内镜超声引导下细针穿刺如何获取高质量的样本

程芳芳 张红燕 夏婷 孟灵

内镜超声引导下细针穿刺如何获取高质量的样本

程芳芳 张红燕 夏婷 孟灵

内镜超声引导下细针穿刺抽吸术(endoscopic ultrasonography guided fine needle aspiration, EUS-FNA)是临床上获取胃肠道及其邻近器官病变和淋巴结组织样本用于病理学诊断的首选方法[1]。在其他常规影像学检查发现病变后，临床上通常采用EUS-FNA获取目标细胞或组织行最终的病理诊断。目前文献所报道的EUS-FNA的诊断准确率为65%～96%[2]。多种因素如病变的位置、大小，现场是否有病理医师及操作医师的个人经验均可影响EUS-FNA的准确性[3]。然而，目前对于能够获得最大准确性和最少穿刺针数的最佳EUS-FNA穿刺技术仍然存在争议。本文就EUS-FNA如何获取高质量样本的相关技术进行探讨。

一、穿刺针

1．常规穿刺针：目前临床上使用的穿刺针有19G、22G、25G 3种不同型号。在实际临床工作中，需要根据不同情况，如是否能够获得最终诊断、能否易于到达病变部位、并发症是否最低等因素选择合适大小的穿刺针。目前认为不同的穿刺针对EUS-FNA的样本获取的质量影响不大[4-10]，但最新一项涉及144例患者的前瞻性随机对照研究显示，对实性肿瘤采用25G针穿刺样本准确性高达95.8%，优于22G穿刺针[11]，因此穿刺针型号的选择仍需进一步的研究。

2．组织针(ProCore)：ProCore针是新近出现的以达到组织活检为目的的在EUS引导下穿刺的穿刺针。ProCore主要特点是在穿刺针的前端存在一个反向斜面。目前有多篇文献评价了EUS引导下ProCore针穿刺的可行性及安全性[12-13]。最近一项Meta分析对ProCore针和常规穿刺针的差异进行了探讨[14]。该项Meta分析纳入9项研究共578例患者，结果发现样本的充足性、诊断准确性及核心样本率差异并无统计学意义，但ProCore针获得诊断所需要的针道数要低于常规穿刺针。

二、EUS-FNA的穿刺技术

1．负压吸引：负压吸引在EUS-FNA穿刺过程中的作用仍然不明确。有文献认为持续的低负压吸引能够获得较好的细胞量和样本质量[15]。2006年的一项Meta分析认为负压吸引并不能提高EUS-FNA的穿刺样本质量[16]。2009年Puri等[17]做的一项前瞻性随机对照试验评价10 ml负压和无负压吸引对最终穿刺样本量的影响。该研究共纳入了52例患者，研究结果显示，与无负压组相比，10 ml负压能够得到较多的样本量，且不会增加样本的血污染程度。另外，负压组的穿刺样本的诊断敏感性和阴性预测值均高于无负压组。最新的一项前瞻性研究采用22G或25G针对85例患者分别采用10 ml负压和无负压进行穿刺，结果显示，10 ml负压穿刺的准确性和敏感性均高于无负压组，但10 ml负压组样本的血污染程度要高于无负压组[18]。Kudo等[19]使用25G穿刺针对34例患者分别采用10 ml和50 ml负压穿刺，发现与低负压相比，高负压能获得更多的样本，但该研究未评价两者获取样本的血污染情况。

2．慢提拉法(slow-pull)：是指穿刺针在病变组织中反复提插穿刺时缓慢地抽出穿刺针针芯，在穿刺针中行成微负压的穿刺方法，以达到增加样本量和减少样本血污染的目的。Nakai等[20]对93例胰腺实性占位病变分别采用slow-pull法和负压吸引(10 ml或20 ml)穿刺，发现用25G针穿刺时与负压吸引相比，slow-pull法虽然得到的穿刺样本细胞量较少，但其最终诊断准确性高(90.0%比67.9%)，且样本血污染程度较轻。但用22G针中穿刺的两组差异无统计学意义。Kin等[21]研究发现，22G穿刺针采用slow-pull法穿刺能够获得充足的质量较高且血污染较少的样本，但slow-pull法与20 ml负压最终诊断准确性相同。

