【摘要】：目的:評價內(nèi)鏡下切除術(shù),包括內(nèi)鏡黏膜下挖除術(shù)(endoscopic submucosal excavation,ESE)和經(jīng)黏膜下隧道內(nèi)鏡腫瘤切除術(shù)(submucosal tunneling endoscopic resection,STER),在食管和賁門固有肌層腫瘤(muscularis propria tumors,MPTs)治療中的臨床應(yīng)用價值,并對比分析兩者的安全性與有效性,分析患者術(shù)后出現(xiàn)并發(fā)癥的危險因素。方法:收集2013年01月-2016年10月于成都軍區(qū)總醫(yī)院消化內(nèi)鏡中心行ESE及STER術(shù)患者資料,篩選出符合入選標(biāo)準(zhǔn)的病例53例,回顧性分析其臨床及病理資料;其中接受ESE手術(shù)患者29例,STER手術(shù)患者24例。主要觀察指標(biāo):手術(shù)時間、術(shù)中并發(fā)癥、整塊切除率、術(shù)后不良事件發(fā)生情況及復(fù)發(fā)情況。根據(jù)術(shù)后病理和病變部位行亞組分析。結(jié)果:1.本研究共納入患者53例,男16例,女37例;平均年齡50.38±8.15歲,MPTs平均直徑為20.13±13.56mm;按發(fā)生部位來分:食管43.4%(23/53),賁門56.6%(30/53);按術(shù)后病理來分:平滑肌瘤28.3%(15/53)、間質(zhì)瘤67.9%(36/53)、其他(神經(jīng)內(nèi)分泌瘤、脂肪瘤等)3.8%(2/53)。2.超聲內(nèi)鏡(endoscopic ultrasonography,EUS)對病變的判斷:來源層次的總體符合率為100%;病變性質(zhì)的符合率為62.3%(33/53),其中間質(zhì)瘤的符合率為87.5%(21/24),平滑肌瘤的符合率為44.4%(12/27);EUS下表現(xiàn)為形狀不規(guī)則的MPTs,我們將其診斷為間質(zhì)瘤的準(zhǔn)確率明顯高于平滑肌瘤(χ~2=6.24,P=0.012)3.本研究53例患者的整塊切除率為96.2%(51/53),兩組在整塊切除率方面無差異(STER 95.8%VS ESE 96.6%,P0.05);STER組手術(shù)時間明顯長于ESE組(140.46±73.48min VS 60.03±51.29min,P0.05);術(shù)中總的并發(fā)癥發(fā)生率11.3%(6/53),均發(fā)生于賁門部,其中術(shù)中明顯出血發(fā)生率為9.4%(5/53),術(shù)中穿孔發(fā)生率為1.9%(1/53),STER組術(shù)中并發(fā)癥低于ESE組(4.2%VS 17.2%,P0.05);術(shù)后總的并發(fā)癥發(fā)生率22.6%(12/53)(有4例患者同時并發(fā)了兩種術(shù)后并發(fā)癥),其中感染發(fā)生率為11.3%(6/53),氣體相關(guān)性并發(fā)癥11.3%(6/53),少量胸腔積液5.7%(3/53),遲發(fā)性出血1.9%(1/53);術(shù)后總的并發(fā)癥STER組明顯高于ESE組(37.5%VS 10.3%,P0.05),特別是術(shù)后氣體相關(guān)性并發(fā)癥(25.0%VS 0,P0.05);兩組在術(shù)后平均住院天數(shù)及禁食天數(shù)方面無明顯差異。4.食管的MPTs,ESE與STER相比:手術(shù)時間短(43.42±17.89min VS156.27±69.23min,P0.001)、鈦夾使用少(1.58±2.87 VS 7.45±1.29,P0.001)、術(shù)后并發(fā)癥發(fā)生率低(0 VS 45.5%,P=0.014)且術(shù)中并發(fā)癥無差異。賁門的MPTs,STER與ESE相比手術(shù)時間較長(127.08±77.01min VS71.76±63.50min,P0.001),但術(shù)中并發(fā)癥較低(7.7%VS 29.4%,P=0.196),且術(shù)后并發(fā)癥無差異。5.結(jié)合單因素分析和多因素Logistic回歸模型分析,本研究表明MPTs直徑大、形狀不規(guī)則、采用STER術(shù)、手術(shù)時間長是術(shù)后并發(fā)癥發(fā)生的危險因素。6.隨訪及預(yù)后:平均隨訪時間4.62±6.53月(2-20月)、平均隨訪次數(shù)1.30±0.70次(1-4次),無一例復(fù)發(fā)。結(jié)論:1.ESE、STER是MPTs安全有效的微創(chuàng)治療方法;STER手術(shù)時間長于ESE,但術(shù)中視野清晰、術(shù)中出血并發(fā)癥發(fā)生低;STER手術(shù)組氣體相關(guān)性并發(fā)癥高于ESE組,但均比較輕微,經(jīng)保守治療后消失。2.食管的MPTs,ESE與STER相比手術(shù)時間短、鈦夾使用少、術(shù)后并發(fā)癥發(fā)生率低且術(shù)中并發(fā)癥無差異,故推薦行ESE術(shù)。賁門的MPTs,STER與ESE相比手術(shù)時間長,但術(shù)中并發(fā)癥較低且術(shù)后并發(fā)癥無差異,故賁門部的MPTs推薦行STER術(shù)。3.EUS對MPTs有較好的診斷作用,特別是超聲下表現(xiàn)為形狀不規(guī)則的MPTs診斷為間質(zhì)瘤的準(zhǔn)確性較高。4.研究表明MPTs直徑大、形狀不規(guī)則、采用STER術(shù)、手術(shù)時間長是術(shù)后并發(fā)癥發(fā)生的危險因素。
[Abstract]:Objective: To evaluate the clinical value of endoscopic submucosal excavation (ESE) and submucosal tunneling endoscopic resection (STER) in the treatment of esophageal and cardiac muscular propria tumors (MPTs). Methods: The clinical and pathological data of 53 patients who underwent ESE and STER in the center of digestive endoscopy of Chengdu Military Region General Hospital from January 2013 to October 2016 were analyzed retrospectively. Main outcome measures: operative time, intraoperative complications, total resection rate, occurrence and recurrence of adverse events after operation. Subgroup analysis was performed according to postoperative pathology and lesion site. Results: 1. 