内镜下基于瘢痕与病变位置关系的分型建立及疗效分析

Curative effect of novel endoscopic classification based on the correlation of the scar and lesion location

目的内镜下基于瘢痕与病变位置关系建立瘢痕-内镜黏膜下剥离术(Scar-endoscopic submucosal dissection,scar-ESD)分型,并探讨ESD临床疗效。方法收集2015年1月至2022年8月在南京中医药大学附属江苏省中医院内镜中心,行伴有瘢痕的ESD患者临床资料132例。根据scar-ESD分型,分为同部位未行外科管腔吻合术的A型(含A0、A1、A2、A3型)和行外科管腔吻合术的B型(含B0、B1、B2型)。统计各型ESD手术时长、标本大小、术中辅助方法、术中穿孔、整块切除率、标本破损率、术后并发症等。结果132例患者年龄(64.22±9.51)岁,男女比为3∶1。病变位于食管49例(37.12%),胃部40例(30.30%),结肠43例(32.58%)。每例患者手术时间(49.66±32.96)min,其中A0型(30.38±12.85)min,与A2型(52.10±36.55)min比较,差异有统计学意义(t=2.15,P<0.05);B0型(45.03±24.35)min,与B2型(90.71±44.95)min比较,差异有统计学意义(t=3.95,P<0.05)。术中使用辅助方式38例(28.79%),发生穿孔5例(其中A2型4例、A3型1例),其中结肠穿孔发生率最高9.3%(4/43)。整块切除率97.73%(129/132),R0切除率88.64%(117/132),治愈性切除率84.09%(111/132)。标本破损23例(17.42%),其中胃部标本破损发生率最高32.50%(13/40)。A2型与A0型比较,标本破损率差异有统计学意义(t=2.31,P<0.05);B2型与A0、A1、A2、A3、B0型比较,标本破损率差异均有统计学意义(P<0.05)。结论scar-ESD分型有利于内镜下描述和预测ESD操作难度。ESD作为伴有瘢痕的早期消化道病变治疗方案,疗效满意,但需要经验丰富的医生操作。

Objective To establish new scar-endoscopic submucosal dissection(scar-ESD)classification based on the relationship between scars and lesion location under endoscopy,and to explore the clinical efficacy of ESD.Methods Clinical data of 132 patients who underwent ESD with scars from January 2015 to August 2022 at the Digestive Endoscopy Center of Affiliated Hospital of Nanjing University of Chinese Medicine,Jiangsu Province Hospital of Chinese Medicine.According to the scar-ESD classification,the lesions without surgical anastomosis at the same location were classified as type A:A0,A1,A2,and A3;and those with surgical anastomosis were classified as type B:B0,B1,and B2.The ESD operation time,specimen size,intraoperative assistant methods,intraoperative perforation,en-bloc resection rate,specimen damage rate,and postoperative complications were recorded for each subtype.Results The age of the 132 patients was 64.22±9.51,with a male-to-female ratio of 3∶1.Forty-nine lesions(37.12%)were located in the esophagus,40 cases(30.30%)in the stomach,and 43 cases(32.58%)in the colon.The operation time was 49.66±32.96 minutes.The operation time for A0 subtype was 30.38±12.85 minutes,which was significantly shorter than that of the A2(52.10±36.55 minutes,t=2.15,P<0.05).The operation time for B0 subtype was 45.03±24.35 minutes,which was significantly shorter than that of the B2(90.71±44.95 minutes,t=3.95,P<0.05).Intraoperative assistance was used in 38 cases(28.79%).Intraoperative perforation occurred in 5 cases(3.79%),including 4 cases of A2 and 1 case of A3,and the highest incidence occurred in the colon[9.30%(4/43)].The en-bloc resection rate was 97.73%(129/132),the R0 resection rate was 88.64%(117/132),and the curative resection rate was 84.09%(111/132).The specimen damage occurred in 23 cases(17.42%),with the highest incidence in the stomach[32.50%(13/40)].There were significant differences between A2 and A0 subtypes(t=2.31,P<0.05)in this variable,and between B2 subtype and A0,A1,A2,A3,and B0 subtypes(P<0.05).Conclusion The scar-ESD classification is beneficial for describing and predicting difficulty of ESD.ESD is still the preferred treatment for early digestive lesions with scars,and the efficacy is satisfactory.But it requires experienced physicians to perform the operation.