内镜超声指导内镜黏膜下剥离术诊治直肠神经内分泌肿瘤的临床价值

Clinical value of endoscopic nitrasonography guided endoscopic submucosal dissection for diagnosis and treatment of rectal neuroendocrine neoplasms

目的评价内镜超声检查术（EUS）指导内镜黏膜下剥离术（ESD）在直肠神经内分泌肿瘤（NENs）治疗中的临床价值。方法回顾性分析2011年1月至2015年11月江苏省人民医院采用ESD治疗的58例直肠NENs患者的临床资料，并进行内镜随访。详细记录病变的EUS表现、临床病理特征、增殖活性分级、完整切除率、并发症发生率以及有无局部复发或远处转移等资料。结果58例患者的64个病灶的EUS检查结果显示，其中3个病灶来源于黏膜层，3个病灶来源于黏膜肌层，58个病灶来源于黏膜下层；34个位于距肛门≤5cm，26个位于距肛门〉5—10cm，4个位于距肛门〉10cm。64个病灶均接受ESD治疗，平均直径为0．8cm（0．2～3．5cm）；平均手术时间为31min（10～60min）；其中60个病灶得到完整切除（完整切除率为93．8％），另4个病灶基底切缘阳性（2例追加外科手术，其余2位患者因拒绝外科治疗且不愿再行ESD遂行内镜下氩离子凝固术）；术后病理学检查结果显示，64个病灶均为NENs（其中59个病灶的病理学分级为G1，5个病灶为G2）；术后4例患者出现迟发性出血（便血），1例予药物止血，3例予钛夹缝合止血，术后均未发生穿孔。患者术后平均随访时间为22．9个月（3～48个月），随访过程中均未发现淋巴结或远处转移。结论在直肠NENs治疗中，EUS检查可以较清楚地界定病变的来源层次以指导内镜下治疗的范围和深度。ESD是局限于黏膜下层盲肠NENs的安全而有效的微创治疗方法。

Objective To evaluate the clinical efficacy and safety of endoscopic submucosal dissection （ESD） guided with endoscopic uhrasonography （EUS） for rectal neuroendocrine neoplasms （NENs）. Methods A retrospective analysis was performed on 58 patients with rectal ENEs who underwent ESD from January 2011 to December 2015 in JiangSu Province Hospital. Manifestations of EUS, clinicopathological characteristics, proliferation activity grade, complete resection rate, complications and follow-up resuhs of lesion were studied. Results Those treated by ESD included 58 patients with 64 lesions of rectal NENs. EUS results showed that 3 lesions originated from mucosa, 3 from muscular＇is mucosa and 58 from submucosa. A total of 34 lesions located within 5 em from anus, 26 in 6-10 cm from anus and 4 more than 10 cm from anus. All 64 lesions were successfully treated by ESD. The mean maximum diameter of the lesions was 0. 8 cm（0. 2-3. 5 cm）, and the mean procedure time was 31 min（ 10-60 min）. The complete resection rate was 93.8% （60/64）. There were 4 patients with positive basal surgical margin, and two of them underwent additional surgery and two others were treated with argon plasma coagulation after rejecting surgery and ESD. Histological examination determined that 59 lesions were pathologic grade 1 （G1） and 5 were pathologic grade 2 （G2）. Delayed bleeding occurred in 4 cases after ESD, which was managed by medicine in 1 case and endoscopic treatment in 3 cases. No perforation occurred after ESD. During a mean follow-up period of 22. 9 months （3-48 months ）, no lymph node metastasis or distant metastasis was observed. Conclusion EUS is able to distinguish the origin of rectal NENs and aid determining the range and depth of ESD. ESD appears to be a safe, feasible and effective procedure for providing accurate histopathological evaluations as well as curative treatments for rectal NENs limited to submucosa.