mediastinal and emphysema subcutaneous and got better spontaneously after 2 ～ 3 days; after pathological and immunohistochemical analysis, 90 tumors were identi?ed as esophageal leiomyoma, which were the most common ones, accounting for91.84%. Conclusion Most ESMTs are found in female, and are commonly located at middle and lower esophagus and most of them are leiomyoma according to the results of pathological test. It can make more accurate diagnosis in terms of different origin layers and property of esophageal tumor by endoscopic ultrasonography(EUS). Endoscopic therapy is safe and effective, and meanwhile, it can provide integral pathological information.
Objectives To analyze the clinical and pathological characteristics of esophageal submucosal tumors(ESMTs), and evaluate the safety, economy and ef?cacy of endoscopic diagnosis and therapy for ESMTs, on account of endoscopic technique. Methods 98 patients with ESMTs were selected from January 2012 to December 2017 by endoscopy and ultrasonography; they were all treated by endoscopic therapy and pathological examination was took in all removed tumors. Result In 98 cases, 55 cases are female patients, accounting for 56.12%; the tumors located at the upper third of the esophagus accounted for 27.55%(27/98), at the middle esophagus for 28.57%(28/98),at the lower esophagus for 43.88%(43/98). 56 cases were treated by endoscopic submucosal dissection, 25 by endoscopic submucosal excavation, 12 by submucosal tunneling endoscopic resection, 3 by endoscopic polypectomy,and the rest 2 were changed to surgical treatment or thoracoscopic surgery because one solitary ?brous tumor was found the basilar part was too deep during the operation and another tumor was found to be too big and dif?cult to dissect by endoscopy; 1 schwannoma occurred post operative pleural effusion, pneumothorax, ?stula and stenosis,1 leiomyoma treated by thoracoscopy occurred pleural effusion, pneumothorax, another 2 occurred mediastinal and emphysema subcutaneous and got better spontaneously after 2 ～ 3 days; after pathological and immunohistochemical analysis, 90 tumors were identi?ed as esophageal leiomyoma, which were the most common ones, accounting for91.84%. Conclusion Most ESMTs are found in female, and are commonly located at middle and lower esophagus and most of them are leiomyoma according to the results of pathological test. It can make more accurate diagnosis in terms of different origin layers and property of esophageal tumor by endoscopic ultrasonography(EUS). Endoscopic therapy is safe and effective, and meanwhile, it can provide integral pathological information.
引文
[1]武育卫,彭贵勇,何双丽,等.食管黏膜下肿瘤超声内镜诊断及内镜治疗的临床研究[J].中国医师进修杂志,2016,39(10):890-893.[1]WU Y W,PENG G Y,HE S L,et al.Clinical study on the diagnosis of endoscopic ultrasonography and endoscopic treatment in patients with esophageal submucosal tumor[J].Chinese Journal of Postgraduates of Medicine,2016,39(10):890-893.Chinese
[2]LI Q Y,MENG Y,XU Y Y,et al.Comparison of endoscopic submucosal tunneling dissection and thoracoscopic enucleation for the treatment of esophageal submucosal tumors[J].Gastraintestinal Endoscopy,2017,86(3):485-491.
[3]M I E T T I N E N M,M A K H L O U F H,S O B I N L H,e t a l.Gastrointestinal stromal tumors of the jejunum and ileum:a clinicopathologic,immunohistochemical,and molecular genetic study of 906 cases before imatinib with long-term follow-up[J].Am J Surg Pathol,2006,30(4):477-489.
[4]DEMETRI G D,VON MEHREN M,ANTONESCU C R,et al.NCCN Task Force Report:update on the management of the patients with gastrointestinal stromal tumors[J].Natl Compr Canc Netw,2010,8(Suppl 2):S1-S41.
[5]HE G,WANG J,CHEN B,et al.Feasibility of endoscopic submucosal dissection for upper gastrointestinal submucosal tumors treatment and value of endoscopic ultrasonography in preoperation assess and postoperation follow-up:a prospective study of 224 cases in a single medical center[J].Surg Endosc,2016,30(10):4206-4213.
[6]XU G Q,QIAN J J,CHEN M H,et al.Endoscopic ultrasonography for the diagnosis and selecting treatment of esophageal leiomyoma[J].J Gastraenterol Hepatol,2012,27(3):521-525.
