目的:评估有多少良性“困难”结直肠病变(DCRLs)患者需要手术切除,可以用内窥镜切除(ER)而不是手术切除治疗。
方法:回顾了我们内窥镜单元前瞻性收集的结肠镜数据库,以确定所有连续的患者,在2011年7月至2013年8月期间,由于DCRLs的存在,在手术切除前进行了内镜下再评估,并在手术钳活检上进行了组织学确认.当病变没有明确的深度浸润性癌症特征时,尝试进行ER。“非解除标志”仅在未事先尝试切除的幼稚病变中排除ER。病变被分类,使用京都-巴黎分类的粘膜瘤。对于无柄和非息肉样病变,使用“注射和切割”切除技术。切除前或切除后,在息肉头下方的茎处横切未切除和半带蒂的病变,在茎上施加金属夹或环以防止出血。根据维也纳标准对病变进行组织学分类,对于带蒂病变,使用Haggitt分类。
结果:82名患者(42名女性,平均年龄62岁),82个病灶(平均大小37毫米)被纳入研究。内窥镜切除了69个(84%)病变,而13例接受了手术切除,因为ER被认为不合适。在组织学上,在21/69个病变中发现了癌症(14个粘膜内,7粘膜下),并与大小(P<0.001)和0-IIa型Is(P=0.011)和0-IIaIIc(P<0.001)病变有关。所有粘膜下癌患者,接受了手术切除。并发症发生在11/69患者中(7例出血,2透壁性烧伤综合征,2个穿孔),所有内镜或保守管理,并与浸润性癌的存在相关(P=0.021)。在随访期间,在14/51无柄或非息肉样病变中发现了复发/残留组织(13例经内镜治疗,1例接受手术切除)并与0-IIa型Is病变相关(P=0.001),局部切除(P=0.01)和病变大小(P=0.004)。总的来说,74%的患者避免手术。手术切除与0-IIa+Is型(P=0.01)和0-IIa+IIc型(P=0.001)病变显著相关,组织学上粘膜下浸润(P<0.001),存在“非解除标志”(P<0.001),与病变大小有关(P=0.001)。在逻辑回归分析中,手术切除的唯一独立预测因素是病灶大小(P=0.002).
结论:在接受良性DCRL手术切除之前,必须由经验丰富的内窥镜医师提供第二种意见,以避免不必要的手术。
OBJECTIVE: To assess how many patients with benign \"difficult\" colorectal lesions (DCRLs) referred to surgical resection, may be treated with endoscopic resection (ER) rather than surgical resection.
METHODS: The prospectively collected colonoscopy database of our Endoscopic Unit was reviewed to identify all consecutive patients who, between July 2011 and August 2013, underwent an endoscopic re-evaluation before surgical resection due to the presence of DCRLs with a histological confirmation of benignancy on forceps biopsy. ER was attempted when the lesion did not have definite features of deeply invasive cancer. The \"nonlifting sign\" excluded ER only in naive lesions without a prior attempted resection. Lesions were classified, using the Kyoto-Paris classification for mucosal neoplasia. For sessile and non-polypoid lesions the \"inject and cut\" resection technique was used. Pedunculated and semi-pedunculated lesions were transected at the stalk just below the polyps head and before or after resection, metal clips or a loop were applied on the stalk to prevent bleeding. The lesions were histologically classified according to the Vienna criteria and for the pedunculated lesions the Haggitt classification was used.
RESULTS: Eighty-two patients (42 females, mean age 62 years) with 82 lesions (mean size 37 mm) were included in the study. Sixty-nine (84%) lesions were endoscopically resected, while 13 underwent surgical resection since ER was deemed unsuitable. On histology, cancer was found in 21/69 lesions (14 intra-mucosal, 7 sub-mucosal) and was associated with the size (P < 0.001) and with type 0-IIa +Is (P = 0.011) and 0-IIa + IIc (P < 0.001) lesions. All patients with sub-mucosal cancer, underwent surgical resection. Complications occurred in 11/69 patients (7 bleedings, 2 transmural burn syndromes, 2 perforations), all managed endoscopically or conservatively, and were associated with presence of invasive cancer (P = 0.021). During follow-up recurrence/residual tissue was found in 14/51 sessile or non-polypoid lesions (13 treated endoscopically, 1 underwent surgical resection) and was associated with type 0-IIa + Is lesions (P = 0.001), piecemeal resections (P = 0.01) and with lesion size (P = 0.004). Overall, 74% of patients avoided surgery. Surgical resection was significantly associated with type 0-IIa + Is (P = 0.01) and 0-IIa + IIc (P = 0.001) lesions, with sub-mucosal invasion on histology (P < 0.001), with presence of the \"nonlifting sign\" (P < 0.001), and related to the dimension of the lesions (P = 0.001). In the logistic regression analysis, the only independent predictor for surgical resection was the dimension of the lesions (P = 0.002).
CONCLUSIONS: Before submitting patients to surgical resection for a benign DCRL, a second opinion by an experienced endoscopist is mandatory to avoid unnecessary surgery.