背景:内窥镜切除方法,包括内镜黏膜下剥离术(ESD),黏膜下隧道内镜切除术(STER)和内镜全层切除术(EFTR),已广泛用于治疗位于上消化道的粘膜下肿瘤(SMTs)。然而,与位于食道或胃中的SMT相比,从食管胃交界处(EGJ)内镜下切除SMTs要困难得多,因为EGJ的尖角和狭窄的管腔。源自EGJ中固有肌层(MP)的SMT,尤其是那些在铝外生长并紧密附着在浆膜上的,使内窥镜切除更加困难。
目的:探讨内镜下从EGJ的MP层切除SMTs困难的预测因素。
方法:本研究共纳入90例来自EGJMP层的SMTs患者。内镜切除的难度定义为手术时间长,整块切除失败,术中出血。临床病理,收集和分析内镜和随访数据.零碎切除的独立风险的统计分析,手术时间长,术中出血采用单因素和多因素分析进行评估.
结果:根据肿瘤的位置和生长方式,44例患者接受STER,14例患者接受了EFTR,其余32例患者接受了标准的ESD程序。肿瘤大小为20.0mm(范围5.0-100.0mm)。90个病变中有47个(52.2%)呈规则形状。整体切除率为84.4%。手术时间为43分钟(范围16-126分钟)。术中出血率为18.9%。在手术期间或之后没有需要治疗干预的不良事件。手术入路与整块切除无明显相关性,手术时间长或术中出血。大肿瘤大小(≥30mm)和不规则肿瘤形状是零碎切除的独立预测因素(分别为OR:7.346,P=0.032和OR:18.004,P=0.029),手术时间长(≥60min)(OR:47.330,P=0.000,OR:6.863,P=0.034),术中出血(OR:20.631,P=0.002,OR:19.020,P=0.021)。
结论:内镜切除是治疗EGJMP层SMTs的有效方法。大尺寸和不规则形状的肿瘤是内镜下难以切除的独立预测因素。
BACKGROUND: Endoscopic resection approaches, including endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR), have been widely used for the treatment of submucosal tumors (SMTs) located in the upper gastrointestinal tract. However, compared to SMTs located in the esophagus or stomach, endoscopic resection of SMTs from the esophagogastric junction (EGJ) is much more difficult because of the sharp angle and narrow lumen of the EGJ. SMTs originating from the muscularis propria (MP) in the EGJ, especially those that grow extraluminally and adhere closely to the serosa, make endoscopic resection even more difficult.
OBJECTIVE: To investigate the predictors of difficult endoscopic resection for SMTs from the MP layer at the EGJ.
METHODS: A total of 90 patients with SMTs from the MP layer at the EGJ were included in the present study. The difficulty of endoscopic resection was defined as a long procedure time, failure of en bloc resection and intraoperative bleeding. Clinicopathological, endoscopic and follow-up data were collected and analyzed. Statistical analysis of independent risks for piecemeal resection, long operative time, and intraoperative bleeding were assessed using univariate and multivariate analyses.
RESULTS: According to the location and growth pattern of the tumor, 44 patients underwent STER, 14 patients underwent EFTR, and the remaining 32 patients received a standard ESD procedure. The tumor size was 20.0 mm (range 5.0-100.0 mm). Fourty-seven out of 90 lesions (52.2%) were regularly shaped. The overall en bloc resection rate was 84.4%. The operation time was 43 min (range 16-126 min). The intraoperative bleeding rate was 18.9%. There were no adverse events that required therapeutic intervention during or after the procedures. The surgical approach had no significant correlation with en bloc resection, long operative time or intraoperative bleeding. Large tumor size (≥ 30 mm) and irregular tumor shape were independent predictors for piecemeal resection (OR: 7.346, P = 0.032 and OR: 18.004, P = 0.029, respectively), long operative time (≥ 60 min) (OR: 47.330, P = 0.000 and OR: 6.863, P = 0.034, respectively) and intraoperative bleeding (OR: 20.631, P = 0.002 and OR: 19.020, P = 0.021, respectively).
CONCLUSIONS: Endoscopic resection is an effective treatment for SMTs in the MP layer at the EGJ. Tumors with large size and irregular shape were independent predictors for difficult endoscopic resection.