3．有无针芯：穿刺针中的针芯是为了防止穿刺针在进入病变组织之前混入胃肠道的组织，影响最终诊断的准确性。然而针芯的存在会增加劳动成本、延长手术时间和增加镇静药物的剂量。Sahai等[22]在2010年进行了一项前瞻性对照试验，对135个病变分别采用有针芯和无针芯针进行了309次穿刺，有针芯针获得的样本含量较少，且血污染情况较重，因此认为有针芯的针穿刺不能提高诊断的准确性。一项涉及3078例患者的大样本研究及最新一项多中心随机对照试验则认为有无针芯对EUS-FNA穿刺的样本含量、血污染情况无影响[23-24]。

4．扇形穿刺：是指在EUS-FNA穿刺过程中，穿刺针从病变左边呈扇形向右边穿刺，直到到达病变右边边缘。与传统的中心区域穿刺相比，扇形穿刺针道的准确性高且样本血污染较轻。Bang等[25]设计了一项随机对照试验比较扇形穿刺法和标准穿刺法获取样本的差异。该试验纳入54例患者，其中26例采用标准穿刺法，28例采用扇形穿刺法，两者诊断准确性和并发症差异无统计学意义。但是与标准穿刺法相比，扇形穿刺法获得的样本达到诊断目的所需的穿刺针数较少。

5．湿抽法(wet-suction)：是指在穿刺靶向病变之前移除针芯，在穿刺针内注以5 ml无菌生理盐水，然后注入3 ml无菌生理盐水用的10 ml注射器中，接到穿刺针的近端，负压吸引病变。Attam等[26]设计了一项前瞻性单盲随机对照试验评价湿抽法穿刺与常规穿刺法获取样本质量的差异。该研究发现与常规穿刺法相比，湿抽法能获得较多的样本量，而血污染情况无差异。但该研究未对两者不同的穿刺方法最终的诊断准确性进行比较。

三、现场病理评估的影响

获得足够的样本是建立准确诊断的前提。快速现场病理亦评估(rapid on-site evaluation, ROSE)的作用在于现场给穿刺样本实时反馈，以达到提高最终诊断的准确性、减少穿刺针道数的目的。然而，目前ROSE的临床作用仍然存在争议。两篇Meta分析结果认为，ROSE的应用能够显著提高穿刺样本量[27-28]。但Matynia等[27]的研究认为ROSE需要更多的针道数，而Schmidt等[28]的研究则发现ROSE并不能提高EUS-FNA的检出率。最新的一项前瞻性随机对照试验显示，ROSE除了可以降低穿刺针道数以外，并不能提高穿刺样本的充足性及最终诊断的准确性[29]，并且有无ROSE穿刺所需的操作时间、并发症、需要重复穿刺率及最终费用也无差异。

另外，由于人员及资金条件受限，多数医疗单位也无法实现ROSE。为此，Iwashita等[30]最近对宏观现场评价(macroscopic on-site evaluation, MOSE)的作用进行了探讨。研究对111例病变采用19G穿刺针进行EUS-FNA穿刺。MOSE显示91.1%的例数存在宏观可见核心样本(macroscopic visible core, MVC)，中位长度为8 mm。ROC曲线显示诊断的临界值为4 mm，曲线下面积达0.893。研究者认为以4 mm作为临界值可作为样本充足性判断从而提高EUS-FNA的诊断收益。因此在ROSE没有条件实现的情况下，MOSE亦能够获得样本进行质量评价，以达到提高诊断准确性的目的。

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(本文编辑：屠振兴)

10.3760/cma.j.issn.1674-1935.2017.04.021

200433 上海，第二军医大学长海医院消化内科

张红燕，Email:13601609798@163.com

2016-06-23)