内镜黏膜下剥离术在食管早期癌及癌前病变治疗中的价值
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摘要
目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗食管早期癌及癌前病变的安全性、有效性。方法回顾性分析2012年3月~2014年8月接受ESD治疗的171例食管早期癌及癌前病变的临床资料,分析病灶特征、ESD技术特征、术中与术后并发症及处理、术后复发等指标。结果 171例均顺利完成ESD治疗,平均手术时间65.0min(12~272 min)。术中穿孔5例(2.9%),术后延迟性出血3例(1.8%),术后延迟性穿孔1例(0.6%)。病灶整块切除165例(96.5%),完整切除159例(93.0%)。术后病理提示高级别上皮内瘤变85例(49.7%),高分化癌70例(40.9%),中分化癌16例(9.4%)。9例(5.3%)因基底部切缘和(或)脉管癌细胞累及追加外科手术。术后2个月食管狭窄37例(21.6%),其中切除范围<1/2周的患者术后食管狭窄发生率为2.3%(2/86),1/2周~3/4周为30.0%(15/50),>3/4周为45.8%(11/24),全周型为81.8%(9/11)。重度食管狭窄19例(11.1%),均接受扩张治疗,平均扩张1.9次(1~6次),其中12例因扩张效果欠佳行食管金属支架置入术,平均支架置入2.2次(1~6次)。术后平均随访40.4月(24~54个月),复发6例(3.5%),均接受二次内镜治疗。结论 ESD治疗食管早期病变是安全有效的。大面积ESD术后食管狭窄发生率高,往往需要多次食管扩张或支架置入治疗。术后病理是判断病灶完整切除的重要依据,定期内镜随访是监测病灶残留与复发的有效手段。
Objective To evaluate the safety and effectiveness of endoscopic submucosal dissection( ESD) in the treatment of early esophageal cancer( EEC) and precancerous lesions. Methods Clinical data of 171 patients who underwent ESD for EEC and precancerous lesions in our center from March 2012 to August 2014 were reviewed,with emphasis on the features of esophageal lesions,the technique features of ESD,intraoperative and post-operative complications and post-operation recurrence. Results The171 patients received ESD treatment smoothly,with an intraoperative perforation rate of 2. 9%( 5/171),a delayed hemorrhage rate of 1. 8%( 3/171),and a delayed perforation rate of 0. 6%( 1/171). The en bloc resection rate was 96. 5%( 165/171) and the complete resection rate was 93. 0%( 159/171). Pathological results showed 85 cases of high grade intraepithelial neoplasia( 49. 7%),70 cases of well differentiated carcinoma( 40. 9%),and 16 cases of moderately differentiated carcinoma( 9. 4%). Nine patients( 5. 3%) received an additional surgical operation due to involvement of cancer tissues at the bottom of the focus. A total of 37 patients developed esophageal stenosis at two months after operation( 21. 6%). The occurrence rate of esophageal stenosis was 2. 3%( 2/86) for a resection range < 1/2 circumference,30. 0%( 15/50) for a range between 1/2 and 3/4 circumference,and 45. 8%( 11/24) for a range larger than 3/4 circumference,while those who underwent circumferential resection had an occurrence rate of81. 8%( 9/11). The serious stenosis rate after operation was 11. 1%( 19/171). All the 19 patients received dilation treatment with an average dilation times of 1. 9( 1-6),and 12 patients received stent implantation simultaneously with an average treatment times of2. 2( 1-6). Follow-ups ranged for 24-54 months( average,40. 4 months) showed 6 cases of recurrence( 3. 5%) which received a second endoscopic treatment. Conclusions ESD is safe and effective in the treatment of early-stage esophageal lesions. In terms of large-scale esophageal lesions,the occurrence rate of esophageal stenosis is high and repeated dilation treatment and stent implantation are often required. Regular endoscopic follow-up after operation is effective to monitor residual tumor and local recurrence.