[7]毛鑫礼,叶丽萍,陈霞,等.内镜超声在食管黏膜下肿瘤诊治中的应用[J].中华消化内镜杂志,2008,25(3):149-150.[7]MAO X L,YE L P,CHEN X,et al.Application of endoscopic ultrasonography in diagnosis and treatment for esphgeal submucosal tumors[J].Chinese Journal of Digestive Endoscopy,2008,25(3):149-150.Chinese
[8]SHIN S,CHOI Y S,SHIM Y M,et al.Enucleation of esophageal submucosal tumors:a single institution’s experience[J].Ann Thorac Surg,2014,97(2):454-459.
[9]荣光宏,马颖才,刘芝兰,等.食管黏膜下肿瘤内镜下切除的疗效分析[J].中华消化内镜杂志,2016,33(9):636-637.[9]RONG G H,MA Y C,LIU Z L,et al.Efficacy analysis on endoscopic resection of esophageal submucosal tumors[J].Chinese Journal of Digestive Endoscopy,2016,33(9):636-637.Chinese
[10]SHI Q,ZHONG Y S,YAO L Q,et al.Endoscopic submucosal dissection for treatment of esophageal submucosal tumors originating from the muscularis propria layer[J].Gastrointest Endosc,2011,74(6):1194-1200.
[11]张明黎,王业涛,宋继中,等.内镜黏膜下挖除术治疗消化道黏膜下肿瘤108例分析[J].中华消化杂志,2013,33(11):756-760.[11]ZHANG M L,WANG Y T,SONG J Z,et al.Analysis of 108cases of snbmucosal tumor treated by endoscopic submucosal excavation[J].Chinese Journal of Digestion,2013,33(11):756-760.Chinese
[12]TANG X,REN Y,HUANG S,et al.Endoscopic submucosal tunnel dissection for upper gastrointestinal submucosal tumors originating from the muscularis propria layer:a single-center study[J].Gut and Liver,2017,11(5):620-627.
[13]焦春花,杨树平,李学良,等.经黏膜下隧道内镜切除术治疗食管中下段黏膜下肿瘤的初步探索[J].中华医学杂志,2013,93(30):2388-2391.[13]JIAO C H,YANG S P,LI X L,et al.Preliminary exploration on submucosal tunneling endoscopic resection for middle and lower esophagus submucosal tumors[J].National Medical Journal of China,2013,93(30):2388-2391.Chinese
[14]LIU B R,SONG J T,KONG L J,et al.Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia[J].Surg Endosc,2013,27(11):4354-4359.
[15]WANG L,REN W,ZHANG Z,et al.Retrospective study of endoscopic submucosal tunnel dissection(ESTD)for surgical resection of esophageal leiomyoma[J].Surg Endosc,2013,27(11):4259-4266.
[16]陈蕾,张澍田.食管平滑肌瘤诊断及治疗研究进展[J].中华消化内镜杂志,2017,34(6):448-450.[16]CHEN L,ZHANG S T.The research development on the diagnosis and treatment of esophageal leiomyoma[J].Chinese Journal of Digestive Endoscopy,2017,34(6):448-450.Chinese
[17]任育宏,张志强,高鸿亮,等.经胃镜治疗胃黏膜下肿瘤61例临床分析[J].中国内镜杂志,2016,22(3):18-22.[17]REN Y H,ZHANG Z Q,GAO H L,et al.Clinical analysis of endoscopic treatment for patients with gastric submucosal tumors(61 cases)[J].China Journal of Endoscopy,2016,22(3):18-22.Chinese
[2]LI Q Y,MENG Y,XU Y Y,et al.Comparison of endoscopic submucosal tunneling dissection and thoracoscopic enucleation for the treatment of esophageal submucosal tumors[J].Gastraintestinal Endoscopy,2017,86(3):485-491.
[3]M I E T T I N E N M,M A K H L O U F H,S O B I N L H,e t a l.Gastrointestinal stromal tumors of the jejunum and ileum:a clinicopathologic,immunohistochemical,and molecular genetic study of 906 cases before imatinib with long-term follow-up[J].Am J Surg Pathol,2006,30(4):477-489.
