内镜黏膜下隧道法剥离术治疗早期食管癌伴黏膜下层纤维化的临床观察

Clinical study of endoscopic submucosal tunnel dissection on treatment of early esophageal cancer with submucosal fibrosis

目的评价内镜黏膜下隧道法剥离术(endoscopic submucosal tunnel dissection,ESTD)治疗早期食管癌伴黏膜下层纤维化的效果和安全性。方法2015年6月—2018年2月间,在江苏省苏北人民医院消化内科采用ESTD或内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗,术后病理证实病灶<1/3食管管周,且伴有黏膜下层纤维化的早期食管癌病例87例纳入回顾性分析,按纤维化程度分成轻度纤维化60例(ESTD 31例、ESD 29例)和重度纤维化27例(ESTD 16例、ESD 11例),比较同一纤维化程度时两种手术方式的剥离速度、整块切除率、完全切除率,以及出血、肌层损伤、穿孔、颈部皮下气肿和术后狭窄的发生率。结果对于伴有轻度黏膜下层纤维化的早期食管癌患者,ESTD的整块切除率[96.8%(30/31)比82.8%(24/29),P<0.05]和完全切除率[96.8%(30/31)比75.9%(22/29),P<0.05]明显高于ESD,固有肌层损伤发生率明显低于ESD[6.5%(2/31)比17.2%(5/29),P<0.05],剥离速度、术中出血发生率、穿孔发生率、术后狭窄发生率与ESD比较差异均无统计学意义(P均>0.05),两种手术方式均无术后迟发性出血和颈部皮下气肿发生。对于伴有重度黏膜下层纤维化的早期食管癌患者,ESTD的剥离速度快于ESD[(12.3±2.8)mm^2/min比(7.1±3.2)mm^2/min],整块切除率、完全切除率、术后狭窄发生率与ESD相近,术中出血发生率[12.5%(2/16)比54.5%(6/11)]、固有肌层损伤发生率[18.8%(3/16)比54.5%(6/11)]、穿孔发生率[6.3%(1/16)比27.3%(3/11)]、颈部皮下气肿发生率[6.3%(1/16)比27.3%(3/11)]低于ESD,两种手术方式均无术后迟发性出血发生。术后12个月2例行ESD和1例行ESTD患者局部复发,术后24个月1例行ESTD患者发生异时癌。结论ESTD能安全、有效切除伴有黏膜下层纤维化的早期食管癌。对于伴有轻度黏膜下层纤维化者,ESTD的优势主要体现在治疗效果方面;对于伴有重度黏膜下层纤维化者,ESTD的优势主要体现在治疗安全性方面。

Objective To evaluate the efficiency and safety of endoscopic submucosal tunnel dissection (ESTD) on treatment of early esophageal cancer with submucosal fibrosis.Methods In the Department of Gastroenterology of Northern Jiangsu People′s Hospital from June 2015 to Feburary 2018, data of 87 patients undergoing ESTD or endoscopic submucosal dissection (ESD) for early esophageal cancer or precancerous lesion were collected with inclusion criteria of cancer size less than 1/3 circumference with submucosal fibrosis, which was confirmed by pathology. According to the degree of submucosal fibrosis, 60 patients had mild fibrosis (31 underwent ESTD and 29 underwent ESD), and 27 patients had severe fibrosis (16 underwent ESTD and 11 underwent ESD). The dissection speed, en bloc resection rate, complete resection rate, and the complications (including bleeding, muscularis injury, perforation, neck subcutaneous emphysema and esophageal stenosis) were compared between the two methods of dissection in the groups with same degree of submucosal fibrosis.Results For patients with mild submucosal fibrosis, ESTD had a higher en bloc resection rate (96.8%, 30/31) and complete resection rate (96.8%, 30/31), and lower muscularis injury rate (6.5%, 2/31) than those of ESD [82.8% (24/29), 75.9% (22/29), and 17.2% (5/29), respectively, all P<0.05]. There was no difference in the dissection speed, incidence of intraoperative bleeding, perforation and postoperative esophageal stenosis between the two methods (all P>0.05), and no postoperative delayed bleeding or neck subcutaneous emphysema occurred. For patients with severe submucosal fibrosis, ESTD had a higher dissection speed (12.3±2.8 mm^2/min), and lower incidence of intraoperative bleeding (12.5%, 2/16), muscularis injury (18.8%, 3/16), perforation (6.3%, 1/16) and neck subcutaneous emphysema (6.3%, 1/16) than those of ESD [7.1±3.2 mm^2/min, 54.5% (6/11), 54.5% (6/11), 27.3% (3/11), and 27.3% (3/11)]. There was no difference in en bloc resection rate, complete resection rate, and the incidence of postoperative esophageal stenosis between the two methods, and no postoperative delayed bleeding occurred. Cancer recurred locally in 2 patients undergoing ESD and 1 patient undergoing ESTD at 12 months after the operation, and 1 patient undergoing ESTD developed metachronous cancer at 24 months after the operation.Conclusion ESTD is safe and effective for endoscopic management of early esophageal cancer or precancerous lesion with submucosal fibrosis. Compared with standard ESD, the advantage of ESTD is more efficient for patients with mild submucosal fibrosis, and is safer for patients with severe submucosal fibrosis.