内镜黏膜下剥离术与内镜下黏膜切除术治疗老年早期胃癌的临床效果比较

Comparison of clinical effects of endoscopic submucosal dissection and endoscopic mucosal resection in the treatment of elderly patients with early gastric cancer

目的比较内镜黏膜下剥离术(ESD)与内镜下黏膜切除术(EMR)治疗老年早期胃癌的临床效果。方法回顾性选择解放军联勤保障部队2019年6月至2022年2月收治的92例老年早期胃癌患者为研究对象,按手术方式不同分为ESD组(60例)与EMR组(32例),比较两组短期临床疗效,术前、术后3 d检测胃功能三项[胃蛋白酶原Ⅰ(PGⅠ)、胃蛋白酶原Ⅱ(PGⅡ)、PGⅠ/PGⅡ比值]、肿瘤标志物[癌胚抗原(CEA)、糖类抗原19-9(CA19-9)、糖类抗原125(CA125)]及病灶内侵袭基因[血管内皮生长因子C(VEGF-C)、钙黏附蛋E(E-cadherin)、微管解聚蛋白(Stathmin)、Krüppel样因子4(KLF4)]水平,并进行比较。随访1年,比较两组复发率及并发症发生情况。结果92例患者均成功切除病变组织,两组R0切除率比较差异无统计学意义(P>0.05)。术后3 d,两组PGⅠ水平、PGⅠ/PGⅡ比值升高,PGⅡ水平降低,并且ESD组PGⅠ水平、PGⅠ/PGⅡ比值高于EMR组[(86.50±8.23)μg/L比(77.47±7.40)μg/L、5.29±0.54比3.65±0.50],PGⅡ水平低于EMR组[(16.34±3.05)μg/L比(21.20±3.27)μg/L],差异有统计学意义(P<0.05)。术后3 d,两组CEA、CA19-9、CA125水平均降低,并且ESD组低于EMR组[(2.42±0.45)μg/L比(3.29±0.40)μg/L、(8.55±2.10)kU/L比(10.62±2.76)kU/L、(13.75±4.28)kU/L比(17.20±4.90)kU/L],差异有统计学意义(P<0.05)。术后3 d,两组E-cadherin、KLF4 mRNA表达升高,VEGF-C、Stathmin mRNA表达下降,并且ESD组E-cadherin、KLF4 mRNA表达量低于EMR组(2.89±0.31比3.03±0.21、2.90±0.28比3.12±0.37),VEGF-C、Stathmin mRNA表达量高于EMR组(0.45±0.11比0.41±0.07、0.52±0.23比0.43±0.09),差异均有统计学意义(P<0.05)。ESD组并发症发生率低于EMR组[5.00%(3/60)比23.33%(14/60)],差异有统计学意义(χ^(2)=8.32,P<0.01)。两组1年复发率比较差异无统计学意义(P>0.05)。结论与EMR比较,ESD治疗老年早期胃癌疗效显著,可更好地纠正胃蛋白酶原异常分泌,促进胃部细胞及腺体功能恢复,降低血清肿瘤标志物水平,抑制肿瘤细胞转移及增殖,安全性较好。

Objective To compare the clinical efficacy of endoscopic submucosal dissection(ESD)and endoscopic mucosal resection(EMR)in the treatment of elderly patients with early gastric cancer.Methods Ninety-two elderly patients with early gastric cancer admitted to the 923th Hospital of the Joint Service Support Force of PLA from June 2019 to February 2022 were enrolled,and they were divided into ESD group(60 cases)and EMR group(32 cases)according to different surgical methods.The ESD group was treated with ESD surgery,while the EMR group was treated with EMR surgery.The short-term clinical efficacy of the two groups was compared.The gastric function including pepsinogenⅠ(PGⅠ),pepsinogenⅡ(PGⅡ),PGⅠ/PGⅡratio and the tumor markers including carcinoembryonic antigen(CEA),carbohydrate antigen 19-9(CA19-9),carbohydrate antigen 125(CA125),and invasion genes within the lesion including vascular endothelial growth factor C(VEGF-C),E-cadherin,microtubule depolymerin(Stathmin),Krüppel like factor 4(KLF4)were detected before and 3 d after surgery.Followed up for 1 year,the recurrence rate and complications between the two groups were compared.Results All of 92 patients successfully removed the diseased tissue as a whole,and the R0 and R1 resection rate between the two groups had no statistical differences(P>0.05).At 3 d after surgery,the levels of PGⅠand PGⅠ/PGⅡin the both groups were higher than those before surgery,and the level of PGⅡin the both groups was lower than that before surgery;the levels of PGⅠand PGⅠ/PGⅡin the ESD group were higher than those in the EMR group:(86.50±8.23)μg/L vs.(77.47±7.40)μg/L,5.29±0.54 vs.3.65±0.50;the level of PGⅡratio in the ESD group was lower than that in the EMR group:(16.34±3.05)μg/L vs.(21.20±3.27)μg/L,there were statistical differences(P<0.05).At 3 d after surgery,the levels of CEA,CA19-9 and CA125 in the two groups were decreased,and the levels of the above indicators in the ESD group were lower than those in the EMR group:(2.42±0.45)μg/L vs.(3.29±0.40)μg/L,(8.55±2.10)kU/L vs.(10.62±2.76)kU/L,(13.75±4.28)kU/L vs.(17.20±4.90)kU/L,there were statistical differences(P<0.05).At 3 d after surgery,the mRNA expression of E-cadherin and KLF4 in the two groups were increased,and the mRNA expression of VEGF-C,Stathmin in the two groups were decreased,and the mRNA expression of E-cadherin and KLF4 in the ESD group were lower than those in the EMR group:2.89±0.31 vs.3.03±0.21,2.90±0.28 vs.3.12±0.37,and the mRNA expression of VEGF-C,Stathmin in the ESD group were higher than those in the EMR group:0.45±0.11 vs.0.41±0.07,0.52±0.23 vs.0.43±0.09,there were statistical differences(P<0.05).The complication rate in the ESD group was lower than that in the EMR group:5.00%(3/60)vs.23.33%(14/60),there was statistical difference(χ^(2)=8.32,P<0.01).The recurrence rate in the 1-year between the two groups had no statistical difference(P>0.05).Conclusions Compared with EMR,ESD is effective in the treatment of elderly early gastric cancer,which can better correct the abnormal secretion of pepsinogen,promote the functional recovery of gastric cells and glands,reduce the level of serum tumor markers,inhibit the metastasis and proliferation of tumor cells,and has good safety.