内镜下切除结直肠侧向发育型肿瘤的 临床结果研究

Endoscopic resection for colorectal laterally spreading tumors

摘要:

目的 比较分析内镜下黏膜切除术(EMR)、预切开EMR(EMR-P)、内镜黏膜下剥离术(ESD)和圈套器辅助ESD(ESD-S)4种内镜下切除方法治疗结直肠侧向发育型肿瘤(LSTs)的安全性和有效性。方法 以2016年1月至2018年3月在解放军总医院第一医学中心接受内镜下治疗的146例结直肠LSTs病例为研究对象，回顾性纳入患者基本信息、内镜下切除结果、术后组织病理学结果和随访结果进行统计分析。结果 146例结直肠LSTs中，23例行EMR治疗，29例行EMR-P治疗，50例行ESD治疗，44例行ESD-S治疗。中位病变直径2.5 cm（1.2~10.0 cm）。EMR、EMR-P、ESD和ESD-S整块切除率分别为73.9%（17/23）,72.4%(21/29),96.0%(48/50),65.9%(29/44)，差异有统计学意义(P=0.000)；R0切除率分别为65.2%（15/23）,69.0%(20/29),94.0%(47/50),63.6%(28/44),差异有统计学意义（P=0.002）。ESD组整块切除率和R0切除率高于其他3组(P均<0.05)。4组术中穿孔率分别为0（0）,0（0）, 6.0%（3/50）,9.1%(4/44),差异无统计学意义(P=0.269)；迟发出血率分别为4.3%（1/23）,0（0）, 2.0%（1/50）,2.3%（1/44）,差异无统计学意义（P=0.768)。117例（80.1%）患者术后进行了肠镜随访，中位随访时间10.0个月（3.0~26.0个月），其中局部复发7例（6.0%）。结论 ESD是结直肠LSTs最理想的治疗方法；EMR可作为直径＜20 mm结直肠LSTs的治疗方法；EMR-P和ESD-S作为改良的内镜下切除方法，在治疗LSTs上具有自身特殊的优势。

Abstract:

Objective To compare the efficacy and safety of endoscopic mucosal resection (EMR), EMR with pre-cutting (EMR-P), endoscopic submucosal dissection (ESD) and ESD with snare (ESD-S) for the treatment of colorectal laterally spreading tumors (LSTs). Methods Between January 2016 and March 2018, a total of 146 patients with 146 colorectal LSTs were undergone endoscopic resection at the first medical center of PLA General Hospital. Data of demographics, treatment information, pathology and follow-up results were retrospectively analyzed. Results Among the 146 patients, EMR, EMR-P, ESD, and ESD-S were performed in 23, 29, 50, and 44 tumors, respectively. Median tumor diameter was 2.5 cm (ranged 1.2-10.0 cm). The en bloc resection rate of EMR, EMR-P, ESD and ESD-S was 73.9% (17/23), 72.4% (21/29), 96.0% (48/50), and 65.9% (29/44), respectively, with statistic difference (P=0.000). And the R0 resection rate was 65.2% (15/23), 69.0% (20/29), 94.0% (47/50), and 63.6% (28/44), respectively, with statistic difference (P=0.002). The en bloc resection rate and R0 resection rate of ESD group were significantly higher than those of the other three groups (both P<0.05). The difference was no statistically significant in terms of perforation rate [0 (0), 0 (0), 6.0% (3/50), and 9.1% (4/44), respectively, P=0.269] and delayed hemorrhage rate [4.3% (1/23), 0 (0), 2.0% (1/50), and 2.3% (1/44), respectively, P=0.768] among the four groups. Follow-up endoscopy was performed in 117 cases with a median period of 10.0 months (ranged 3.0-26.0 months), and local recurrence was identified in 7 (6.0%) cases. Conclusion ESD could be the optimal method for the resection of colorectal LSTs, while LSTs smaller than 20 mm can be resect by EMR. EMR-P and ESD-D as modified method have their respective advantages for the treatment of LSTs.