大型低位直肠肿瘤的内镜下黏膜切除术与内镜黏膜下层剥离术的临床对比研究

Comparative clinical study on endoscopic mucosal resection and endoscopic submucosal dissection for treatment of low rectal tumors

目的 对比观察内镜下黏膜切除术（endoscopic mucosal resection，EMR）与内镜黏膜下层剥离术（endoscopic submucosal dissection，ESD）对大型低位直肠肿瘤的治疗效果。方法选择肿瘤直径大于3．0cm，肿瘤下缘距肛缘齿状线小于5cm，有内镜治疗适应证的56例低位直肠肿瘤，应用EMR或ESD进行治疗，其中EMR治疗36例，ESD治疗20例，术后3～18个月行内镜随访确认有无残留，以评价切除效果，记录术中及术后发生的并发症及处理情况，并分析切除标本的病理组织学结果。结果 接受EMR治疗的36例中，35例经首次或再次EMR治疗病变完整清除，肛门功能完好，保肛治愈率为97．2％，术后病理报浸润癌（SM癌）再追加外科Mile’s根治手术者1例（2．8％）；接受ESD治疗的20例中，11例经首次或再次ESD治疗完整清除病变，肛门功能完好，治愈率55．0％，ESD治疗未成功改行EMR成功清除病变6例（30．0％），肛门功能均完好，全组保肛治愈率为85．0％，ESD组因严重并发症（迟发性大出血）转外科行Mile’s手术者2例（10．0％），因病变残留转行外科Mile’s手术者1例（5．0％）。并发症：EMR组术中平均出血20ml，最大出血160ml，均无需输血治疗，无穿孔发生，无术后并发症。ESD组平均术中出血150ml，最大术中出血量800ml，均内镜下止血成功，但3例患者需接受输血400ml，另有2例于术后26h及44h发生迟发大出血，内镜下止血失败转行外科手术。结论EMR是一种安全微创的内镜治疗手段，对大多数平坦型大肠肿瘤能达到完全切除效果，与EMR相比，ESD对低位直肠病变切除的效果不及EMR术，且手术风险更大。

Objective To investigate and compare the curative effect of endoscopic mucosal resection （EMR） and endoscopic submucosal dissection （ESD） for large size low rectal flat tumors. Methods Included in the present study were 56 patients with low rectal tumors larger than 3.0 cm and located less than 5.0 cm from the anus which were indicative of endoscopic treatment. EMR was performed by the en bloc or piecemeal snare cut method. ESD was performed using an IT knife. The curative effect was evaluated by following up the patients for 3 months. The postoperative morbidity was evaluated and recorded. All resected specimens were retrieved for pathological study. Results Of the 36 patients who re- ceived EMR, 35 patients had their tumors removed completely by one or a second procedure with the anus retained perfectly, the curative rate being 97.2 %. No residue or recurrent tumor was found during the follow-up period. The remaining patient received mile＇s operation because the postoperative pathology suggested that the tumor was an invasive cancer. Of the 20 patients who received ESD, 11 patients had their tumors removed completely by one or multiple procedures with the anus retained perfectly, the curative rate being 55.0%; 6 patients （30.0%） failed ESD and were converted to EMR for complete removal of the tumors with the anus retained perfectly; 2 patients received additional mile＇s operation due to delayed massive hemorrhage; and the remaining patient received mile＇s operation because of postoperative tumor residuals. The main intra-operative complication in EMR group was hemorrhage, ranging from 20 to 160 ml, but no transfusion was needed in any patient, nor did perforation occur. No postoperative complication was observed. Intra-operative hemorrhage in ESD group ranged from 150 to 800 ml, and 400 ml RBC transfusion was needed in 3 patients, of whom 2 patients were converted to open surgery because of delayed massive hemorrhage 24 h and 44 h after the ESD procedure. No perforation occurred. Postoperative pathology revealed that of the 56 patients, 45 patients had benign adenomas, 9 had intramucosal carcinomas （high-grade intraepithelial neoplasia）, one had submucosal invasive carcinoma, and one had serrated adenoma. Conclusion EMR is a safe and minimally invasive therapy for the treatment of low rectal tumors, and can be used to resect most low rectal benign tumors. The curative effect of ESD is not as good as that of EMR, and it runs more intra-operative risks.