套扎器法内镜黏膜下切除术治疗直肠类癌患者三年疗效评价

Endoscopic submucosal resection with ligation of rectal carcinoids:3 years experience

目的评价套扎器法内镜黏膜下切除术(ESMRL)治疗直肠类癌患者的远期疗效。方法 2002年4月至2006年4月复旦大学附属中山医院内镜中心收治的45例直径≤2 cm 直肠类癌患者,均行 ESMRL,其中男20例,女25例,年龄19～73岁,平均年龄(58±18)岁。分析本组患者切除根治性、术后并发症和远期疗效。结果本组患者占同期内镜中心肠镜检查患者的1.8%(45/24600),病灶距离肛缘从2～15 cm,直径从0.3～2.0 cm,平均(1.4±0.3)cm。超声内镜提示本组中24例(53%)患者的病灶为仅位于黏膜下层(第3层)的无回声占位,后方不伴有声影,肌层完整,平均病灶直径(0.8±0.2)cm,另21例(47%)患者的病灶同时位于黏膜层(第2层)和黏膜下层(第3层),平均病灶直径(1.5±0.2)cm,两者相比,差异具有统计意义(P<0.05)。所有患者均接受ESMRL 术,手术成功率100%,平均手术时间(25±4)min,有34例(75.6%)患者切除后切缘有动脉性出血,予止血夹夹闭止血或硬化剂注射止血。有7例(15.6%)患者于术后2～7 d 出现迟发性出血,其中3例(43%)为创面底部肌层渗血,另4例(57%)为切缘渗血或动脉性出血,需再次内镜检查进行止血处理。无穿孔、感染等其他并发症。病理检查切除标本直径从1～3 cm,平均(2.2±0.6)cm,厚度从0.3～1.5 cm,平均(0.5±0.3)cm。切缘阴性率86.7%(39/45),另有6例患者镜检下肿瘤周边无法见到正常黏膜下层结构,无法判断切缘有无受累,但肿瘤包膜完整,边界清晰,重新活检无肿瘤依据,选择随访。平均随访时间31(6～52)个月,随访率100%,无转移、复发和死亡病例。结论ESMRL 是治疗直肠类癌的一种安全、疗效肯定的方法,值得推广。

Objective To assess the value of endoscopic submucosal resection with ligation （ESMRL） in rectal carcinoids. Methods 45 patients with rectal carcinoids, 20 males and 25 females, aged 58 ± 18 （ 19-73）, were treated with ESMRL from April, 2002 to April, 2006. The radical resection rate, complication rate, relapse rate, and metastasis rate were analyzed. Results Carcinoids accounted for 1.8% of the 24 600 cases undergoing colonoscopy at the same time. All the carcinoids were located 2-15 cm from anal border, with a mean diameter of （1. 4 ± 0. 3） cm （0. 3-2. 0 cm） . The endoscopic ultrasonographic （EUS） characteristic was a hypoechoic solid tumor in the superficial submucosa （24 cases, 53% ） or in both the mucosa and submucosa （21 cases, 47% ） without involvement of the muscularis propria. All patients received ESMRL of the rectal carcinoids, of which 34 cases （75.6%） needed more hemostasis of the incision margin. The mean operation time was （25 ±4 ） min. 7 cases （ 15.6% ） with tardy bleeding 2-7 days after ESMRL needed endoscopic re-hemostasis, of which 3 cases （43%） showed oozing of blood from the muscle layer and another 4 showed oozing of blood or arterial bleeding from the incision border. No perforation or inflammatory was reported. 39 cases （86.7%） had negative margin in pathological examination, and the incision margins of the other 6 patients, as normal submucosal layer could not be seen outside the tumor envelope, could not be evaluated. But the tumor envelope was integrated without involvement of tumor and other biopsy results 7 days after ESMRL was negative. So no more therapies were selected. All 45 patients were followed up for 31 months （6-52 months）, there was no metastasis, relapse and dead cases. Conclusion ESMRL is an effective, safe, and minimally invasive method to deal with rectal carcinoids.