上消化道黏膜下肿瘤的诊治和随访

Therapy and follow-up of upper gastrointestinal subepithelial lesions

目的:随着各种消化内镜和薄层计算机断层扫描(computed tomography,CT)等技术的临床广泛应用,消化道黏膜下病变(submucosal lesion,SML)的检出率越来越高.针对SML治疗的内镜黏膜下层剥离术(endoscopic submucosal dissection,ESD)、外科手术数量越来越多.对于SML临床转归、ESD或外科手术的必要性及患者是否受益存在争论.本研究主要针对上消化道黏膜下病变的性质、生长速度、恶变可能及ESD或外科手术的必要性、疗效.方法:回顾性分析安徽医科大学附属安徽省立医院2004-01/2014-12经超声内镜(endoscopic ultrasonography,EUS)诊断为消化道SML的1915例患者的临床资料.运用超声内镜观察病变部位(食管、胃),病变大小,回声表现、来源等特征.根据黏膜下病变性质、大小、患者意愿等选择不同治疗方案.包括EUS的随访观察、内镜下治疗[ESD、内镜下黏膜剥离切除术、内镜黏膜下挖除术(endoscopic submucosalexcavation,ESE)、内镜经黏膜下隧道肿瘤切除术]和外科手术(开放手术、胸腔镜腹腔镜)(内镜或外科手术的指证是病灶短期内明显增大或相关内镜或影像评估怀疑有恶变的可能或患者主观要求内镜或手术切除).随访记录病灶的大小变化、切除病变的性质、大小、来源及并发症发生情况(出血、穿孔)、中转手术情况.结果:超声随访1135例SML患者(食道687例,胃448例),平均年龄50.7岁±10.3岁,男女比例为1.16∶1;食道SML初始病灶大小为:0.82 c m±0.24 c m,共计18例病灶随访过程中明显增大包括5例显著增大发生在6 mo内病理结果诊断为3例良性病变(固有肌层平滑肌瘤1例,囊肿2例)及两例恶性病变(平滑肌肉瘤1例,恶性颗粒细胞瘤1例).胃SML初始病灶大小为:1.31 cm±0.44 cm,16例病灶明显增大,包括10例病灶明显增大,病理诊断为2例平滑肌瘤病灶增大发生于12 mo内,8例间质瘤.病灶增大均在6 mo内发生.内镜下手术患者668例(食道412例,胃256例),6例(4例ESE组,2例ESD组)于术中发生穿孔,2例(均为E S E组)于术中发生出血,2例病变未完整剥离,内镜下治疗成功率为98.5%.外科手术患者112例(食道19例,胃93例)两例(GIST及食道平滑肌肉瘤)发生迟发性出血,手术成功率为98.2%.食道SML中,平滑肌瘤占86.1%,GIST占4.9%,囊肿占3%.胃S M L中,G I S T占48.1%,平滑肌瘤占24.9%,异位胰腺占17.3%,囊肿占3.4%,脂肪瘤占2.6%.结论:不论食管还是胃部黏膜下瘤,病灶的显著增大多发生于初次随访后6 mo内,6 mo后变化不明显.食管黏膜下肿瘤以平滑肌瘤为主,间质瘤少见,生长迅速的病灶及恶性病变罕见,食管病变无论外科手术或ESD术创伤及经济代价较大,不建议常规施行.胃部黏膜下病灶以间质瘤多见,迅速生长病灶较食管增多,建议12 mo内随访期间对生长迅速病灶施行ESD或外科手术.

AIM：To explore the nature,growth,and malignant transformation of upper gastrointestinal submucosal lesions（SMLs）,and evaluate the clinical efficacy,necessity and safety of surgery or endoscopic therapy for SMLs.METHODS：We retrospectively collected1915 cases of upper gastrointestinal submucous lesions,which were evaluated by endoscopic ultrasonography from January2014 to December 2014 at our department.This diagnostic modality provided features about lesion location（esophagus and stomach）,size,echo performance,layer of origin,etc.Different therapeutic methods were chosen according to the size,origin,and location of SMLs as well as patient＇s preferences.Clinical treatments included follow-up,endoscopic therapy（endoscopic snare resection,endoscopic resection,endoscopic submucosal resection,endoscopic submucosal dissection（ESD）,endoscopic submucosal excavation（ESE）,submucosal tunneling endoscopic resection,etc.）,and surgery（open surgery,laparoscopy,and thoracoscopy）.Endoscopic or surgical treatment of SMLs was performed when lesion size was significantly increased or suspected to have malignant transformation.Successful cases,size of the mass and layer of origin（mucosa layer,muscularis mucosa layer,submucosa layer,and serosal layer）,complications（bleeding,perforation） and conversion surgery or not were recorded.RESULTS：In 1135 cases followed by EUS,median age was 50.7 years ± 10.3 years（range,19-78 years）,and male/ female ratio was 1.16.There were 687 esophageal SMLs and 448 gastric SMLs followed by regular endoscopy（range,3-60 mo）.Esophageal cases at initial measurement had a mean size of 0.82 cm ± 0.24 cm,and gastric cases had an initial mean size of 1.31 cm ± 0.44 cm.Of the followed cases of esophagus SMLs,18 showed an obviously increased size（2 cm）,including 5 significantly increased cases（3cm） over a period of 6 mo and 13 moderately increased cases（2 cm and 3 cm） during 12 mo.Surgical resection was performed in 5lesions ≥ 3 cm in size,which were diagnosed as benign lesions in 3（one leiomyoma and two cysts） and malignant lesions in 2（1leiomyosarcoma and 1 malignant granular cell tumor）.Of the followed cases of gastric SMLs,16 had an obviously increased size（2 cm）,including 10 significantly increased cases（3 cm）.Traditional surgery and endoscopic therapy were performed in 10 lesions ≥ 3 cm in size,which were diagnosed as gastrointestinal stromal tumors（GISTs） in8 and leiomyomas in 2.A total of 780 cases underwent endoscopic or surgical therapy.Of 112 cases（19 esophageal cases and 93 gastric cases） treated by surgery,2（GIST and leiomyosarcoma） developed delayed bleeding,and the success rate of surgical treatment was 98.2%.Of 668 cases who underwent endoscopic therapy,6（4 in ESE group and 2 in ESD group） ended up with perforation and 4 of them（4 in ESE group）were converted to surgery;2（both in ESE group） developed intraoperative bleeding,which was managed by endoscopic spraying of drugs,electric coagulation and clips to achieve hemostasis;2 cases in ESE group had failed dissection and then followed by EUS.The success rate of endoscopic therapy was98.5%.Of 431 esophageal SMLs,there were371（86.08%） leiomyomas,21（4.87%） GISTs,and 13（3.02%） cysts.Of 349 gastric SMLs,there were 168（48.13%） GISTs,87（24.92%）leiomyomas,and 60（17.91%） cases of ectopic pancreas.CONCLUSION：No matter where the lesion is located,the esophagus or stomach,lesion size significantly increased over a period of 6mo after initial measurement.However,few further change were observed in size,shape and EUS finding such as echo pattern or regularity of the outer margin over a period of 6-60 mo.Leiomyoma is the most common gastrointestinal SML in the esophagus,while GISTs are common in the stomach.Leiomyoma lesions rarely showed significant change as shown by endoscopic examination.Excessive medical therapy involves known issues associated with cost-effectiveness,patient compliance and risk of complications,and conservative treatment with regular clinical follow-up is recommended.