Gastric peroral endoscopic myotomy for the resection of a predominantly extraluminal submucosal tumor in the duodenal bulb.
Gastric peroral endoscopic myotomy for the resection of a predominantly extraluminal submucosal tumor in the duodenal bulb.
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作者：
一名53岁男性在常规体检中发现十二指肠粘膜下肿瘤（见图1a， b）。由于肿瘤位于十二指肠球后壁，靠近幽门，主要是腔外生长，因此很难进行内镜下全层切除和缝合伤口。因此，我们建议进行胃经口内窥镜肌切开术（G-POEM），使用隧道技术切除肿瘤，同时保持十二指肠黏膜的完整性（▶视频1）。在进行粘膜下注射后，在幽门上方3厘米的后壁处做一个2厘米的粘膜切口（见图1c）。建立粘膜下隧道，延伸至幽门环（见图1 d）。在确定幽门环后，对环形肌进行部分幽门肌切开术（见图1e），以扩大视野并探查肿瘤。隧道延伸至十二指肠球部，我们观察到肿瘤起源于固有肌层的深层，并伴有腔外生长（见图1f）。用IT刀结合钩刀逐渐分离肿瘤，然后用圈套整体切除肿瘤。用热活检钳止血后（见图1g），用夹子关闭胃粘膜入口点（见图1h）。肿瘤大小为1.8× 1.5 cm（见图1），术后病理显示为胃肠道间质瘤。患者顺利恢复，术后第3天出院。术后内镜检查和计算机断层扫描显示术后3个月无复发。G-POEM是胃轻瘫的传统治疗方法[1,2]。我们推荐一种新的应用G-POEM切除十二指肠球部粘膜下肿瘤的方法，该方法允许使用隧道技术切除肿瘤，从而保持十二指肠粘膜的完整性并减少并发症的可能性。
A 53-year-old man was admitted with a duodenal submucosal tumor (▶ Fig. 1 a, b) that had been detected on a regular physical examination. Because the tumor was located on the posterior wall of the duodenal bulb near the pylorus and had predominantly extraluminal growth, it would have been difficult to perform endoscopic full-thickness resection and close the wound. Therefore, we proposed performing a gastric peroral endoscopic myotomy (G-POEM), which allowed the tumor to be removed using the tunnel technique, while maintaining the integrity of the duodenal mucosa (▶ Video 1). After the submucosal injection had been performed, a 2-cm mucosal incision was made on the posterior wall 3 cm above of pylorus (▶ Fig. 1 c). The submucosal tunnel was created, extending to the pyloric ring (▶ Fig. 1 d). After the pyloric ring had been identified, partial pyloromyotomy was performed on the circular muscle (▶ Fig. 1 e) to expand the visual field and explore the tumor. The tunnel was extended to the duodenal bulb and we observed that the tumor originated from the deep layer of the muscularis propria with extraluminal growth (▶ Fig. 1 f). The tumor was gradually separated with an IT knife combined with a hook knife, then the tumor was removed en bloc with a snare. After hemostasis had been achieved with hot biopsy forceps (▶ Fig. 1g), the mucosal entry point in the stomach was closed with clips (▶ Fig. 1 h). The size of tumor was 1.8× 1.5 cm (▶ Fig. 1 i) and postoperative pathology showed a gastrointestinal stromal tumor. The patient recovered uneventfully and was discharged on postoperative day 3. Postoperative endoscopy and a computed tomography scan showed no recurrence 3 months after surgery. G-POEM was traditionally a treatment for gastroparesis [1, 2]. We recommend a novel application of G-POEM for the resection of a submucosal tumor in the duodenal bulb, which allowed the tumor to be resected using the tunnel technique, thereby maintaining the integrity of the duodenal mucosa and reducing the possibility of complications.
影响因子：
12.6
作者：
Abdelfatah, Mohamed M.;Noll, Alan;Cai, Qiang
通讯作者：
Cai, Qiang