内镜黏膜下剥离术治疗结直肠黏膜病变的长期疗效研究

Study on the long-term clinical efficacy of endoscopic submucosal dissection in colorectal mucosal lesions

目的评价内镜黏膜下剥离术(ESD)治疗早期结直肠癌及癌前病变的长期疗效,并探究术后局部复发相关危险因素。方法回顾性分析2011年1月1日至2022年12月31日于北京大学第三医院行ESD且术后病理诊断为早期结直肠癌或癌前病变的1095例患者(1186个病变)的临床及内镜随访资料。评价ESD长期疗效,包括5年总体生存率、疾病特异性生存率、局部复发率和无复发生存率。应用Kaplan-Meier法进行生存分析,多因素Cox比例风险回归模型分析局部复发相关临床病理因素。结果ESD术后1067例患者完成随访,中位随访期为44.4(20.3,62.1)个月。734例(798个病变)完成内镜随访,内镜随访率为67.0%。随访期间死亡26例,5年总体生存率、疾病特异性生存率分别为96.0%、100.0%。随访期间17个病变出现局部复发,局部复发率为2.1%(17/798),ESD术后中位复发时间为11.8(4.9,21.4)个月。5年累积复发率为3.4%,5年无复发生存率为94.0%。多因素Cox比例风险回归分析显示,病变位于直肠(HR=2.64,95%置信区间1.00~6.94,P=0.049)、组织学不完全切除(HR=4.40,95%置信区间1.62~11.94,P=0.004)和垂直切缘阳性(HR=10.27,95%置信区间2.95~35.77,P<0.001)是ESD治疗结直肠黏膜病变术后局部复发的独立危险因素。结论ESD治疗结直肠黏膜病变具有良好的长期疗效,病变位于直肠、组织学不完全切除、垂直切缘阳性是ESD治疗早期结直肠癌及癌前病变术后局部复发的独立危险因素。

Objective To evaluate the long-term clinical efficacy of endoscopic submucosal dissection(ESD)in the treatment of early colorectal cancer and precancerous lesions,and to explore the risk factors of local recurrence after operation.Methods From January 1,2011 to December 31,2022,the clinical and endoscopic follow-up data of 1095 patients(1186 lesions)who underwent ESD at Peking University Third Hospital and were pathologically diagnosed as early colorectal cancer or precancerous lesions after ESD were retrospectively analyzed.The long-term efficacy of ESD was evaluated,which included 5-year overall survival rate,disease-specific survival rate,local recurrence rate,and recurrence-free survival rate.The Kaplan-Meier method was used for survival analysis.Multivariate Cox proportional hazards regression models were performed to analyze local recurrence related clinical pathological factors.Results After ESD,1067 patients were followed up,and the median follow-up period was 44.4(20.3,62.1)months.There were 734 patients having endoscopic follow-up(798 lesions,the follow-up rate was 67.0%).During the follow-up period,26 patients died,and the 5-year overall survival rate and disease-specific survival rate were 96.0%and 100.0%,respectively.During the follow-up period,local recurrence was observed in 17 lesions,with a recurrence rate of 2.1%(17/798)and a median time of recurrence after ESD was 11.8(4.9,21.4)months.The 5-year cumulative recurrence rate was 3.4%,and the 5-year recurrence-free survival rate was 94.0%.The results of multivariate Cox regression analysis showed that lesions located in the rectum(HR=2.64,95%confidence interval(95%CI)1.00 to 6.94,P=0.049),histologically incomplete resection(HR=4.40,95%CI 1.62 to 11.94,P=0.004),and positive vertical margin(HR=10.27,95%CI 2.95 to 35.77,P<0.001)were independent risk factors for local recurrence after ESD in the treatment of colorectal mucosal lesions.Conclusions Long-term efficacy of ESD in the treatment of colorectal mucosal lesions are favorable.Lesions located in the rectum,histologically incomplete resection,and positive vertical margin are independent risk factors for local recurrence after ESD in the treatment of colorectal mucosal lesions.