气囊辅助小肠镜下狭窄切开术治疗空回肠良性狭窄的临床价值

Clinical value of endoscopic stricturotomy under balloon-assisted enteroscopy in the treatment of benign jejuno-ileal stenosis

目的评估气囊辅助小肠镜(BAE)下狭窄切开术(EST)治疗空回肠良性狭窄的安全性和有效性。方法回顾性收集2015年12月至2021年8月在空军特色医学中心诊断为空回肠良性狭窄,且因无药物治疗机会或药物治疗无效行BAE下深部小肠EST和(或)外科手术治疗的41例患者,其中21例行EST治疗(EST组),20例行手术治疗(手术组)。分析患者的病因、随访时间,比较两组的一般情况(男性比例和年龄)、即时技术成功率(EST后小肠镜镜身可通过的狭窄数占所有接受治疗的狭窄总数的百分比)、并发症(包括穿孔和出血等)发生率,以及治疗后3个月、6个月、1年的症状缓解率(完全缓解患者数与部分缓解患者数之和占患者总数的百分比)、累积无症状(行EST或外科手术后至末次随访仍未出现梗阻相关症状)生存率和累积无手术生存率。统计学方法采用卡方检验、独立样本t检验、Fisher确切概率法和Kaplan-Meier法。结果EST组和手术组患者狭窄的主要病因均为克罗恩病[分别占71.4%(15/21)和60.0%(12/20)],中位随访时间(范围)分别为12个月(6~46个月)和45个月(14~73个月)。EST组和手术组患者的男性比例、年龄、即时技术成功率、并发症发生率比较[57.1%(12/21)比65.0%(13/20)、(45.2±17.4)岁比(43.1±20.3)岁、95.3%(41/43)比100.0%(30/30)、26.9%(7/26)比10.0%(2/20)]差异均无统计学意义(均P>0.05);EST组因EST并发穿孔而手术的患者占9.5%(2/21),EST治疗后未再手术者占76.2%(16/21),EST组中位无症状生存时间为13.3个月。EST组与手术组治疗后3个月症状缓解率比较[17/19比100.0%(20/20)]差异无统计学意义(P>0.05);EST组治疗后6个月和1年症状缓解率均低于手术组同期[15/19比100.0%(20/20)、8/11比100.0%(20/20)],差异均有统计学意义(均采用Fisher确切概率法,P=0.047、0.037)。EST组和手术组治疗后3个月、6个月和1年累积无症状生存率比较(分别为66.0%比90.0%、61.0%比85.0%、54.0%比80.0%),Kaplan-Meier法分析显示两组无症状生存曲线差异均无统计学意义(均P>0.05)。EST组治疗后3个月、6个月、1年累积无手术生存率分别为90.0%、81.0%、73.0%,手术组治疗后3个月、6个月、1年累积无手术生存率均为100.0%。结论BAE下EST治疗空回肠良性狭窄技术上可行、安全性较好,短期内能有效缓解临床梗阻症状,避免或推迟外科手术。

Objective To evaluate the efficacy and safety of endoscopic stricturotomy(EST)under balloon-assisted enteroscopy(BAE)in treatment of benign jejuno-ileal stenosis.Methods From December 2015 to August 2021,at the Air Force Medical Center,41 patients who were diagnosed with benign jejuno-ileal stenosis underwent BAE deep small bowel EST and/or surgery due to ineffective or ineffective drug treatment were retrospectively analyzed.Twenty-one patients were treated with EST(EST group)and 20 patients were treated with surgery(surgery group).The etiology and follow-up time were analyzed,the general conditions(male proportion and age),the immediate technical success rate(the percentage of the stenosis that the enteroscope could pass through after EST in the total number of treated stenoses),the incidence of complications(including perforation,bleeding,etc.),the symptom remission rates at 3-month,6-month,and 1-year after treatment(the percentage of patients with complete or partial remission in the total number of patients),cumulative symptom-free survival rate(no obstruction-related symptoms after EST or surgery till the last follow-up)and cumulative surgery-free survival rate of two groups were compared.Chi-square test,independent t-test,Fisher′s exact probability method and Kaplan-Meier analysis were used for statistical analysis.Results The main etiology of stricture of EST group and surgery group was Crohn′s disease(71.4%,15/21 and 60.0%,12/20,respectively),and the median follow-up time was 12 months(6 to 46 months)and 45 months(14 to 73 months),respectively.There were no significant differences in male proportion,age,immediate technical success rate and incidence of complication between EST group and surgery group(57.1%,12/21 vs.65.0%,13/20;(45.2±17.4)years old vs.(43.1±20.3)years old;95.3%,41/43 vs.100.0%,30/30;26.9%,7/26 vs.10.0%,2/20,all P>0.05).In the EST group,9.5%(2/21)of the patients received surgery because of perforation during EST,76.2%(16/21)of the patients did not need surgery after EST,and the median symptom-free survival time of patients without symptoms in EST group was 13.3 months.There was no significant difference in the symptom remission rate at 3-month after treatment between EST group and the surgery group(17/19 vs.100.0%,20/20,P>0.05).The symptom remission rate at 6-month and 1-year of EST group were lower than those of the surgery group(15/19 vs.100.0%,20/20;8/11 vs.100.0%,20/20),and the differences were statistically significant(both were Fisher′s exact probability method,P=0.047 and 0.037).The cumulative symptom-free survival rates at 3-month,6-month and 1-year of EST group and surgery group were 66.0%vs.90.0%,61.0%vs.85.0%and 54.0%vs.80.0%,respectively.The results of Kaplan-Meier analysis indicated that there was no significant difference in the symptom-free survival curve between two groups(P>0.05).The 3-month,6-month and 1-year cumulative surgery-free survival rates after treatment in EST group were 90.0%,81.0%and 73.0%,respectively.The 3-month,6-month and 1-year cumulative surgery-free survival rates after treatment in surgery group were all 100.0%.Conclusion EST under BAE is technically feasible,and safe in the treatment of benign jejuno-ileal stenosis,and can effectively relieve clinical obstruction symptoms and avoid or delay surgery in the short term.