剪状刀内镜黏膜下剥离术治疗无蒂隆起型结直肠上皮源性肿瘤的有效性及安全性

Efficacy and safety of scissor‑type knife for endoscopic submucosal dissection in patients with sessile elevated colorectal epithelium‑derived tumors

摘要:

目的 评价内镜黏膜下剥离术（endoscopic submucosal dissection，ESD）治疗无蒂隆起型结直肠上皮源性肿瘤术中使用剪状刀的有效性及安全性。方法 2015年1月至2023年6月间在北京积水潭医院接受ESD治疗的127例无蒂隆起型结直肠上皮源性肿瘤病例纳入回顾性队列研究，按所用电刀的形状分成2组，即剪状刀组（n=62）和针状刀组（n=65），主要观察2组病变整块切除率、完全切除率、手术时间以及并发症发生率差异。结果 2组在患者中位年龄、性别构成、既往腹部手术史病例占比、病变中位长径以及黏膜下注射抬举征不良病例、黏膜下纤维化病例、跨越皱襞病例、浸润深度≥1 000 µm病例、腺癌病例占比方面差异均无统计学意义（P>0.05）；在病变分布（χ2=19.288，P<0.001）及跨越曲折部位病例占比（χ2=5.148，P=0.023）方面差异均有统计学意义，且剪状刀组结肠病例占比［82.3%（51/62）比44.6%（29/65）］、跨越曲折部位病例占比［24.2%（15/62）比9.2%（6/65）］更高。在手术效果方面，剪状刀组病变整块切除率、完全切除率和手术时间分别为95.2%（59/62）、91.9%（57/62）和38.5（24.0，73.0）min，针状刀组对应分别为89.2%（58/65）（χ2=1.539，P=0.325）、87.7%（57/65）（χ2=0.622，P=0.430）和28.0（25.0，82.0）min（Z=-0.912，P=0.362）。在手术并发症方面，剪状刀组术中难治性出血发生率明显低于针状刀组［12.9%（8/62）比29.2%（19/65），χ2=5.053，P=0.025］，术中穿孔、迟发性出血、迟发性穿孔、电凝综合征和术后发热发生率2组间差异均无统计学意义（P>0.05）。结论 对于无蒂隆起型结直肠上皮来源性肿瘤的ESD治疗，即便受到结肠病例、病变跨越曲折部位病例占比更多的不利因素影响，使用剪状刀依然可以达到与使用针状刀相似的治疗效果，且术中难治性出血发生更少、安全性更高。

Abstract:

To evaluate the efficacy and safety of scissor-type knife for endoscopic submucosal dissection (ESD) in patients with sessile elevated colorectal epithelium-derived tumors. Methods A retrospective cohort study was conducted on 127 patients who underwent ESD for sessile elevated colorectal epithelium-derived tumor at Beijing Jishuitan Hospital from January 2015 to June 2023. Patients were divided into two groups based on the electric knife type: scissor-type knife ESD group (n=62) and needle-type knife ESD group (n=65). Parameters evaluated included en bloc resection rate, complete resection rate, operation time, and associated complications. Results There were no statistical differences between the two groups in terms of the median age of patients, gender, cases with a history of previous abdominal surgery, median long diameter of lesions, poor submucosal injection lifting sign, submucosal fibrosis, lesions crossing folds, depth of invasion≥1 000 µm or adenocarcinoma cases (P>0.05). However, there were statistical differences in lesion distribution (χ2=19.288, P<0.001) and proportion of cases crossing tortuous areas (χ2=5.148, P=0.023). The proportion of colon cases [82.3% (51/62) VS 44.6% (29/65)] and proportion of cases crossing tortuous areas [24.2% (15/62) VS 9.2% (6/65)] were higher in the scissor knife group. In terms of surgical outcomes, the en bloc resection rate, complete resection rate and operation time in the scissor knife group were 95.2% (59/62), 91.9% (57/62), and 38.5 (24.0, 73.0) min respectively. The corresponding outcomes in the needle knife group were 89.2% (58/65) (χ2=1.539, P=0.325), 87.7% (57/65) (χ2=0.622, P=0.430), and 28.0 (25.0, 82.0) min (Z=-0.912, P=0.362) respectively. Regarding surgical complications, the incidence of intraoperative refractory bleeding was significantly lower in the scissor knife group [12.9% (8/62) VS 29.2% (19/65), χ2=5.053, P=0.025], while there were no statistical differences in the incidence of intraoperative perforation, delayed bleeding, delayed perforation, electrocoagulation syndrome, or postoperative fever between the two groups (P>0.05). Conclusion In performing ESD for sessile elevated colorectal epithelium tumors, the use of a scissor-type knife demonstrates comparable therapeutic efficacy to the needle knife, even in cases with challenging factors like a higher proportion of colon cases and those crossing tortuous areas. Additionally, the scissor knife approach shows a lower incidence of intraoperative refractory bleeding, indicating enhanced safety during the procedure.