上消化道黏膜下肿瘤内镜治疗的关键问题分析

Key issues about the endoscopic treatment for upper gastrointestinal submucosal tumors

目的探讨不同部位上消化道黏膜下肿瘤（SMT）内镜治疗的必要性及内镜治疗术式选择。方法回顾2012年1月至2013年10月在上海长海医院消化内镜中心接受内镜治疗的306例上消化道SMT患者的临床资料，重点分析SMT的部位分布特征、病理类型、内镜术式选择等关键问题。结果306例病灶中，食管SMT55例（18．0％），胃SMT244例（79．7％），十二指肠SMT7例（2．3％）。病理类型：平滑肌瘤142例（46．4％），胃肠间质瘤（GIST）114例（37．3％），异位胰腺15例（4．9％），脂肪瘤14例（4．6％），神经内分泌肿瘤7例（2．3％），其他类型14（4．6％）。食管SMT中平滑肌瘤比例为85．4％，GIST比例为5．4％；贲门SMT中平滑肌瘤比例为78．8％，GIST比例为12．1％；胃底SMT中平滑肌瘤比例为28．7％，GIST比例为69．O％；胃体SMT中平滑肌瘤比例为38．6％，GIST比例为45．5％；胃窦SMT中平滑肌瘤比例为25．7％，GIST比例为14．3％；十二指肠SMT中平滑肌瘤比例为14．3％，GIST比例为28．6％。306例病灶中，接受内镜黏膜下挖除术（ESE）治疗242例（79．1％），内镜黏膜下隧道切除术（STER）28例（9．2％），内镜全层切除术（EFR）25例（8．2％）。食管SMT治疗中ESE54．5％、STER40％，胃SMT治疗中ESE84．4％、STER2．5％、EFR10．2％，十二指肠SMT均行ESE。STER主要应用于食管（78．6％），EFR主要应用于胃底（72．0％）、胃体（24．0％）。结论食管、贲门、胃窦部位SMT以良性居多，如无明显相关症状，可定期内镜随访。胃底、胃体SMT以GIST为主，且存在中危、高危病灶，应选择内镜治疗。食管SMT选择STER较为安全，但不适合较大的病变；胃SMT以ESE为主，起源较深的胃底、胃体病变必要时应选择EFR；十二指肠SMT以ESE为主。当内镜治疗风险高或切除困难时，应选择腹腔镜或外科手术治疗。

Objective To investigate the necessity and selection of endoscopic treatment in patients with upper gastrointestinal submucosal tumors （SMTs）. Methods Clinical data of 306 patients with upper gastrointestinal SMTs at the Digestive Endoscopy Center of Shanghai Changhai Hospital from January 2012 to October 2013 were reviewed, and distribution characteristics, pathology types, endoscopic operation option of SMTs were analyzed. Results Of all 306 cases, 55 lesions （ 18. 0%） were located in esophagus, 244 （79. 7%） in stomach, 7 （2. 3%） in duodenum. Pathological results showed that there were 142 cases （ 46.4% ） of leiomyoma, 114 （ 37. 3% ） gastrointestinal stromal tumors （ GIST ）, 15 （ 4. 9% ） ectopic pancreas, 14 （4. 6% ） lipomas,7 （2. 3%） neuroendocrine tumors （ NETs）, and 14 （4. 6%） other types. Of esophageal SMTs, leiomyoma accounted for 85.4%, GIST 5.4%. Of cardiac SMTs, leiomyoma was 78.8%, GIST was 12. 1%. Of gastric fundus SMTs, leiomyoma was 28.7%, GIST was 69. 0%. Of gastric body SMTs, leiomyoma was 38.6%, GIST was 45.5%. Of gastric antrum SMTs, leiomyoma was 25.7%, GIST was 14. 3%. Of duodenal SMTs, leiomyoma was 14. 3%, GIST was 28. 6%. Of all 306 cases, 242 cases （79. 1%） received ESE, 28 cases（9. 2%） received STER, 25 cases（8. 2%） received EFR. Of esophageal operations, ESE was 54. 5%, STER was 40%. Of gastric operations, ESE was 84.4%, STER was 2. 5%, EFR was 10. 2%. All duodena/patients received ESE. STER was mainly used in esophagus （78. 6% ）, and EFR was mainly used at gastric fundus （ 72. 0%） and body （ 24. 0%）. Conclusion Regular endoscopic follow-up could be a good option for SMTs located in esophagus, gastric cardiac and antrum, which are mostly benign lesions, especially when no obvious symptoms develop. Endoscopic therapy should be recommended for SMTs located in gastric fundus and body, which are mostly GISTs. STER may be more safe and effective for esophageal SMTs, but not suitable for giant lesions. ESE is the major operation for gastric SMTs, while EFR is more suitable for deep-origin lesions, especially in fandus and body. ESE is the major mode for duodenal SMTs. However, laparoscopic or surgical treatment should be considered when endoscopic treatment is difficult or risky.