内镜下切除术在食管及贲门固有肌层肿瘤治疗中的应用

发布时间：2018-09-17 09:16

【摘要】：目的:评价内镜下切除术,包括内镜黏膜下挖除术(endoscopic submucosal excavation,ESE)和经黏膜下隧道内镜肿瘤切除术(submucosal tunneling endoscopic resection,STER),在食管和贲门固有肌层肿瘤(muscularis propria tumors,MPTs)治疗中的临床应用价值,并对比分析两者的安全性与有效性,分析患者术后出现并发症的危险因素。方法:收集2013年01月-2016年10月于成都军区总医院消化内镜中心行ESE及STER术患者资料,筛选出符合入选标准的病例53例,回顾性分析其临床及病理资料;其中接受ESE手术患者29例,STER手术患者24例。主要观察指标:手术时间、术中并发症、整块切除率、术后不良事件发生情况及复发情况。根据术后病理和病变部位行亚组分析。结果:1.本研究共纳入患者53例,男16例,女37例;平均年龄50.38±8.15岁,MPTs平均直径为20.13±13.56mm;按发生部位来分:食管43.4%(23/53),贲门56.6%(30/53);按术后病理来分:平滑肌瘤28.3%(15/53)、间质瘤67.9%(36/53)、其他(神经内分泌瘤、脂肪瘤等)3.8%(2/53)。2.超声内镜(endoscopic ultrasonography,EUS)对病变的判断:来源层次的总体符合率为100%;病变性质的符合率为62.3%(33/53),其中间质瘤的符合率为87.5%(21/24),平滑肌瘤的符合率为44.4%(12/27);EUS下表现为形状不规则的MPTs,我们将其诊断为间质瘤的准确率明显高于平滑肌瘤(χ~2=6.24,P=0.012)3.本研究53例患者的整块切除率为96.2%(51/53),两组在整块切除率方面无差异(STER 95.8%VS ESE 96.6%,P0.05);STER组手术时间明显长于ESE组(140.46±73.48min VS 60.03±51.29min,P0.05);术中总的并发症发生率11.3%(6/53),均发生于贲门部,其中术中明显出血发生率为9.4%(5/53),术中穿孔发生率为1.9%(1/53),STER组术中并发症低于ESE组(4.2%VS 17.2%,P0.05);术后总的并发症发生率22.6%(12/53)(有4例患者同时并发了两种术后并发症),其中感染发生率为11.3%(6/53),气体相关性并发症11.3%(6/53),少量胸腔积液5.7%(3/53),迟发性出血1.9%(1/53);术后总的并发症STER组明显高于ESE组(37.5%VS 10.3%,P0.05),特别是术后气体相关性并发症(25.0%VS 0,P0.05);两组在术后平均住院天数及禁食天数方面无明显差异。4.食管的MPTs,ESE与STER相比:手术时间短(43.42±17.89min VS156.27±69.23min,P0.001)、钛夹使用少(1.58±2.87 VS 7.45±1.29,P0.001)、术后并发症发生率低(0 VS 45.5%,P=0.014)且术中并发症无差异。贲门的MPTs,STER与ESE相比手术时间较长(127.08±77.01min VS71.76±63.50min,P0.001),但术中并发症较低(7.7%VS 29.4%,P=0.196),且术后并发症无差异。5.结合单因素分析和多因素Logistic回归模型分析,本研究表明MPTs直径大、形状不规则、采用STER术、手术时间长是术后并发症发生的危险因素。6.随访及预后:平均随访时间4.62±6.53月(2-20月)、平均随访次数1.30±0.70次(1-4次),无一例复发。结论:1.ESE、STER是MPTs安全有效的微创治疗方法;STER手术时间长于ESE,但术中视野清晰、术中出血并发症发生低;STER手术组气体相关性并发症高于ESE组,但均比较轻微,经保守治疗后消失。2.食管的MPTs,ESE与STER相比手术时间短、钛夹使用少、术后并发症发生率低且术中并发症无差异,故推荐行ESE术。贲门的MPTs,STER与ESE相比手术时间长,但术中并发症较低且术后并发症无差异,故贲门部的MPTs推荐行STER术。3.EUS对MPTs有较好的诊断作用,特别是超声下表现为形状不规则的MPTs诊断为间质瘤的准确性较高。4.研究表明MPTs直径大、形状不规则、采用STER术、手术时间长是术后并发症发生的危险因素。
[Abstract]:Objective: To evaluate the clinical value of endoscopic submucosal excavation (ESE) and submucosal tunneling endoscopic resection (STER) in the treatment of esophageal and cardiac muscular propria tumors (MPTs). Methods: The clinical and pathological data of 53 patients who underwent ESE and STER in the center of digestive endoscopy of Chengdu Military Region General Hospital from January 2013 to October 2016 were analyzed retrospectively. Main outcome measures: operative time, intraoperative complications, total resection rate, occurrence and recurrence of adverse events after operation. Subgroup analysis was performed according to postoperative pathology and lesion site. Results: 1. 53 patients, 16 males and 37 females, with an average age of 50.38 (+ 8.15 years), were included in this study. MPTs were 20. 13 [13.56 mm], 43.4% (23/53) of the esophagus and 56.6% (30/53) of the cardia, 28.3% (15/53) of leiomyomas, 67.9% (36/53) of stromal tumors, and 3.8% (2/53) of other tumors (neuroendocrine tumors, lipomas, etc.). 2. Endoscopic ultrasonography (EUS) showed that the overall coincidence rate at the source level was 100%; The coincidence rate of degeneration was 62.3% (33/53), including 87.5% (21/24) of stromal tumors and 44.4% (12/27) of leiomyomas, and the accuracy of diagnosing stromal tumors (_~2 = 6.24, P = 0.012) was significantly higher in patients with EUS with irregular shape MPTS than that of leiomyomas (_~2 = 6.24, P = 0.012). There was no significant difference in the total resection rate between the two groups (STER 95.8% VS ESE 96.6%, P 0.05); the operation time in STER group was significantly longer than that in ESE group (140.46 65507 The intraoperative complications in ER group were lower than those in ESE group (4.2% VS 17.2%, P 0.05); the total postoperative complications rate was 22.6% (12/53) (4 patients had two postoperative complications simultaneously), including infection rate 11.3% (6/53), gas-related complications 11.3% (6/53), small amount of pleural effusion 5.7% (3/53), delayed hemorrhage 1.9% (1/53); Esophageal MPTS and ESE were significantly shorter than STER (43.42 17.89 6550 Compared with ESE, MPTs and STER had longer operation time (127.08 VS 71.76 Regression model analysis showed that MPTs with large diameter and irregular shape were risk factors for postoperative complications. 6. Follow-up and prognosis: the average follow-up time was 4.62 (+ 6.53 months) (2-20 months), the average follow-up time was 1.30 (+ 0.70 times) (1-4 times), no recurrence. Conclusion: 1. ESE, STER is a safe and effective minimally invasive treatment for MPTs. Methods: The operation time of STER was longer than that of ESE, but the visual field was clear and the complications of bleeding were lower. The gas-related complications in STER group were higher than that of ESE group, but all were slight, and disappeared after conservative treatment. It is recommended that ESE be performed. MPTs of cardia and STER have longer operation time than ESE, but the intraoperative complications are lower and there is no difference in postoperative complications. So MPTs of cardia are recommended to use STER. 3. EUS has better diagnostic effect on MPTs, especially for MPTs with irregular shape under ultrasound. 4. Research shows that MPTs are straightforward. Large diameter and irregular shape, STER operation and long operation time are the risk factors of postoperative complications.
【学位授予单位】：西南医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735

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