大范围食管早期癌及癌前病变内镜黏膜下剥离术后发生顽固性狭窄的危险因素分析

Risk factors for esophageal refractory stenosis after large-scale endoscopic submucosal dissection of superficial esophageal neoplasms

目的探讨大范围早期食管癌及其癌前病变内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)术后发生食管顽固性狭窄的危险因素。方法2013年7月—2017年12月,在中国医学科学院肿瘤医院内镜科行内镜黏膜下剥离术治疗,病变范围≥3/4食管环周的186例患者(共212处食管早期癌或癌前病变)纳入回顾性分析,根据术后内镜下食管球囊扩张次数分为顽固性狭窄组(69例,扩张≥6次)和非顽固性狭窄组(117例,扩张0~5次)。单因素分析使用t检验或Mann-Whitney U检验、χ2检验或Fisher精确概率法,多因素分析使用Logistic回归。结果与非顽固性狭窄组比较,顽固性狭窄组在病变纵径、人工溃疡(ESD术后创面)纵径以及病变位置、病变环周范围和固有肌层损伤构成方面差异均有统计学意义(P均<0.05)。剔除人工溃疡纵径这一因素后(因人工溃疡纵径与病变纵径在临床上存在明显相关性),多因素Logistic回归分析结果显示,病变纵径>5 cm(P=0.003,OR=3.531,95%CI:1.547~8.060)、病变位于胸上段(与胸下段比较:P=0.001,OR=36.720,95%CI:4.233~318.551)、颈段(与胸下段比较:P=0.003,OR=24.959,95%CI:2.927~212.795)、全周病变(P<0.001,OR=10.082,95%CI:4.196~24.226)和存在术中固有肌层损伤(P<0.001,OR=7.128,95%CI:2.748~18.486)的早期食管癌及其癌前病变行ESD术后易发生食管顽固性狭窄。结论对于大范围(病变范围≥3/4食管环周)早期食管癌及其癌前病变,病变纵径>5 cm,病变位于胸上段、颈段,全周病变,以及存在术中固有肌层损伤均是ESD术后发生食管顽固性狭窄的独立危险因素。

Objective To determine risk factors for postoperative esophageal refractory stenosis after endoscopic submucosal dissection(ESD)of large-scale early esophageal carcinomas and precancerous lesions.Methods Two hundred and twelve early esophageal carcinomas or precancerous lesions in 186 patients who underwent ESD larger than 3/4 the total esophageal circumference in Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,between July 2013 and December 2017 were divided into two groups according to session number of endoscopic balloon dilatation(EBD),the refractory stenosis group(n=69,≥6 EBD sessions)and non-refractory stenosis group(n=117,≤5 EBD sessions).Student′s t-test or Mann-Whitney U test was used for univariate analysis andχ2 test and Fisher exact test were used for comparison of categorical variables.Logistic regression was used for multivariate analysis.Results Compared with the non-refractory stenosis group,the refractory stenosis group had statistically significant differences in the longitudinal diameter of lesions,the longitudinal diameter of artificial ulcer,lesion location,the circumferential range of lesions and the composition of the muscular layer injury(all P<0.05).After eliminating the factor of the vertical diameter of artificial ulcer(because there was significant correlation between the vertical diameter of artificial ulcer and the longitudinal diameter of lesion in clinical practice),multivariate logistic regression analysis showed that the longitudinal diameter of lesion>5 cm(VS≤5 cm:P=0.003,OR=3.531,95%CI:1.547-8.060),the location of lesion in the upper thoracic segment(VS lower thoracic segment:P=0.001,OR=36.720,95%CI:4.233-318.551),in the cervical segment(VS lower thoracic segment:P=0.003,OR=24.959,95%CI:2.927-212.795),the whole circumferential lesion(VS≥3/4 but not the whole circumference:P<0.001,OR=10.082,95%CI:4.196-24.226)and the presence of muscular layer injury(P<0.001,OR=7.128,95%CI:2.748-18.486)were more likely to lead to esophageal refractory stenosis after ESD.Conclusion The longitudinal lesion diameter of more than 5 cm,the circumferential extent of esophageal ESD,cervical or upper-thoracic esophageal lesions,and muscular layer damage are independent risk factors for postoperative esophageal refractory stenosis after ESD for large-scale esophageal cancer and precancerous lesions.