食管胃结合部早期癌内镜黏膜下剥离术与外科手术的长期随访结果比较

Comparison of long-term outcomes between endoscopic submucosal dissection and surgery on treatment of early esophagogastric junction adenocarcinoma

摘要:

目的 评估内镜黏膜下剥离术（endoscopic submucosal dissection，ESD）与外科切除治疗食管胃结合部（esophagogastric junction，EGJ）早期腺癌的远期疗效。 方法 2004年1月至2018年6月，山西省人民医院消化内镜中心和胃肠胰外科连续收治的EGJ早期腺癌病例纳入回顾性分析，术前评估符合ESD治疗绝对标准或扩大标准，且术后病理评估符合治愈性切除绝对标准或扩大标准的166例病例资料纳入数据分析，按治疗方法分成ESD组（n=77）和外科切除组（n=89），对比2组的近期结果（治愈性切除率、并发症）和远期结果（累积生存率）。 结果 ESD组中符合ESD治疗绝对标准者65例（84.4%）、符合扩大标准者12例（15.6%），外科切除组中符合ESD治疗绝对标准者60例（67.4%）、符合扩大标准者29例（32.6%），2组在患者ESD治疗标准的构成上差异有统计学意义（P=0.011）；其他基线指标2组间比较差异均无统计学意义（P均＞0.05）。ESD组整块切除率为98.7%（76/77）、完全切除率为94.8%（73/77）、治愈性切除率为93.5%（72/77），外科切除组治愈性切除率为100.0%（89/89），2组治愈性切除率比较差异无统计学意义（P=0.05）。ESD组有3例（3.9%）术中出血、1例（1.3%）术后早期出血和2例（2.6%）术中穿孔，外科切除组有1例（1.1%）术中出血、4例（4.5%）术后出血和2例（2.2%）术后吻合口微漏。2组均无术后1个月内死亡病例，亦无局部复发病例。ESD组随访时间72.5～105.7个月，中位时间89.3个月；外科治疗组随访时间69.6～101.0个月，中位时间82.3个月。2组随访期间均无肿瘤相关死亡病例和复发。ESD组与外科切除组的5年生存率分别为94.8%（73/77）和96.6%（86/89），2组累积生存率比较差异无统计学意义（P=0.648）。亚组分析显示，符合ESD绝对标准者，ESD治疗与外科切除治疗的累积生存率比较，差异无统计学意义（P=0.449）；符合ESD扩大标准者，ESD治疗与外科切除治疗的累积生存率比较，差异亦无统计学意义（P=0.505）。 结论 对于符合ESD治疗绝对标准和扩大标准的EGJ早期腺癌，ESD治疗的远期肿瘤学结果与外科切除类似，可作为外科切除治疗的有效替代方式。

Abstract:

Objective To evaluate the long-term efficacy of endoscopic submucosal dissection (ESD) and surgical resection on the treatment of early esophagogastric junction (EGJ) adenocarcinoma. Methods A retrospective analysis was performed on the data of 166 consecutive cases with early EGJ adenocarcinoma in Digestive Endoscopy Center and Department of General Surgery of Shanxi Provincial People′s Hospital from January 2004 to June 2018. Their preoperative assessment conformed to the absolute and expanded criteria of ESD, and postoperative pathological assessment accorded with the absolute and expanded criteria of curative resection. Patients were divided into the ESD group (n=77) and the surgical resection group (n=89), and the recent results (curative resection rate and complications) and long-term results (cumulative survival rate) were compared between the two groups. Results In the ESD group, 65 (84.4%) patients met the absolute criteria of ESD treatment and 12 (15.6%) patients met the expanded criteria. In the surgical resection group, 60 (67.4%) patients met the absolute criteria of ESD and 29 (32.6%) patients met the expanded criteria. The difference in the composition of ESD criteria was statistically significant between the two groups (P=0.011). Other baseline indicators showed no significant difference between the two groups (P > 0.05). In the ESD group, the overall resection rate was 98.7% (76/77), the complete resection rate was 94.8% (73/77), and the curative resection rate was 93.5% (72/77). In the surgical resection group, the curative resection rate was 100.0% (89/89). The difference in the curative resection rate between the two groups was not statistically significant (P=0.05). In the ESD group, there were 3 (3.9%) cases of intraoperative bleeding, 1 (1.3%) case of early postoperative bleeding, and 2 (2.6%) cases of intraoperative perforation. In the surgical resection group, there was 1 (1.1%) case of intraoperative bleeding, 4 (4.5%) cases of postoperative bleeding, and 2 (2.2%) cases of postoperative anastomotic leakage. There was no death or local recurrence occurred in the both groups within 1 month after treatment. The median follow-up time was 89.3 months (ranged 72.5-105.7 months) in the ESD group and 82.3 months (ranged 69.6-101.0 months) in the surgical treatment group, respectively. There was no tumor-related death or recurrence occurred in the two groups during follow-up. The 5-year survival rate in the ESD group and the surgical resection group was 94.8% (73/77) and 96.6% (86/89), respectively. The difference in the cumulative survival rate was not significant between the two groups (P=0.648). Subgroup analysis showed that there was no significant difference in the cumulative survival rate between patients receiving ESD and those receiving surgical resection who met the absolute criteria of ESD (P=0.449) and met ESD expanded criteria (P=0.505). Conclusion For EGJ adenocarcinoma conforming to the ESD treatment absolute and expanded criteria, ESD may be an alternative treatment option to surgery with the comparable long-term outcomes.