内镜黏膜下剥离术与外科手术治疗环周浅表食管鳞状细胞肿瘤的疗效对比

Comparison of endoscopic submucosal dissection and surgery for circumferential superficial esophageal squamous cell neoplasm

目的比较内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)和外科手术治疗环周浅表食管鳞状细胞肿瘤的疗效。方法对2013年11月—2021年10月在中国医学科学院肿瘤医院行ESD或外科手术治疗的153例病变累及食管环周的浅表食管鳞状细胞肿瘤患者进行回顾性分析,ESD组116例,外科手术组37例,分析比较病变整块切除率、完整切除率、手术时间、围手术期并发症、术后生活质量、术后无疾病复发生存率及总生存率等。结果ESD组的整块切除率为100.0%(116/116),完整切除率为96.6%(112/116),病变长径与并发症和完整切除率无明显相关性(P>0.05)。ESD组手术时间短于外科手术组[(175.1±52.2)min比(266.7±88.2)min,t=-5.991,P<0.001]。两组围手术期并发症发生率差异无统计学意义[5.2%(6/116)比8.1%(3/37),P=0.452]。根据EORTC-QLQ-C30量表功能及EORTC-QLQ-OES18量表评分,ESD组的情绪功能(P=0.008)、认知功能(P=0.013)及总健康水平(P<0.001)的评分高于外科手术组,外科手术组出现疲倦(P=0.002)、疼痛(P<0.001)、气促(P<0.001)、失眠(P<0.001)、食欲减退或丧失(P<0.001)、腹泻(P<0.001)及反流(P<0.001)等症状高于ESD组。两组无疾病复发生存率及术后总生存率差异无统计学意义(P>0.05)。与单纯球囊扩张相比,聚乙醇酸纤维膜联合自体食管黏膜移植联合临时性食管覆膜支架置入可降低ESD术后食管瘢痕狭窄率[53.3%(24/45)比100.0%(55/55),P<0.001],减少术后扩张次数[1.00(0.00,5.00)比9.00(5.00,14.00),P<0.001]。结论对环周浅表食管鳞状细胞肿瘤行ESD治疗安全性高,与传统外科手术相比,ESD手术时间更短、创伤更小,患者术后生存质量更高,术后食管狭窄问题通过内镜下治疗能够达到较好的治疗效果,ESD可作为环周浅表食管鳞状细胞肿瘤的首选治疗方法。

Objective To compare the efficacy of endoscopic submucosal dissection(ESD)and surgery for circumferential superficial esophageal squamous cell neoplasm.Methods A retrospective analysis was performed on 153 patients with superficial esophageal squamous cell neoplasm who underwent ESD or surgery at Cancer Hospital,Chinese Academy of Medical Sciences from November 2013 to October 2021.There were 116 cases in ESD group and 37 cases in the surgical group.The en block resection rate,complete resection rate,operation time,perioperative complication incidence,postoperative quality of life,postoperative disease-free survival and overall survival were compared.Results In the ESD group,the en block resection rate was 100.0%(116/116)and the complete resection rate was 96.6%(112/116).The longitudinal diameter of lesion had no significant correlation with complications or complete resection rate(P>0.05).The operation time of the ESD group was significantly shorter than that of the surgical group(175.1±52.2 min VS 266.7±88.2 min,t=-5.991,P<0.001).There was no significant difference in the incidence of perioperative complications between the ESD group and surgical group[5.2%(6/116)VS 8.1%(3/37),P=0.452].According to EORTC-QLQ-C30 and EORTC-QLQ-OES18,emotional function(P=0.008),cognitive function(P=0.013)and the total health level(P<0.001)of the ESD group were significantly higher than those in the surgical group.Fatigue(P=0.002),pain(P<0.001),dyspnea(P<0.001),insomnia(P<0.001),anorexia(P<0.001),diarrhea(P<0.001)and reflux(P<0.001)in the surgical group were significantly higher than those in ESD group.There was no significant difference in disease-free survival or overall survival between the two groups(P>0.05).Polyglycolic acid combined with autologous esophageal mucosal transplantation combined with temporary esophageal stent implantation could reduce the rate of esophageal scar stenosis after ESD[53.3%(24/45)VS 100.0%(55/55),P<0.001]and significantly reduce the number of postoperative dilation[1.00(0.00,5.00)VS 9.00(5.00,14.00),P<0.001]compared with balloon dilation alone.Conclusion ESD is superior to traditional surgery for the treatment of circumferential superficial esophageal squamous cell neoplasm because of high operational safety,shorter operation time,less trauma,better postoperative life quality.Postoperative esophageal stenosis can still be well cured after endoscopic treatment.Therefore,ESD can be used as the first choice for the treatment of circumferential superficial esophageal squamous cell neoplasm.