环周内镜黏膜下剥离术后食管狭窄55例的疾病进程及预后初探

Preliminary study on the process and prognosis of 55 cases of esophageal stricture after circumferential endoscopic submucosal dissection

目的探究行环周内镜黏膜下剥离术(ESD)后食管狭窄的特征、进程及预后,并初步分析单纯扩张、支架置入、黏膜移植、糖皮质激素(以下简称激素)应用等方式对于食管狭窄的防治作用。方法回顾性分析郑州大学第一附属医院于2017年8月至2022年3月因早期食管癌及癌前病变行环周ESD的55例患者的临床和随访数据,根据对食管狭窄采取的防治方式将其分为单纯扩张组(23例)和联合扩张组(32例),其中联合扩张组分为黏膜移植亚组(9例)、支架置入亚组(14例)、激素应用亚组(7例)、博来霉素亚组(2例,因例数过少而未纳入对比分析)。观察患者的总体预后情况,比较单纯扩张组与黏膜移植、支架置入、激素应用亚组治疗、预后和不良事件发生情况。统计学方法采用独立样本t检验、卡方检验或Fisher确切概率法。结果55例患者中,随访(894.1±417.7)d,33例(60.0%)发生难治性食管狭窄(总扩张次数≥5次),52例(94.5%)达到狭窄临床缓解,总扩张次数为(5.8±4.0)次,平均无吞咽困难期为(52.3±37.1)d。黏膜移植亚组的平均无吞咽困难期长于单纯扩张组、支架置入亚组、激素应用亚组[(114.5±50.0)d比(40.9±20.0)、(39.7±10.0)、(40.9±25.5)d],差异均有统计学意义(t=4.82、3.77、3.14,P<0.001、=0.011、=0.009)。单纯扩张组与黏膜移植、支架置入、激素应用亚组患者的总扩张次数[(6.8±4.8)次比(3.0±2.5)、(5.8±2.2)、(5.7±5.0)次]、狭窄临床缓解率[95.7%(22/23)比8/9、13/14、7/7]、不良事件发生率[17.4%(4/23)比5/9、5/14、2/7]比较,差异均无统计学意义(均P>0.05)。结论食管环周ESD治疗形成的食管狭窄具有复发性、难治性的特征,整体扩张次数较多,平均无吞咽困难期较短,经多次内镜下扩张治疗后,患者大多能达到狭窄临床缓解,但黏膜移植、支架置入、激素应用等方式均不能很好地干预此类食管狭窄患者的自然进程。

ObjectiveTo investigate the characteristics,process,and prognosis of esophageal stricture after circumferential endoscopic submucosal dissection(ESD),and to preliminarily analyze the prevention and treatment effects of simple dilation,stent placement,mucosal transplantation,and glucocorticoid(hereinafter referred to as hormone)application in esophageal stricture.MethodsFrom August 2017 to March 2022,at the First Affiliated Hospital of Zhengzhou University,the clinical and follow-up data of 55 patients who underwent circumferential ESD for early esophageal cancer and precancerous lesions were retrospectively analyzed.According to the prevention and treatment methods for esophageal stricture,the patients were divided into two groups:simple dilation group(23 cases)and combined dilation group(32 cases).The combined dilation group was divided into mucosal transplantation subgroup(9 cases),stent placement subgroup(14 cases),hormone application subgroup(7 cases),and bleomycin subgroup(2 cases,excluded from comparative analysis due to limited cases).Overall prognosis of patients was observed.Treatment efficacy,prognosis,and adverse events were compared among the simple dilation group,mucosal transplantation subgroup,stent placement subgroup,and hormone application subgroup.Independent samples t-test,chi-square test,and Fisher′s exact test were used for statistical analysis.ResultsAmong the 55 patients,the follow-up time was(894.1±417.7)days.Refractory esophageal stricture(total dilation times≥5)occurred in 33 patients(60.0%).Fifty-two patients(94.5%)achieved clinical remission of the stricture.The total number of dilations was 5.8±4.0,and the average dysphagia-free period was(52.3±37.1)days.The dysphagia-free period of mucosal transplantation subgroup was longer than that of the simple dilation group,stent placement subgroup,and hormone application subgroup((114.5±50.0)days vs.(40.9±20.0),(39.7±10.0),and(40.9±25.5)days,respectively),and the differences were statistically significant(t=4.82,3.77 and 3.14,P<0.001,=0.011,=0.009).There were no statistically significant differences between the simple dilation group and the mucosal transplantation subgroup,stent placement subgroup,and hormone application subgroup in the total number of dilations(6.8±4.8 vs.3.0±2.5,5.8±2.2,and 5.7±5.0),stricture remission rate(95.7%,22/23 vs.8/9,13/14,and 7/7),and incidence of adverse events(17.4%,4/23 vs.5/9,5/14,and 2/7;all P>0.05).ConclusionsEsophageal stricture formed after circumferential ESD shows the characteristics of recurrence and intractability.The over all number of dilations is high,and the average dysphagia-free period is short.Most patients can achieve clinical remission of the stricture after multiple times of endoscopic dilation treatment.However mucosal transplantation,stent placement,and hormone application cannot well intervene the natural process of esophageal stricture.