上消化道异位胰腺内镜诊治价值

Endoscopy and endoscopic ultrasonography for heterotopic pancreas in upper gastrointestinal tract

目的探讨上消化道异位胰腺胃镜和超声内镜下的表现及内镜下治疗价值。方法回顾性分析2004年3月至2009年11月间经病理结果证实为上消化道异位胰腺的67例患者的临床资料，总结其临床症状、内镜和超声内镜下表现以及内镜下治疗结果。结果67例异位胰腺患者中，病灶多见于胃窦部（占92．5％，62／67），其他还可见于胃角、十二指肠等处。胃镜下表现为隆起于胃壁的表面光滑的黏膜下肿物，顶部可有脐样凹陷。有59例患者在内镜治疗前接受了超声内镜检查，病灶在超声内镜下表现为累及管壁第2和第3层为主的回声不均、边界不清的以混合回声为主的病变，部分还可累及第1层和第4层。EMR切除60例，其中25例术后见基底残留，尤以累及第4层的病变为著（占92．0％，23／25）；只有1例病变术后第3天出现残基出血，其余病例均无明显出血等并发症发生。ESD切除的8例（包括1例曾先行EMR治疗的患者），病变均完整切除，均未出现穿孔等严重并发症。术后病理结果显示，术前超声检查判断病变起源总符合率为91．5％（54／59）。结论胃镜结合超声内镜检查是判断上消化道异位胰腺范围及指导治疗的重要手段。未累及固有肌层时，EMR是最佳选择，特别是透明帽辅助法EMR；累及第4层时，宜采用ESD或随访观察。

Objective To study the characteristics of heterotopic pancreas （HP） in upper gastrointestinal tract （UGIT） under endoscopy and endoscopic sonography （EUS）, and its endoscopic manage- ments. Methods Data of 67 patients with pathologically confirmed HP in our hospital from March 2004 to November 2009, including clinical and endoscopic manifestations and sequelae after endoscopic resection, were retrospectively studied. Results Heterotopic pancreas were most commonly found as a single lesion in gastric antrum （62/67, 92. 5% ） and in gastric angle and duodenum as well, which were characterized by protrusion, with intact mucous membrane and centrally umbilicated. Of the 67 patients, 59 underwent EUS before endoscopic resection. Findings were heterogeneous and mixed echogenic lesions with indistinct borders involving both the second and third layers of the gastrointestinal wall, sometimes even involving the first and fourth layers. Most lesions （n = 60） were removed by endoscopic mucosal resection （EMR） , with basal res- idues in 25 eases, in which fourth layer involvement was observed in 23 cases （92. 0% ）. Delayed bleeding occurred in 1 case at 3rd day after the procedure, and no other complications were observed. Complete re- moval was achieved in 8 cases （including one receiving EMR previously） with endoscopic submucosal dis- section （ESD） , and there was no such severe complications as perforation. Postoperative pathological exami- nations revealed that the consistent rate of preoperative diagnosis with EUS was 91.5% （54/59）. Conclu- sion Endoscopy combined with EUS is critical in diagnosis of HP in UGIT. EMR, especially with cap assistance, is the best method for those without involvement of muscularis propria, while ESD or endoscopic surveillance is a better alternative for those with 4th layer involvement.