内镜下精准肌层剥离术治疗黏膜下层纤维化早期胃癌疗效探讨

Efficacy of Endoscopic Precision Muscularis Dissection for Early Gastric Cancer with Submucosal Fibrosis

摘要:

目的 探讨内镜下精准肌层剥离术（endoscopic precise muscle dissection,EPMD)治疗伴黏膜下层纤维化的早期胃癌的有效性和安全性。方法 回顾2022年6月到2024年1月期间在江苏省中医院消化内镜中心住院治疗的63例伴黏膜下层纤维化的早期胃癌患者资料，随机数字表法分为EPMD组（29例）和常规内镜黏膜下剥离术（endoscopic submucosal dissection，ESD）组（34例），再以各组中≥60岁者，分为EPMD老年组（18例）、ESD老年组（21例），分析标本热损伤率、治愈性切除率等临床资料及疗效。结果 EPMD组标本热损伤率3.45%（1/29）明显低于ESD组26.47%（9/34，P=0.013），切除病变平均面积（15.71±8.61）cm2、治愈性切除率96.55%（28/29）和创面金属夹封闭率58.62%（17/29）均高于ESD组（11.65±6.05）cm2（t=2.19，P=0.032）、79.41%（27/34， P=0.042）、26.47%（9/34，P=0.010），标本破损率10.34%（3/29）稍低于ESD组14.71%（5/34，P=0.745）。在剥离速度、手术时间、术中牵引辅助、R0切除率、整块切除率、并发症等组间比较，差异无统计学意义（P＞0.05）。EPMD老年组（18例）治愈性切除率100%（18/18）及术中牵引辅助率33.33%（6/18）高于ESD老年组（21例）76.19%（16/21，P=0.035）、4.76%（1/21，P=0.027），余老年两组间比较，差异无统计学意义（P＞0.05）。结论 EPMD能降低伴黏膜下纤维化的早期胃癌切除标本的热损伤率、提高治愈性切除率，同时不增加并发症的发生率；对于老年患者EPMD亦能提高治愈性切除率，值得临床推广应用。

Abstract:

Objective: To investigate the efficacy and safety of endoscopic precise muscle dissection (EPMD) in treating early gastric cancer with submucosal fibrosis. Methods: Data from 63 patients with early gastric cancer and submucosal fibrosis, hospitalized at the Digestive Endoscopy Center of Jiangsu Provincial Hospital of Traditional Chinese Medicine between June 2022 and January 2024, were retrospectively analyzed. Patients were randomly divided into an EPMD group (29 cases) and a conventional endoscopic submucosal dissection (ESD) group (34 cases) using a random number table. Those aged ≥60 years in each group were further categorized into an EPMD elderly subgroup (18 cases) and an ESD elderly subgroup (21 cases). Clinical data and outcomes, including the rate of specimen thermal injury and curative resection rate, were analyzed. Results：The rate of specimen thermal injury in the EPMD group was 3.45% (1/29), significantly lower than the 26.47% (9/34) in the ESD group (P=0.013). The average lesion resection area (15.71±8.61 cm2), curative resection rate (96.55%, 28/29), and wound closure rate with metal clips (58.62%, 17/29) in the EPMD group were higher than those in the ESD group (11.65±6.05 cm2, t=2.19, P=0.032; 79.41%, 27/34, P=0.042; and 26.47%, 9/34, P=0.010, respectively). The specimen fragmentation rate was slightly lower in the EPMD group (10.34%, 3/29) compared to the ESD group (14.71%, 5/34, P=0.745). No statistically significant differences were observed between groups in dissection speed, operation time, intraoperative traction assistance, R0 resection rate, en bloc resection rate, or complications (P>0.05). In the elderly subgroups, the curative resection rate (100%, 18/18) and intraoperative traction assistance rate (33.33%, 6/18) in the EPMD elderly group were higher than those in the ESD elderly group (76.19%, 16/21, P=0.035; and 4.76%, 1/21, P=0.027, respectively). No other significant differences were found between the two elderly subgroups (P>0.05). Conclusion：EPMD can reduce the rate of specimen thermal injury and improve the curative resection rate in early gastric cancer with submucosal fibrosis, without increasing complications. For elderly patients, EPMD also enhances the curative resection rate, making it worthy of clinical application.