内镜黏膜下剥离术联合黏膜切除术在非壶腹部十二指肠占位性病变治疗中的应用价值研究

The value of endoscopic submucosal dissection and hybrid endoscopic submucosal dissection in the treatment of non-ampullary duodenal lesions

目的评估内镜黏膜下剥离术(ESD)与内镜黏膜下剥离术联合黏膜切除术(ESD+EMR)在非壶腹部十二指肠占位性病变治疗中的疗效及安全性。方法选取2015年4月至2019年4月在首都医科大学附属北京友谊医院应用ESD术及ESD+EMR术治疗的14例非壶腹部十二指肠占位性病变患者为研究对象,根据手术方式的不同将患者分为ESD组和ESD+EMR组,回顾性分析患者的基线资料、手术方式、并发症发生情况与转归、病理结果及手术时间等资料。结果 14例患者均成功完成内镜下治疗,整块切除率为100%(14/14)。其中ESD 4例,完全切除率为100%(4/4),ESD+EMR 10例,完全切除率为80%(8/10)。总体并发症发生4例(4/14,28. 6%),均为围手术期穿孔。在4例ESD的操作中,1例来源于黏膜下层的病变最大直径较大(16 mm),术前予外科手术备案,术中发生穿孔(1/4,25. 0%),行腹腔镜下十二指肠修补术后好转出院。在10例ESD+EMR的操作中,发生穿孔3例(30%,3/10),其中2例行内镜下金属夹封闭术治疗后好转;1例为内镜下金属夹封闭术治疗不佳,转外科开腹探查修补术后好转出院。ESD组与ESD+EMR组内镜下病灶最大直径分别为(16±7)、(16±6) mm,差异无统计学意义(P=0. 971);手术时间分别为(71. 8±39. 7)、(32. 0±18. 4) min,差异具有统计学意义(P=0. 022)。结论对于空间狭小、操作困难的非壶腹部十二指肠占位性病变,ESD及ESD+EMR治疗均是安全有效的,相比于ESD,ESD+EMR操作更快捷有效,具有良好的临床应用前景。

Objective To evaluate the efficacy and safety of endoscopic submucosal dissection( ESD) and hybrid endoscopic submucosal dissection( ESD + EMR) for non-ampullary duodenal lesions. Methods A retrospective analysis was performed on data collected from 14 consecutive patients with non-ampullary duodenum lesions,who underwent ESD or ESD + EMR from April 2015 to April 2019 at Beijing Friendship Hospital,Capital Medical University. Patients were divided into ESD group and ESD + EMR group. Patient’s baseline data,endoscopic and pathological features,operation time,the occurrence and outcome of complications were studied. Results 14 patients were enrolled,and the en bloc resection rate was 100%( 14/14). Among them,4 patients underwent ESD and the compete resection rate is 100%( 4/4). 10 patients underwent ESD + EMR,and the compete resection rate is 80%( 8/10). Complications occurred in 4 cases( 4/14,28. 6%),all of which were perforated during perioperative period. In one of the 4 ESD cases,a larger lesion( 16 mm) was derived from submucosa,a surgical escort was prepared,and laparoscopic treatment was performed promptly after the appearance of perforation. In the 10 ESD + EMR cases,3 cases were perforated during the perioperative period,2 cases recovered after endoscopic treatment,another case was poorly treated after endoscopic treatment,and recovered after emergency surgery. The maximum diameter of the lesion estimated by endoscopy were( 16 ± 7),( 16 ± 6) mm,respectively,for group ESD and group ESD + EMR( P = 0. 971). The operation time was( 71. 8 ± 39. 7) min and( 32. 0 ± 18. 4) min in group ESD and ESD + EMR( P =0. 022). Conclusion It is presumed that ESD and ESD + EMR are safe and effective for non-ampullary duodenal lesions. Compared with ESD,ESD + EMR may be more convenient and effective,indicating a potential clinical application prospect.