食管癌术后吻合口狭窄扩张后再狭窄的影响因素探讨

Risk factors of restenosis after dilation of anastomotic stenosis in patients with esophageal cancer surgery

目的探讨食管癌术后吻合口狭窄扩张后再狭窄的影响因素。方法本研究为回顾性研究,回顾2015年6月至2021年7月于南京医科大学附属淮安第一医院因食管癌根治术后并发吻合口狭窄于内镜中心行内镜下探条扩张患者的病例资料,根据是否进行过二次扩张分为单次扩张组及多次扩张组,使用单因素、多因素、分层及平滑曲线拟合探讨再狭窄的影响因素。结果共997例患者纳入分析,其中男性占68.4%(682/997)。患者中位年龄65(61,70)岁,狭窄距门齿中位距离为20(20,22)cm,中位狭窄直径为4(3,5)mm,中位初次扩张后直径为11(11,13)mm。单次扩张组患者486例,多次扩张组患者511例。两组患者狭窄距门齿距离(Z=-2.303)、狭窄直径(Z=-4.637)、初次扩张后直径(Z=-5.773)比较差异均有统计学意义(P<0.05)。多因素分层logistic结果显示:男性患者狭窄距门齿距离每增加1 cm,多次扩张的风险下降约3%(OR=0.97,95%CI:0.93~1.00,P=0.047),狭窄直径每增加1 mm,多次扩张的风险下降约15%(OR=0.85,95%CI:0.76~0.94,P=0.004),扩张后直径每增加1 mm,多次扩张的风险下降约13%(OR=0.87,95%CI:0.78~0.96,P=0.007)。<60岁的女性患者,扩张后直径每增加1 mm,多次扩张的风险下降约31%(OR=0.69,95%CI:0.47~0.98,P=0.049)。≥60岁的女性患者,年龄每增加1岁,风险降低约5%(OR=0.95,95%CI:0.91~1.00,P=0.037),扩张后直径增加1 mm,风险降低17%(OR=0.83,95%CI:0.70~0.99,P=0.039)。分层平滑曲线拟合显示:距门齿距离<23.00 cm、狭窄直径<4.51 mm、扩张后直径<12.00 mm是多次扩张的危险因素。结论狭窄距门齿距离<23.00 cm、狭窄直径<4.51 mm、扩张后直径<12.00 mm的患者更易多次扩张。首次扩张治疗应尽量将吻合口直径扩张至12.00 mm及以上,可降低再狭窄风险。

Objective To investigate the risk factors of restenosis after dilation of anastomotic stenosis in patients with esophageal cancer surgery.Methods Clinical data of 997 patients who underwent endoscopic dilation due to anastomotic stenosis after esophageal cancer radical surgery in the Affiliated Huai′an First Hospital of Nanjing Medical University from June 2015 to July 2021,were retrospectively analyzed.There were 486 cases receiving single dilation(single dilation group)and 511 cases receiving more than two dilations(multiple dilation group).The risk factors of restenosis were explored using univariate and multivariate logistic regression analysis.Results There were 682 males and 315 females with a median age of 65 years,the median distance between the stenosis and incisor was 20(20,22)cm,the median stenosis diameter was 4(3,5)mm,and the median stenosis diameter after dilation was 11(11,13)mm.Univariate analysis showed that there were significant differences in the distance of the stenosis and incisor(Z=-2.303,P<0.05),stenosis diameter(Z=-4.637,P<0.05)and stenosis diameter after dilation(Z=-5.773,P<0.05)between single and multiple dilation groups.Stratified multivariate logistic regression showed that for male patients,risk of multiple dilations dropped by approximately 3%for every 1-mm increase in the distance between the stenosis and incisor(OR=0.97,95%CI:0.93-1.00,P=0.047);the risk of multiple dilations decreased by about 15%,for every 1-mm increase in stenosis diameter(OR=0.85,95%CI:0.76-0.94,P=0.004);the risk of multiple dilations decreased by about 13%for every 1-mm increase in stenosis diameter after dilation(OR=0.87,95%CI:0.78-0.96,P=0.007).For females patients under 60 years old,the risk of multiple dilations decreased by about 31%,for every 1-mm increase in stenosis diameter after dilation(OR=0.69,95%CI:0.47-0.98,P=0.049);for female patients≥60 years old,the risk decreased by about 5%,for every 1-year increase in age(OR=0.95,95%CI:0.91-1.00,P=0.037),risk of multiple dilations dropped by 17%(OR=0.83,95%CI:0.70-0.99,P=0.039)for every 1 mm increase in stenosis diameter after dilation.Stratified smooth curve fitting indicated that the distance between the stenosis and incisor≤23 mm,stenosis diameter≤4.5 mm,stenosis diameter after dilation≤12 mm were risk factors for multiple dilations.Conclusions The study indicates that patients with the distance between the stenosis and incisor≤23 mm,stenosis diameter≤4.5 mm,stenosis diameter after dilation≤12 mm may need multiple dilations;and the first dilation should expand the stenosis diameter to 12 mm or above as far as possible to reduce the risk of restenosis in patients receiving esophageal cancer radical surgery.