内镜切除治疗直肠小神经内分泌肿瘤垂直切缘不充分的危险因素研究

Risk factors for inadequate vertical margin in endoscopic resection of small rectal neuroendocrine tumors

摘要:

目的 探讨影响内镜切除治疗直肠小神经内分泌肿瘤（neuroendocrine tumor，NET）临床疗效的危险因素。方法 回顾分析2013至2022年进行内镜下切除治疗的≤10 mm的直肠NET患者资料，按治疗术式分为内镜黏膜下剥离术（endoscopic submucosal dissection，ESD）组和内镜黏膜套扎切除术（endoscopic mucosal resection with ligation，EMRL）组，比较基线资料后，两组进行倾向性评分匹配，再比较R1切除率、垂直切缘距离充分率。结果 共纳入186例患者，其中ESD组139例，EMRL组47例。R1切除率在ESD组和EMRL组分别为12.2%（17/139）比2.1%（1/47）（χ2=3.027，P=0.082），垂直切缘距离充分率比较两组差异有统计学意义［69.1%（96/139）比85.1%（40/47），χ2=4.598，P=0.032］。两组经倾向性评分匹配后，各为46例。匹配后的ESD组和EMRL组在R1切除率［6.5%（3/46）比2.2%（1/46），χ2=0.261，P=0.609］和垂直切缘距离充分率［78.3%（36/46）比84.8%（39/46），χ2=0.649，P=0.420］方面差异均无统计学意义。单因素及多因素Logistic回归提示操作者经验及术前活检是造成切缘不充分的独立危险因素。结论 治疗方式可能不是影响术后垂直切缘距离的关键因素，但术前活检及操作者经验对切缘有显著影响，应避免术前进行活检，对经验不丰富的医师推荐使用更容易掌握的EMRL进行小NET切除。

Abstract:

Objective To identify risk factors influencing clinical efficacy of endoscopic resection of small rectal neuroendocrine tumor (NETs). Methods A retrospective analysis was conducted on patients with rectal NETs ≤10 mm who underwent endoscopic resection from 2013 to 2022. Patients were divided into the endoscopic submucosal dissection (ESD) group and the endoscopic mucosal resection with ligation (EMRL) group according to the treatment methods. After comparing the baseline data, propensity score matching was performed to compare the rates of R1 resection and adequacy of vertical margin distance. Results A total of 186 patients were included in this study, with 139 receiving ESD and 47 receiving EMRL. The R1 resection rates were 12.2% (17/139) and 2.1% (1/47) in the ESD and EMRL group, respectively (χ2=3.027, P=0.082). A significant difference in vertical margin adequacy was observed between the two groups [69.1% (96/139) VS 85.1% (40/47), χ2=4.598, P=0.032]. After propensity score matching, 46 pairs of cases were included, and there were no significant differences in the R1 resection rate [6.5% (3/46) VS 2.2% (1/46), χ2=0.261,P=0.609] and vertical margin adequacy [78.3% (36/46) VS 84.8% (39/46), χ2=0.649,P=0.420] between the two groups. Univariate and multivariate Logistic regression analyses revealed that operator experience and preoperative biopsy were independent risk factors for inadequate margin. Conclusion Treatment method may not be the key factor affecting the distance of the vertical margin after endoscopic resection, but preoperative biopsy and operator experience have a significant impact on margins. Biopsy before endoscopic resection should be avoided, and less experienced doctors are recommended to use EMRL method for small NETs due to its ease of execution.