内镜黏膜下剥离术的疗效及出血危险因素分析

The therapeutic effect of endoscopic submucosal dissection and risk factors of bleeding

目的分析内镜黏膜下剥离术（ESD）治疗消化道黏膜浅表性病变的有效性及并发症的危险因素。方法．前瞻性观测上海长海医院应用ESD治疗154例？肖化道浅表性病变的效果以及并发症发生情况，并对后者发生率较高的出血及其相关危险因素进行统计学分析。结果完成ESD的145例中，一次性整块切除率100．0％，其中组织学完全治愈性切除率99．3％；9例因术中出血（5例）或穿孔（4例）未能完成ESD。发生术中大量出血6例（6／154，3．9％），少量出血5例（3．2％），术后延迟出血1例（0．6％），消化道穿孔4例（2．6％），消化道狭窄1例（0．6％），以上均经相应治疗后好转，无死亡病例。术后残留1例，经再次ESD治愈。术后8周复查，溃疡愈合率100％；平均随访10．6（8～18）个月，无局部复发。ESD出血并发症的独立危险因素为：病变部位（贲门胃底部），病变面积（随着病变面积增大其危险度提高）。结论ESD是治疗消化道浅表性病变安全、有效的方法，严格掌握手术适应证、个体化治疗，有助于降低并发症发生。

Objective To evaluate the efficacy and safety of endoscopic submucosal dissection （ESD） for digestive tract mucosal lesions, and risk factor of complications. Methods The data of 154 con secutive patients who underwent ESD for superficial digestive tract mueosal lesions were analyzed prospective ly for therapeutic effect and rate of complications. Risk factors for bleeding was analyzed. Results The en bloc resection rate in 145 completed ESD procedures was 100. 0%. Histologically, complete resection rate was 99. 3%. ESD was not completed in 9 patients due to bleeding （n =5） and perforation （n =4）. Acute massive bleeding occurred in 6 patients （6/154,3.9%）, mild bleeding in 5 （3.2%）, delayed bleeding in 1 （0. 6% ） ,perforation in 4 （2. 6% ） and postESD stenosis in 1 （0. 6% ）. All complications were cured. The postESD uleer healing was achieved in 100% at 8 weeks after treatment. During followup of 10. 6 months （ranged from 8 to 18 months）, no residual or local recurrence was found. Statistic analysis showed in dependent risk factors for bleeding in ESD were lesion location （cardiac fundus） , and lesion size. Conclu sion ESD is an effective and safe procedure in treatment of digestive tract mucosal lesions. The complica tions of ESD are preventable and curable. Strictly controlling operation indications, individualized treatment and the proficient operation skills of physicians are the keys to success.