53 patients, 16 males and 37 females, with an average age of 50.38 (+ 8.15 years), were included in this study. MPTs were 20. 13 [13.56 mm], 43.4% (23/53) of the esophagus and 56.6% (30/53) of the cardia, 28.3% (15/53) of leiomyomas, 67.9% (36/53) of stromal tumors, and 3.8% (2/53) of other tumors (neuroendocrine tumors, lipomas, etc.). 2. Endoscopic ultrasonography (EUS) showed that the overall coincidence rate at the source level was 100%; The coincidence rate of degeneration was 62.3% (33/53), including 87.5% (21/24) of stromal tumors and 44.4% (12/27) of leiomyomas, and the accuracy of diagnosing stromal tumors (_~2 = 6.24, P = 0.012) was significantly higher in patients with EUS with irregular shape MPTS than that of leiomyomas (_~2 = 6.24, P = 0.012). There was no significant difference in the total resection rate between the two groups (STER 95.8% VS ESE 96.6%, P 0.05); the operation time in STER group was significantly longer than that in ESE group (140.46 65507 The intraoperative complications in ER group were lower than those in ESE group (4.2% VS 17.2%, P 0.05); the total postoperative complications rate was 22.6% (12/53) (4 patients had two postoperative complications simultaneously), including infection rate 11.3% (6/53), gas-related complications 11.3% (6/53), small amount of pleural effusion 5.7% (3/53), delayed hemorrhage 1.9% (1/53); Esophageal MPTS and ESE were significantly shorter than STER (43.42 17.89 6550 Compared with ESE, MPTs and STER had longer operation time (127.08 VS 71.76 Regression model analysis showed that MPTs with large diameter and irregular shape were risk factors for postoperative complications. 6. Follow-up and prognosis: the average follow-up time was 4.62 (+ 6.53 months) (2-20 months), the average follow-up time was 1.30 (+ 0.70 times) (1-4 times), no recurrence. Conclusion: 1. ESE, STER is a safe and effective minimally invasive treatment for MPTs. Methods: The operation time of STER was longer than that of ESE, but the visual field was clear and the complications of bleeding were lower. The gas-related complications in STER group were higher than that of ESE group, but all were slight, and disappeared after conservative treatment. It is recommended that ESE be performed. MPTs of cardia and STER have longer operation time than ESE, but the intraoperative complications are lower and there is no difference in postoperative complications. So MPTs of cardia are recommended to use STER. 3. EUS has better diagnostic effect on MPTs, especially for MPTs with irregular shape under ultrasound. 4. Research shows that MPTs are straightforward. Large diameter and irregular shape, STER operation and long operation time are the risk factors of postoperative complications.
【學(xué)位授予單位】：西南醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R735

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