Objective To evaluate the safety and effectiveness of endoscopic submucosal dissection( ESD) in the treatment of early esophageal cancer( EEC) and precancerous lesions. Methods Clinical data of 171 patients who underwent ESD for EEC and precancerous lesions in our center from March 2012 to August 2014 were reviewed,with emphasis on the features of esophageal lesions,the technique features of ESD,intraoperative and post-operative complications and post-operation recurrence. Results The171 patients received ESD treatment smoothly,with an intraoperative perforation rate of 2. 9%( 5/171),a delayed hemorrhage rate of 1. 8%( 3/171),and a delayed perforation rate of 0. 6%( 1/171). The en bloc resection rate was 96. 5%( 165/171) and the complete resection rate was 93. 0%( 159/171). Pathological results showed 85 cases of high grade intraepithelial neoplasia( 49. 7%),70 cases of well differentiated carcinoma( 40. 9%),and 16 cases of moderately differentiated carcinoma( 9. 4%). Nine patients( 5. 3%) received an additional surgical operation due to involvement of cancer tissues at the bottom of the focus. A total of 37 patients developed esophageal stenosis at two months after operation( 21. 6%). The occurrence rate of esophageal stenosis was 2. 3%( 2/86) for a resection range < 1/2 circumference,30. 0%( 15/50) for a range between 1/2 and 3/4 circumference,and 45. 8%( 11/24) for a range larger than 3/4 circumference,while those who underwent circumferential resection had an occurrence rate of81. 8%( 9/11). The serious stenosis rate after operation was 11. 1%( 19/171). All the 19 patients received dilation treatment with an average dilation times of 1. 9( 1-6),and 12 patients received stent implantation simultaneously with an average treatment times of2. 2( 1-6). Follow-ups ranged for 24-54 months( average,40. 4 months) showed 6 cases of recurrence( 3. 5%) which received a second endoscopic treatment. Conclusions ESD is safe and effective in the treatment of early-stage esophageal lesions. In terms of large-scale esophageal lesions,the occurrence rate of esophageal stenosis is high and repeated dilation treatment and stent implantation are often required. Regular endoscopic follow-up after operation is effective to monitor residual tumor and local recurrence.
引文
1 Barnes JA,Willingham FF.Endoscopic management of early esophageal cancer.J Clin Gastroenterol,2015,49(8):638-646.
2 Ono S,Fujishiro M,Koike K.Endoscopic submucosal dissection for superficial esophageal neoplasms.World J Gastrointest Endosc,2012,4(5):162-166.
3 Repici A,Hassan C,Carlino A,et al.Endoscopic submucosal dissection in patients with early esophageal squamous cell carcinoma:results from a prospective Western series.Gastrointest Endosc,2010,71(4):715-721.
4 Yamamoto H.Technology insight:endoscopic submucosal dissection of gastrointestinal neoplasms.Nat Clin Pract Gastroenterol Hepatol,2007,4(9):511-520.
5 Facciorusso A,Antonino M,Di Maso M,et al.Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer:a meta-analysis.World J Gastrointest Endosc,2014,6(11):555-563.
6 Kakushina N,Fujishiro M.Endoscopic submucosal dissection for gastrointestinal neoplasms.World J Gastroenterol,2008,14(19):962-2967.
7 Joh DH,Park CH,Jung S,et al.Safety and feasibility of simultaneous endoscopic submucosal dissection for multiple gastric neoplasias.Surg Endosc,2015,29(12):3690-3697.
8 Chio KD,Jung HY,Lee GH,et al.Application of metal hemoclips for closure of endoscopic mucosal resection-induced ulcers of the stomach to prevent delayed bleeding.Surg Endosc,2008,22(12):1882-1886.
9 Na S,Ahn JY,Choi KD,et al.Delayed bleeding rate according to the Forrest classification in second-look endoscopy after endoscopic submucosal dissection.Dig Dis Sci,2015,60(10):3108-3117.
10 Mizushima T,Kato M,Iwanaga I,et al.Technical difficulty according to location,and risk factors for perforation,in endoscopic submucosal dissection of colorectal tumors.Surg Endosc,2015,29(1):133-139.
11 Suzuki H,Oda I,Sekiguchi M,et al.Management and associated factors of delayed perforation after gastric endoscopic submucosal dissection.World J Gastroenterol,2015,21(44):12635-12643.
12 Ezoe Y,Muto M,Horimatsu T,et al.Efficacy of preventive Endoscopic balloon dilation for esophageal stricture after endoscopic resection.J Clin Gastroenterol,2011,45:222-227.
13 鞠辉,钟芸诗,姚礼庆,等.早期食管癌内镜黏膜下剥离术后食管狭窄的危险因素分析.中华消化内镜杂志,2013,30(6):310-314.
