经黏膜下隧道内镜剥离术治疗食管浅表肿瘤的临床研究

Effects of endoscopic submucosal tunnel dissection for esophageal superficial neoplasms

目的评价经黏膜下隧道内镜剥离术(ESTD)治疗食管浅表性肿瘤的效率及安全性。方法 74例食管浅表性肿瘤患者按病灶周径(<1/3周,1/3~2/3周,>2/3周)分层随机分为内镜黏膜下剥离术(ESD)组(36例)和ESTD组(38例),分别行ESD及ESTD治疗,比较各组的剥离面积、手术时间、剥离速度、整块切除率、治愈性切除率和出血、穿孔及术后狭窄等并发症情况。结果各组剥离面积无差异(P>0.05)。在病灶周径<1/3周时,两组的手术时间、剥离速度、整块切除率及治愈性切除率均差异无统计学意义(P>0.05),在病灶周径1/3~2/3周及>2/3周时,ESTD组的手术时间[(50.7±21.3)min及(61.7±29.8)min]明显短于ESD组[(79.8±19.5)min及(119.8±35.4)min](P<0.05)、剥离速度[(21.1±5.6)mm^2/min及(28.8±6.1)mm^2/min]明显快于ESD组[(14.5±3.7)mm^2/min及(15.2±5.1)mm2/min](P<0.05)。在病灶周径1/3~2/3周时,两组整块切除率及治愈性切除率均无差异(P>0.05),在周径>2/3周时,ESTD组整块切除率及治愈性切除率均高于ESD组(P<0.05)。ESD组中,术中出血6例,术后迟发性穿孔2例,术后狭窄10例;ESTD组中,术中出血5例,术后狭窄13例,无穿孔发生。结论 ESTD能安全有效地切除食管浅表肿瘤,大面积食管肿瘤同传统ESD相比,具有手术时间短、剥离速度快、治愈性切除率高的优势。

Objective To evaluate the efficiency and safety of endoscopic submucosal tunnel dissection （ESTD） for esophageal superficial neoplasms. Method After stratification by circumferential lesion sizes （ i. e. 〈 1/3 circumference, 1/3-2/3 circumference, 〉 2/3 circumference） , a total of 74 patients who underwent endoscopic resection for esophageal superficial neoplasms were randomly assigned to endoscopic submucosal dissection （ESD） group （n--36） and ESTD group （n = 38 ） , and received ESD or ESTD. The time of operation, dissection area and speed, en bloc recetion rate and the radical curative rate were counted, the complications associated with dissection（ bleeding, perforation and esophageal stenosis） were observed. Results There were no difference in area of lesion of each group . In the lesion size of 1/3- 2/3 circumference and more than 2/3 circumference, the operation time of ESTD group were [ （50.7 ± 21.3）min, （61.7 ± 29.8）min], which were shorter than those of ESD group[ （79.8 ± 19.5）min, （119.8 ± 35.4）min]（P 〈0. 05）,the dissection speed of ESTD were [（21. 1 ± 5. 6） mm^2/min, （28.8 ± 6.1 ） mm^2/min ] ,which were higher than those of ESD group [ （ 14.5 ± 3.7） mm^2/min, （ 15.2 ± 5.1 ）mm^2/min] （P 〈0.05）. In the lesion size of less than 1/3 circumference, there were no difference in operation time , dissection speed, en bloc recetion rate and the radical curative rate. Despite a similar en bloc rate and the radical curative rate between two group in the lesion size of 1/3-2/3 circumference, en bloc rate and the radical curative rate of ESTD group were significantly greater than those of ESD group （P 〈 0.05 ）. Intraoperative bleeding occurred in 5 patients in ESTD group and 6 patients in ESD group. No perforation occurred in ESTD group except for 2 patients in ESD group after surgery. 13 patients of ESTD group and 10 patients of ESD group had postoperative esophageal stenosis. Conclusions ESTD was safe and effective for the endoscopic management of superficial esophageal neoplasms. Compared with standard ESD, the advantage of ESTD for large superficial esophageal lesions was a shortened operative time, a higher dissection speed and a higher radical curative rate.