[4]DEMETRI G D,VON MEHREN M,ANTONESCU C R,et al.NCCN Task Force Report:update on the management of the patients with gastrointestinal stromal tumors[J].Natl Compr Canc Netw,2010,8(Suppl 2):S1-S41.
[5]HE G,WANG J,CHEN B,et al.Feasibility of endoscopic submucosal dissection for upper gastrointestinal submucosal tumors treatment and value of endoscopic ultrasonography in preoperation assess and postoperation follow-up:a prospective study of 224 cases in a single medical center[J].Surg Endosc,2016,30(10):4206-4213.
[6]XU G Q,QIAN J J,CHEN M H,et al.Endoscopic ultrasonography for the diagnosis and selecting treatment of esophageal leiomyoma[J].J Gastraenterol Hepatol,2012,27(3):521-525.
[7]毛鑫礼,叶丽萍,陈霞,等.内镜超声在食管黏膜下肿瘤诊治中的应用[J].中华消化内镜杂志,2008,25(3):149-150.[7]MAO X L,YE L P,CHEN X,et al.Application of endoscopic ultrasonography in diagnosis and treatment for esphgeal submucosal tumors[J].Chinese Journal of Digestive Endoscopy,2008,25(3):149-150.Chinese
[8]SHIN S,CHOI Y S,SHIM Y M,et al.Enucleation of esophageal submucosal tumors:a single institution’s experience[J].Ann Thorac Surg,2014,97(2):454-459.
[9]荣光宏,马颖才,刘芝兰,等.食管黏膜下肿瘤内镜下切除的疗效分析[J].中华消化内镜杂志,2016,33(9):636-637.[9]RONG G H,MA Y C,LIU Z L,et al.Efficacy analysis on endoscopic resection of esophageal submucosal tumors[J].Chinese Journal of Digestive Endoscopy,2016,33(9):636-637.Chinese
[10]SHI Q,ZHONG Y S,YAO L Q,et al.Endoscopic submucosal dissection for treatment of esophageal submucosal tumors originating from the muscularis propria layer[J].Gastrointest Endosc,2011,74(6):1194-1200.
[11]张明黎,王业涛,宋继中,等.内镜黏膜下挖除术治疗消化道黏膜下肿瘤108例分析[J].中华消化杂志,2013,33(11):756-760.[11]ZHANG M L,WANG Y T,SONG J Z,et al.Analysis of 108cases of snbmucosal tumor treated by endoscopic submucosal excavation[J].Chinese Journal of Digestion,2013,33(11):756-760.Chinese
[12]TANG X,REN Y,HUANG S,et al.Endoscopic submucosal tunnel dissection for upper gastrointestinal submucosal tumors originating from the muscularis propria layer:a single-center study[J].Gut and Liver,2017,11(5):620-627.
[13]焦春花,杨树平,李学良,等.经黏膜下隧道内镜切除术治疗食管中下段黏膜下肿瘤的初步探索[J].中华医学杂志,2013,93(30):2388-2391.[13]JIAO C H,YANG S P,LI X L,et al.Preliminary exploration on submucosal tunneling endoscopic resection for middle and lower esophagus submucosal tumors[J].National Medical Journal of China,2013,93(30):2388-2391.Chinese
[14]LIU B R,SONG J T,KONG L J,et al.Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia[J].Surg Endosc,2013,27(11):4354-4359.
[15]WANG L,REN W,ZHANG Z,et al.Retrospective study of endoscopic submucosal tunnel dissection(ESTD)for surgical resection of esophageal leiomyoma[J].Surg Endosc,2013,27(11):4259-4266.
[16]陈蕾,张澍田.食管平滑肌瘤诊断及治疗研究进展[J].中华消化内镜杂志,2017,34(6):448-450.[16]CHEN L,ZHANG S T.The research development on the diagnosis and treatment of esophageal leiomyoma[J].Chinese Journal of Digestive Endoscopy,2017,34(6):448-450.Chinese
[17]任育宏,张志强,高鸿亮,等.经胃镜治疗胃黏膜下肿瘤61例临床分析[J].中国内镜杂志,2016,22(3):18-22.[17]REN Y H,ZHANG Z Q,GAO H L,et al.Clinical analysis of endoscopic treatment for patients with gastric submucosal tumors(61 cases)[J].China Journal of Endoscopy,2016,22(3):18-22.Chinese
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