【作者】 赵鑫；

【导师】 徐红；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2018， 硕士

【摘要】 目的:评价内镜下治疗胃小间质瘤的可行性,探讨内镜治疗胃小间质瘤与腹腔镜治疗的优势和弊端,为以后的临床工作提供指导。方法:回顾性分析2013年1月至2017年12月于吉林大学白求恩第一医院行腹腔镜以及内镜下治疗的胃小间质瘤患者72例。所有患者均行病理学及免疫组化检查确诊。结果:1.一般资料:本研究共纳入病例72例,其中男性患者28例,女性患者44例,男女比率0.64:1。平均年龄57.51±10.21岁,最大年龄75岁,最小年龄35岁,以中年、老年为主。患者因腹痛、腹胀、上腹部不适、恶心、呕吐等非特异性症状入院的有56例,常规体检发现入院的有16例,无因消化道出血、腹部包块入院的患者。72例患者均为单一部位发病,所切除肿瘤最大直径均小于2厘米,平均大小1.35±0.46厘米。肿瘤位于胃底及贲门者共48例,位于胃体者19例,位于胃窦者5例。超声内镜术前诊断胃间质瘤60例,10例误诊为胃平滑肌瘤,2例误诊为胃异位胰腺,其有效检出率为83.3%。腹部CT平扫及增强术前诊断胃间质瘤48例,22例仅提示病变部位胃壁略增厚,2例未发现任何异常,其有效检出率为66.7%。所有患者切除标本均送病理及免疫组化:CD117(+)72例,CD34(+)71例,dog-1(+)70例。镜下核分裂数小于5/50 HPF者71例,均为极低危险组,核分裂数大于5/50 HPF者仅1例,为中等危险组。本研究72例患者中,27例于我院行内镜下治疗,ESD术17例,EFR术10例,所有肿瘤均成功一次性切除,均为R0切除,切缘阴性。患者无1例急性大量出血,ESD组1例急性少量出血,给予电凝成功止血。EFR组出现1例明显皮下气肿及气腹症,术中经腹腔穿刺排气后明显缓解,内科保守治疗后皮下气肿消失。同期于我院行腹腔镜切除胃小间质瘤45例,均成功切除,无术中转开腹手术,其中1例术后出现腹腔感染,2例出现术后低热。所有病例术后均获得随访,分别于术后第3或者6个月行胃镜检查,结果显示手术切口愈合良好,未见肿瘤复发。2.将内镜组和腹腔镜组资料进行对比,内镜切除胃小间质瘤与腹腔镜相比,手术时间缩短,住院费用减少(P<0.05)。在性别、年龄、临床主诉、肿瘤部位、治愈率、复发率、并发症的发生率上无统计学差异(P>0.05)。内镜下切除胃小间质瘤是安全有效的,具有可行性。结论:(1)胃小间质瘤以中老年为主,临床表现无明显特异性。在术前诊断上,超声内镜优于增强CT。(2)内镜下切除胃小间质瘤是安全有效的,疗效确切,具有可行性。(3)内镜切除胃小间质瘤与腹腔镜相比具有相同效果,但可以减少手术时间,降低住院费用。对于胃小间质瘤,内镜治疗完全可以取代腹腔镜治疗。更多还原

【Abstract】 Objective: Evaluate the feasibility of endoscopic treatment of small gastric stromal tumors,and discuss the advantages and disadvantages of endoscopic treatment of small gastric stromal tumors and laparoscopic treatment to provide guidance for future clinical work.Methods: A retrospective analysis of 72 patients with small gastric stromal tumors treated with laparoscopy and endoscopic therapy at the Bethune First Hospital of Jilin University from January 2013 to December 2017 was performed.All were pathological and immunohistochemical examination confirmed.Results: 1.General information: A total of 72 cases were included in the study,including 28 male patients and 44 female patients.The male to female ratio was 0.64:1.The average age is 57.51±10.21 years old,the maximum age is 75 years old,and the minimum age is 35 years old,mainly middle age and old age.Fifty-six patients admitted to hospital for abdominal pain,bloating,abdominal discomfort,nausea,vomiting and other non-specific symptoms were admitted to the hospital on routine physical examination.There were no patients admitted to hospital because of gastrointestinal bleeding and abdominal masses.All72 patients had a single site disease.The largest tumor diameter was less than 2 cm and the average size was 1.35±0.46 cm.The tumors were located in the fundus and cardia in 48 cases,19 cases in the stomach body,and 5 cases in the gastric antrum.Ultrasound endoscopy preoperative diagnosis of gastric stromal tumors in 60 cases,10 cases misdiagnosed as gastric leiomyoma,2 cases misdiagnosed as gastric ectopic pancreas,its effective detection rate 83.3%.Abdominal CT plain scan and enhanced preoperative diagnosis of gastric stromal tumors in 48 cases,22 cases only showed a slight thickening of the gastric wall lesions,2 cases found no abnormalities,the effective detection rate 66.7 %.Resection specimens were sent to pathology and immunohistochemistry: 72 CD117(+),71 CD34(+),70 dog-1(+).Seventy-one patients with microscopic mitoses less than 5/50 HPF were in the extremely low risk group.Only 1 case had a mitose greater than 5/50 HPF,which was a moderate risk group.Of the 72 patients in the study,27 underwent endoscopic treatment in our hospital,17 underwent ESD,and 10 underwent EFR.All tumors were successfullyresected once and all were R0 resections with negative margins.There was no acute massive bleeding in the patient.One patient in the ESD group had acute bleeding and given electrocoagulation to stop bleeding.In the EFR group,there was one case of subcutaneous emphysema and pneumoperitoneum,which was relieved after abdominal paracentesis,and subcutaneous emphysema disappeared after conservative treatment.In the same period,45 cases of gastric stromal tumors were removed by laparoscopy in our hospital.All of them were successfully resected.No laparotomy was performed until laparotomy.One case had abdominal infection after operation and 2 cases had postoperative low fever.All patients were followed up after operation.Gastroscopes were performed at the 3rd or 6th months after operation.The results showed that the surgical incision healed well and no tumor recurrence was found.2.Comparing the data of the endoscopic group with the laparoscopic group,endoscopic excision of small gastric stromal tumors was associated with shortened operative time and reduced hospital costs compared with laparoscopy(P<0.05).There was no significant difference in gender,age,clinical complaints,tumor site,cure rate,recurrence rate,and incidence of complications(P>0.05).Endoscopic resection of small gastric stromal tumors is safe,effective and feasible.Conclusions:(1)Small gastric stromal tumors are mainly middle-aged and elderly,and their clinical manifestations have no obvious specificity..In preoperative diagnosis,EUS is superior to enhanced CT.(2)Endoscopic resection of small gastric stromal tumors is safe,effective and feasible.(3)Endoscopic resection of small gastric stromal tumors has the same effect as laparoscopy,but it can reduce operative time and hospital costs.For small gastric stromal tumors,endoscopic treatment can completely replace laparoscopic treatment.更多还原