上消化道固有肌层肿瘤经内镜黏膜下隧道肿瘤切除术和黏膜下肿瘤挖除术的治疗对比

doi:10.19723/j.issn.1671-167X.2019.01.029

摘要/Abstract

摘要：

目的:评价内镜经黏膜下隧道肿瘤切除术(submucosal tunneling endoscopic resection,STER)和黏膜下肿瘤挖除术(endoscopic submucosal excavation,ESE)治疗上消化道固有肌层肿瘤的疗效和安全性。方法:选择2013 年4 月至2016 年12 月在北京大学第三医院诊断为上消化道固有肌层肿瘤并行STER治疗(n=28)和ESE治疗(n=14)的患者病例资料进行回顾分析,分析比较两组的临床病理和内镜结果、治疗和并发症发生情况。结果:42 例病变均顺利完成切除,成功率100%。两组间(STER组 vs. ESE组)从性别、年龄、病变大小[1.5(1.0~6.0) cm vs. 1.3(0.5~2.0) cm,P=0.056]差异均无统计学意义,STER组的病变切除时间长于ESE组[46.5(11.0~163.0) min vs. 19.5(6.0~56.0) min, P=0.007],创面钛夹缝合时间短于ESE组[3.5(1.0~11.0) min vs. 8.0(2.0~33.0) min, P=0.006],两组差异均有统计学意义,但总的手术时间的差异无统计学意义[52.0(14.0~167.0) min vs. 31.5(10.0~88.0) min,P=0.080]。术后一次性整块切除率(92.9% vs. 85.7%)、治疗后住院时间、术后并发症(10.7% vs. 0)两组间差异无统计学意义。STER组术后发生肺炎2 例,纵隔气肿1 例,保守对症支持治疗后痊愈;ESE组术后无并发症发生。术后经常规病理及免疫组化染色确诊平滑肌瘤28 例,间质瘤14 例。STER组6 例间质瘤均为极低危险度;ESE组4 例间质瘤为极低危险度,4例间质瘤为中等危险度[病变大小约1.0~2.0 cm,核分裂像(6~8)个/50 高倍视野]。所有患者中位随访时间46.5 个月(24~60个月),中等危险度间质瘤的患者最短随访时间为32个月,均未见肿瘤残留、复发及隧道内种植。结论:STER和ESE均可成为治疗来源于上消化道固有肌层的黏膜下肿瘤的有效、安全的方案选择之一,与STER相比,ESE切除病变时间短,但创面缝合时间长,总的手术时间相当。

关键词: 上消化道固有肌层肿瘤, 内镜, 对比研究, 内镜经黏膜下隧道肿瘤切除术, 内镜黏膜下肿瘤挖除术

Abstract:

Objective:To evaluate the efficacy and safety of submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) for upper gastroenterology submucosal tumors (SMT) originating from the muscularis propria (MP) layer. Methods: Clinicopathological and endoscopic data of 42 cases with upper gastroenterology tumors originating from the MP layer who were treated with STER (n=28) or ESE (n=14) between April 2013 and December 2016 in Peking University Third Hospital were retrospectively analyzed. The treatment and complications of the two groups were compared. Results: In the study, 42 cases were all resected by therapeutic endoscopy successfully.There was no significant difference (STER vs. ESE) in gender, age, mean tumor size [1.5 (1.0-6.0) cm vs. 1.3 (0.5-2.0) cm,P=0.056]. STER was superior to ESE with reduced sutured time [3.5 (1.0-11.0) min vs. 8.0 (2.0-33.0) min, P=0.006], but more resection time [46.5 (11.0-163.0) min vs.19.5 (6.0-56.0) min, P=0.007]. There was statistical difference between the two groups in resection time or sutured time, but no significant difference (STER vs. ESE) in total operative time [52.0 (14.0-167.0) min vs. 31.5 (10.0-88.0) min, P=0.080]. En bloc resection rates (92.9% vs. 85.7%), hospital stay duration and complications (10.7 vs. 0.0) were similar in the STER and ESE groups. One case developed mediastinal emphysema and 2 pneumonia after operation in STER group, and all of them recovered uneventfully after conservative treatments; There were no complications in the ESE group. After operation, 28 cases of leiomyoma and 14 cases of stromal tumor were diagnosed by routine pathological and immunohistochemical staining. Among them, 6 cases of stromal tumors in group STER were all extremely low risk, 4 cases of stromal tumors in group ESE were extremely low risk, 4 cases of stromal tumors in group ESE were medium risk (the size of the lesion was about 1.0-2.0 cm, and mitotic figures counted (6-8)/50 high power field). The median follow-up time of all the patients was 46.5 (24-60) months, and the shortest follow-up time for medium risk stromal tumors was 32 months. No residual tumor, recurrence and implantation in the tunnel were observed. Conclusion: STER or ESE can be used as an effective and safe option for treatment of submucosal tumors originating from the muscularis propria of the upper digestive tract. Compared with STER, ESE had shorter resection time but longer wound closure time. There was no significant difference in total operation time.

Key words: Upper gastroenterology submucosal neoplasms, Endoscopes, Comparative study, Submucosal tunneling endoscopic resection, Endoscopic submucosal excavation

中图分类号:

R735

田雪丽,黄永辉,姚炜,李渊,陆京京. 上消化道固有肌层肿瘤经内镜黏膜下隧道肿瘤切除术和黏膜下肿瘤挖除术的治疗对比[J]. 北京大学学报（医学版）, 2019, 51(1): 171-176.

Xue-li TIAN,Yong-hui HUANG,Wei YAO,Yuan LI,Jing-jing LU. Comparative treatment analysis of upper gastroenterology submucosal tumors originating from muscularis propria layer: submucosal tunneling endoscopic resection versus endoscopic submucosal excavation[J]. Journal of Peking University(Health Sciences), 2019, 51(1): 171-176.

图/表 5

图1

图2

表1

STER组和ESE组患者基线特征分析"

Items	STER (n=28)	ESE (n=14)	P value
Patients	27	14	-
Gender, n (%)
Male	11 (40.7)	6 (42.9)	1.000
Female	16 (59.3)	8 (57.1)
Age/years, $x ?$ ±s	50.1 (9.7)	56.3 (14.3)	0.105
Tumor size/cm, median (range)	1.5 (1.0-6.0)	1.3 (0.5-2.0)	0.056
Pathological diagnosis, n (%)
Leiomyoma	22 (78.6)	6 (42.9)	0.021
GIST	6 (21.4)	8 (57.1)

表1

表2

表3

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Items	STER (n=28)	ESE (n=14)	P value
Resection time/min, median(range)	46.5 (11.0-163.0)	19.5 (6.0-56.0)	0.007
Suture time/min, median (range)	3.5 (1.0-11.0)	8.0 (2.0-33.0)	0.006
Total operation time/min, median (range)	52.0 (14.0-167.0)	31.5 (10.0-88.0)	0.080
En bloc resection, n (%)	26 (92.9)	12 (85.7)	0.457
Complete resection, n (%)	28 (100)	14 (100)	-
Residual, n (%)	0 (0)	0 (0)	-
Recurrence, n (%)	0 (0)	0 (0)	-
Follow up-time/months, median (range)	49.5 (24-60)	43.5 (24-58)	0.126

Items	STER (n=28)	ESE (n=14)	P value
Complications, n (%)	3 (10.7)	0 (0)	0.539
Gas-related	1 (3.6)	0	-
Infection	2 (7.1)	0	-
Bleeding	0	0	-
Others	0	0	-
Hospital stay duration/d, median (range)	7 (4-15)	7 (5-11)	0.420