上消化管神经内分泌肿瘤超声内镜检查及内镜黏膜下剥离术的临床价值

The application significance of endoscopic ultrasonography and endoscopic submucosal dissection in upper digestive tract neuroendocrine tumor

目的 ：评价超声内镜（endoscopic ultrasonography,EUS）检查及内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）在上消化管神经内分泌肿瘤（neuroendocrine neoplasm,NEN）治疗中的临床价值。方法 ：回顾性分析2010年8月—2014年1月接受EUS检查及ESD治疗的26例上消化管NEN患者的临床资料,并进行内镜随访。观察指标包括NEN的EUS表现、病理学分级、完整切除情况、并发症、复发和转移等。结果 ：26例患者的31个病灶的EUS检查结果显示,其中18个病灶来源于黏膜肌层,13个病灶来源于黏膜下层;2个位于食管,24个位于胃部,5个位于十二指肠。31个病灶均接受ESD,平均直径为1.0（0.3~3.1）cm;其中29个病灶得到完整切除（完整切除率为93.5%）,另2个病灶[1例胃NEN（病理分级为G2）,1例十二指肠NEN（病理分级为G1）]基底切缘阳性（前者再行ESD完整切除,后者因拒绝外科治疗且不愿再行ESD,遂行内镜下氩离子凝固术）;平均手术时间为37（15~65）min;术后病理学检查结果显示,31个病灶均为NEN（其中27个病灶的病理学分级为G1,4个病灶为G2）;术后均未发生明显的迟发性出血和穿孔。随访率为93.5%（29/31）,平均随访时间为21（范围：10~41）个月,随访过程中均未发现淋巴结或远处转移。结论 ：EUS检查可以较清楚地界定上消化管NEN的来源层次以指导内镜治疗的范围和深度。ESD是局限于黏膜下层NEN的安全而有效的微创治疗方法。

Objective：To evaluate the feasibility and efficacy of endoscopic ultrasonography（EUS） and endoscopic submucosal dissection（ESD） in treatment of upper digestive tract neuroendocrine tumor（NEN）.Methods：A retrospective review of 26 cases of upper digestive tract NEN undergoing EUS and ESD between August 201 0 and January 201 4was conducted.All patients were followed-up using endoscopy.The clinical features and outcomes including EUS features,pathological grade,complete resection rate,complications,recurrence and metastasis were evaluated.Results：EUS results showed that 26 patients had 31 NENs（18 originated from muscularis mucosa and 1 3 from submucosa;2 located in esophagus,24 in stomach and 5 in duodenal bulb）.All 26 lesions were removed by ESD en bloc;the average maximum diameter of the lesions was 1.0（0.3-3.1） cm;the complete resection rate was 93.5%（29/31）.Two patients with positive basal surgical margin included one patient with pathologic grade 2NEN in stomach（who then underwent an additional ESD） and one patient with pathologic grade 1 NEN in duodenal bulb（who was treated with argon plasma coagulation after rejecting surgery and ESD）.Histological examination determined that 27 NEN lesions were pathologic grade 1 and 4 were pathologic grade 2.No patients underwent delayed bleeding or perforation after ESD.The follow-up rate was 93.5%（29/31）.During a mean followup period of 21 months（range：10-41 months）,no lymph node metastasis or distant metastasis was observed.Conclusion：EUS is able to distinguish the origin of upper digestive tract NEN and give aid to determing the range and depth of ESD.ESD appears to be a safe and effective treatment for upper digestive tract NEN limited to submucosa.