14 Takhashi H,Arimura Y,Okahara S,et al.Risk of perforation during dilation for esophageal strictures after endoscopic resection in patients with early squamous cell carcinoma.Endoscopy,2011,43(3):184-189.
15 马丽梅,张银,钱云,等.内镜黏膜下注射糖皮质激素联合扩张术治疗早期食管癌内镜黏膜下剥离术后狭窄的初步探索.中国微创外科杂志,2014,14(8):732-734.
16 Ezoe Y,Muto M,Horimatsu T,et al.Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection.J Clin Gastroenterol,2011,45(3):222-227.
17 Wen J,Yang Y,Liu Q,et al.Preventing stricture formation by covered esophageal stent placement after endoscopic submucosal dissection for early esophageal cancer.Dig Dis Sci,2014,59(3):658-663.
18 Tsujii Y,Nishida T,Nishiyama O,et al.Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms:a multicenter retrospective cohort study.Endoscopy,2015,47(9):775-783.
2 Ono S,Fujishiro M,Koike K.Endoscopic submucosal dissection for superficial esophageal neoplasms.World J Gastrointest Endosc,2012,4(5):162-166.
3 Repici A,Hassan C,Carlino A,et al.Endoscopic submucosal dissection in patients with early esophageal squamous cell carcinoma:results from a prospective Western series.Gastrointest Endosc,2010,71(4):715-721.
4 Yamamoto H.Technology insight:endoscopic submucosal dissection of gastrointestinal neoplasms.Nat Clin Pract Gastroenterol Hepatol,2007,4(9):511-520.
5 Facciorusso A,Antonino M,Di Maso M,et al.Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer:a meta-analysis.World J Gastrointest Endosc,2014,6(11):555-563.
6 Kakushina N,Fujishiro M.Endoscopic submucosal dissection for gastrointestinal neoplasms.World J Gastroenterol,2008,14(19):962-2967.
7 Joh DH,Park CH,Jung S,et al.Safety and feasibility of simultaneous endoscopic submucosal dissection for multiple gastric neoplasias.Surg Endosc,2015,29(12):3690-3697.
8 Chio KD,Jung HY,Lee GH,et al.Application of metal hemoclips for closure of endoscopic mucosal resection-induced ulcers of the stomach to prevent delayed bleeding.Surg Endosc,2008,22(12):1882-1886.
9 Na S,Ahn JY,Choi KD,et al.Delayed bleeding rate according to the Forrest classification in second-look endoscopy after endoscopic submucosal dissection.Dig Dis Sci,2015,60(10):3108-3117.
10 Mizushima T,Kato M,Iwanaga I,et al.Technical difficulty according to location,and risk factors for perforation,in endoscopic submucosal dissection of colorectal tumors.Surg Endosc,2015,29(1):133-139.
11 Suzuki H,Oda I,Sekiguchi M,et al.Management and associated factors of delayed perforation after gastric endoscopic submucosal dissection.World J Gastroenterol,2015,21(44):12635-12643.
12 Ezoe Y,Muto M,Horimatsu T,et al.Efficacy of preventive Endoscopic balloon dilation for esophageal stricture after endoscopic resection.J Clin Gastroenterol,2011,45:222-227.
13 鞠辉,钟芸诗,姚礼庆,等.早期食管癌内镜黏膜下剥离术后食管狭窄的危险因素分析.中华消化内镜杂志,2013,30(6):310-314.
14 Takhashi H,Arimura Y,Okahara S,et al.Risk of perforation during dilation for esophageal strictures after endoscopic resection in patients with early squamous cell carcinoma.Endoscopy,2011,43(3):184-189.
15 马丽梅,张银,钱云,等.内镜黏膜下注射糖皮质激素联合扩张术治疗早期食管癌内镜黏膜下剥离术后狭窄的初步探索.中国微创外科杂志,2014,14(8):732-734.
16 Ezoe Y,Muto M,Horimatsu T,et al.Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection.J Clin Gastroenterol,2011,45(3):222-227.
17 Wen J,Yang Y,Liu Q,et al.Preventing stricture formation by covered esophageal stent placement after endoscopic submucosal dissection for early esophageal cancer.Dig Dis Sci,2014,59(3):658-663.
18 Tsujii Y,Nishida T,Nishiyama O,et al.Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms:a multicenter retrospective cohort study.Endoscopy,2015,47(9):775-783.
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