内镜黏膜下剥离术培训体系建设分析

Analysis of endoscopic submucosal dissection training system construction

摘要:

目的 研究如何挑选合适的内镜医师接受内镜黏膜下剥离术（ESD）培训。方法 纳入2017年1月至2018年6月在南京鼓楼医院消化内镜中心进行ESD培训的3期共41名学员，收集相关资料，包括姓名，年龄，性别，培训前独立操作胃镜例数，独立操作肠镜例数，肠镜操作手法，是否使用窄带光成像（NBI）、放大内镜（ME），是否单独开展内镜黏膜切除术（EMR）、ESD、内镜超声检查（EUS）、经内镜逆行胰胆管造影术（ERCP）等指标。安排每位学员完成4次离体猪食管模型ESD，记录剥离标本面积、操作时间，计算平均操作速度评价学员学习指标，并记录术中穿孔发生情况。对影响ESD学员操作速度的相关因素进行线性回归分析。结果 41名学员中男26名、女15名，年龄（36.07±4.44）岁，离体动物实验切除标本大小（4.67±1.61）cm2，操作时间（24.54±5.97）min，操作速度（0.19±0.05）cm2/min。单因素线性回归分析提示，学员培训前独立操作胃镜例数（n>5 000例，P=0.001 8），独立单人操作肠镜例数（n>3 000例，P=0.000 1），上消化道早癌发现例数（n>30例，P=0.000 3），下消化道早癌发现例数（n>10例，P=0.019 7）及培训前独立开展ME（P=0.047 8）、EMR（P=0.019 6）、ESD（P=0.000 3）情况与学员离体猪食管ESD操作速度密切相关；但只开展NBI（P=0.532 9）、ERCP（P=0.500 7）、EUS（P=0.766 8）与学员操作速度无明显相关性。ESD学员操作速度与穿孔率呈负相关（P<0.000 1）。多元线性回归分析提示培训前独立开展EMR（P=0.029）、ESD（P=0.034）与ESD学员操作速度密切相关。结论 ESD培训学员培训前独立胃镜操作例数>5 000例，独立单人肠镜操作例数>3 000例，上消化道早癌发现例数>30例，下消化道早癌发现例数>10例，以及培训前独立开展ME、EMR、ESD，对提高ESD培训效果有明显帮助。本研究为我们今后挑选合适的内镜学员进行ESD培训提供了理论依据。

Abstract:

Objective To investigate the prerequisites for endoscopists, who were chosen to receive endoscopic submucosal dissection (ESD) training. Methods A total of 41 trainees, who attended ESD training in the endoscopic center of Nanjing Drum Tower Hospital from January 2017 to June 2018 were enrolled in the study. The general information of the subjects were collected, including name, age, gender, the number of gastroscopy and colonoscopy independently performed before training, the independent usage of narrow band image (NBI), magnifying endoscopy (ME), endoscopic mucosal resection (EMR), ESD, endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) before training. And then every trainee independently finished four in vitro experiments of pig esophagus ESD. The specimen area and operating time were recorded, and the operating speed was calculated. Linear regression analysis was used to analyze the affecting factors of operating speed of ESD. Results Among the 41 trainees, 26 were male and 15 were female, with age of 36.07±4.44 years. The specimen area, operating time and operating speed of pig esophagus ESD was 4.67±1.61 cm2, 24.54±5.97 min, and 0.19±0.05 cm2/min, respectively. Univariate linear regression analysis showed that the number of gastroscopy (n>5 000, P=0.001 8) and colonoscopy (n>3 000, P=0.000 1), the detect number of early cancer in upper digestive tract (n>30, P=0.000 3) and lower digestive tract (n>10, P=0.019 7), and the usage of ME (P=0.047 8), EMR (P=0.019 6) and ESD (P=0.000 3) before training were statistically correlated with the operating speed of ESD. Carrying out NBI (P=0.532 9), ERCP (P=0.500 7) and EUS (P=0.766 8) before training were not statistically correlated with the operating speed of ESD. The operating speed of ESD was negatively correlated with the perforation rate of ESD (P<0.000 1). According to multivariable linear regression model, the usage of EMR (P=0.029) and ESD (P=0.034) were statistically correlated with the operating speed of ESD. Conclusion ESD trainees, who have the number of gastroscopy more than 5 000, the number of colonoscopy more than 3 000, the detect number of early cancer more than 30 in upper digestive tract and 10 in lower digestive tract, and the usage of ME, EMR and ESD before training, can get a better training effect. The study provides a theoretical basis for selecting appropriate ESD trainees.