ESD与STER治疗食管平滑肌瘤的临床应用及效果分析

Clinical application and efficacy analysis of ESD and STER in the treatment of esophageal leiomyoma

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)和经内镜黏膜下隧道肿瘤切除术(submucosal tunneling endoscopic resection,STER)在食管平滑肌瘤治疗中的价值。方法回顾性分析2016年1月至2022年6月于武汉大学人民医院消化内科进行ESD与STER治疗、术后病理及免疫组化确诊为食管平滑肌瘤的181例患者的临床资料。结果181例患者的食管平滑肌瘤在内镜下被成功切除,病灶多呈表面光滑隆起形态(175/181,96.7%),色泽多正常,多位于食管下段处(84/181,46.4%)。ESD组135例,其中125例(92.6%)行EUS检查,结果显示,91例(72.8%)病灶起源于黏膜肌层,15例(12.0%)起源于黏膜下层,15例(12.0%)起源于固有肌层,4例(3.2%)起源于黏膜多层,大部分为均匀低回声灶,有5例内部回声欠均匀。STER组46例,其中45例(97.8%)行EUS检查,10例(22.2%)病灶起源于黏膜肌层,1例(2.2%)起源于黏膜下层,31例(68.9%)起源于固有肌层,3例(6.7%)起源于黏膜多层,大部分呈均匀低回声灶,仅有2例内部回声欠均匀。在病灶位置上,ESD组中食管上段45例,食管中段40例,食管下段50例,STER组中食管上段4例,食管中段8例,食管下段34例。在病灶大小上,ESD组中病灶<2 cm有127例、≥2 cm有8例,STER组中34例<2 cm、12例≥2 cm;两组在病灶起源、位置、大小方面比较,差异有显著统计学意义(P<0.001)。行内镜下治疗时,STER组手术时间较ESD组时间长,且其在住院天数、治疗费用、术后发生并发症方面也比ESD手术组多,差异均有统计学意义(P<0.05)。随访出院后门诊行胃镜检查发现,181例患者中有64例(35.4%)完成术后1~24个月内随访,其中有8例(12.5%)发现食管肿物残留或复发。结论食管平滑肌瘤多位于食管下段且病灶常<2 cm,以黏膜肌层来源常见。ESD治疗黏膜肌层来源、STER治疗固有肌层来源的食管平滑肌瘤均较为安全有效,STER治疗技术仍需进一步优化从而减少并发症的发生。

Objective To investigate the value of endoscopic submucosal dissection(ESD)and submucosal tunneling endoscopic resection(STER)in the treatment of esophageal smooth muscle tumors.Methods The clinical data of 181 patients who underwent ESD and STER in the Department of Gastroenterology,Renmin Hospital of Wuhan University from Jan.2016 to Jun.2022,and whose diagnosis of esophageal smooth muscle tumor was confirmed by postoperative pathology and immunohistochemistry were retrospectively analyzed.Results A total of 181 cases of esophageal smooth muscle tumors were successfully resected endoscopically,and most of the lesions showed a smooth surface elevation pattern(175/181,96.7%)with normal color,mostly located at the lower esophagus(84/181,46.4%).One hundred and thirty-five cases in the ESD group,of which 125 patients(92.6%)underwent EUS,91 lesions(72.8%)originated in the muscularis mucosae,15 lesions(12.0%)originated in the submucosa,15 lesions(12.0%)originated in the muscularis propria,and 4 lesions(3.2%)originated in multiple layers of the mucosa,most of which were homogeneous hypoechoic foci,with 5 cases having inhomogeneous internal echoes.In the STER group of 46 cases,of which up to 45 patients(97.8%)underwent EUS,10 lesions(22.2%)originated in the muscularis mucosae,1 lesion(2.2%)originated in the submucosa,31 lesions(68.9%)originated in the muscularis propria,and 3 lesions(6.7%)originated in the multiple layers of the mucosa,most of which were homogeneous hypoechoic foci,and only 2 cases had inhomogeneous internal echoes.In terms of lesion location,there were 45 cases in the upper esophagus,40 cases in the middle esophagus,50 cases in the lower esophagus in the ESD group,and 4 cases in the upper esophagus,8 cases in the middle esophagus,34 cases in the lower esophagus in the STER group.In terms of lesion size,there were 127 cases of lesions<2 cm and 8 cases of≥2 cm in the ESD group and 34 cases of<2 cm and 12 cases of≥2 cm in the STER group.The differences in lesion origin,location and size between the two groups were statistically significant(P<0.001).When endoscopic treatment was performed,the STER group had a longer operative time than that in the ESD group,and their hospitalization days,treatment costs,postoperative complications were also higher than those of the ESD group(P<0.05).Follow-up gastroscopy performed in the outpatient clinic after discharge revealed that 64 of 181 patients(35.4%)completed follow-up within 1 to 24 months after surgery,among which 8 cases(12.5%)were found to have residual esophageal masses or recurrence.Conclusion Esophageal smooth muscle tumors are mostly located in the lower esophagus and the lesions are often<2 cm,and the muscularis mucosae origin is common.ESD treatment for the muscularis mucosae origin and STER treatment for the muscularis propria origin of esophageal smooth muscle tumors are safe and effective,and STER treatment techniques still need to be further optimized to reduce the occurrence of complications.