局部注射曲安奈德与口服甲泼尼龙预防食管早期癌内镜黏膜下剥离术后食管狭窄的疗效观察

Efficacy of local injection of triamcinolone and oral methylprednisolone in preventing stricture formationafter endoscopic submucosal dissection in early esophageal cancer

目的比较局部注射曲安奈德与口服甲泼尼龙预防食管早期癌患者内镜黏膜下剥离术（ESD）术后食管狭窄的有效性和安全性。方法纳入2014年1月至2016年1月就诊的67例食管早期癌患者，均行ESD治疗，分成曲安奈德组（22例）、甲泼尼龙组（22例）和对照组（23例）。曲安奈德组患者在ESD术后立即予缺损处内镜下注射曲安奈德；甲泼尼龙组在ESD术后第3天开始口服甲泼尼龙片（30mg），以后每隔1周减量5mg直至停药；对照组仅行ESD治疗。术后复查胃镜以评估食管狭窄程度，食管狭窄者予内镜下球囊扩张术（EBD）治疗。比较3组的食管狭窄发生率和进行EBD治疗的次数。统计学方法采用卡方检验、Wilcoxon秩和检验和Kruskal-wallis秩和检验。结果曲安奈德组、甲泼尼龙组和对照组的食管狭窄发生率分别为18．2％（4／22）、13．6％（3／22）和73．9％（17／23），差异有统计学意义（X^2=22．20，P〈O．01）；曲安奈德组与甲泼尼龙组的食管狭窄发生率差异无统计学意义（X^2=0．17，P〈0．50）；曲安奈德组的食管狭窄发生率低于对照组，差异有统计学意义（X^2=14．03，P〈O．01）；甲泼尼龙组的食管狭窄发生率低于对照组，差异有统计学意义（X^2=16．55，P〈O．01）。曲安奈德组、甲泼尼龙组和对照组接受EBD治疗次数的中位数（范围）分别为2．1次（O～4．0次）、1．6次（O～3．0次）和6．0次（O～13．0次），差异有统计学意义（H一17．80，P〈0．01）；曲安奈德组与甲泼尼龙组的EBD治疗次数比较差异无统计学意义（Z=1．21，P=0．23）；曲安奈德组的EBD治疗次数少于对照组，差异有统计学意义（Z=4．96，P〈0.01）；甲泼尼龙组的EBD治疗次数少于对照组，差异有统计学意义（Z=4．32，P〈o．01）。3组均无严重不良反应发生。结论局部注射曲安奈德与口服甲泼尼龙均可降低ESD术后的食管狭窄发生率，亦可减少食管狭窄发生后患者进行EBD治疗的次数，且疗效相当，安全性好。

Objective To compare the efficacy and safety between local injection of triamcinolone and oral methylprednisolone in preventing esophageal stricture formation after endoscopic submucosal dissection （ESD） in patients with early esophageal cancer. Methods From January 2014 to January 2016, 67 patients with early esophageal cancer were enrolled, all of them received ESD and were divided into triamcinolone injection group （22 cases）, oral methylprednisolone group （22 cases） and control group （23 cases）. Patients of triamcinolone group received injection of triamcinolone at injured mucosal under endoscope immediately after ESD. Patients of oral methylprednisolone group took methylprednisolone 30 mg per day since the third day after ESD, and then dosage reduced 5 mg every other week until drug withdrawal. Patients of control group only received ESD. After operation, gastroendoscopy examination was repeated to evaluate the extent of esophageal stricture. Patients with esophageal stricture were treated with an additional endoscopic balloon dilatation （EBD）. The rate of esophageal stricture and the frequency of EBD treatment of the three groups were compared. Chi-square test, Wilcoxon rank sum test and Kruskal-Wallis rank sum test were used for statistical analysis. Results The rates of esophageal stricture of triamcinolone injection group, oral methylprednisolone group and control group were 18.2% （4/22）, 13.60% （3/22） and 73.9% （17/23）, respectively, and the difference was statistically significant （X^2 =22.20, P〈0.01）. There was no significant difference in the rates of esophageal stricture between triamcinolone injection group and oral methylprednisolone group （X^2 =0. 17, P=0. 50）, but the rate of esophageal stricture in triamcinolone injection group was lower than control group, and the difference was statistically significant （X^2 = 14.03, P〈0.01）; the rate of esophageal stricture in oral rnethylprednisolone group was lower than control group, and the difference was also statistically significant （Z= 16.55, P%0.01）. The median frequency of EBD treatment of triamcinolone injection group, oral methylprednisolone group and control group were 2. 1 （range 0 to 4. 0）, 1. 6 （range 0 to 3. 0） and 6. 0 （range 0 to 13. 0） times, respectively, and the difference was statistically significant （H = 17. 80, P〈0. 01）. There was no significant difference in the frequency of EBD treatment between triamcinolone injection group and oral methylprednisolone group （Z= 1. 21, P=O. 23）; but the frequency of EBD treatment in triamcinolone injection group was less than control group, and the difference was statistically significant （Z= 4.96,P 〈0.01） ; the frequency of EBD treatment in oral methylprednisolone group was less than control group, and the difference was also statistically significant （Z=4.32, P〈0.01）. There was no severe adverse effect in the three groups. Conclusions Local injections of triamcinolone and oral methylprednisolone both reduced the rate of esophageal stricture after ESD, and decreased frequency of EBD treatment in patients with esophageal stricture. The two regimens showed equal efficacy and good safety.