内镜黏膜下剥离术失败的危险因素分析  

Risk factors of unsuccessful endoscopic submucosal dissection

作　　者：韩铁妹[1,2] 张晨静[1] 潘文胜[1] 叶再元[3] 徐翔[4] 吾红光[5] 陈光兰[6] 

机构地区：[1]浙江大学医学院附属第二医院消化内科,浙江杭州310009 [2]浙江大学医学院附属义乌医院消化内科,浙江义乌322000 [3]浙江省人民医院外科,浙江杭州310009 [4]浙江大学医学院附属第二医院药剂科,浙江杭州310009 [5]浙江大学医学院附属第二医院衢江分院消化内科,浙江衢州324000 [6]丽水市人民医院内镜中心,浙江丽水323000

出　　处：《实用肿瘤杂志》2012年第6期587-592,共6页Journal of Practical Oncology

基　　金：浙江省自然基金项目(Y2080001;Z2080514);浙江省重大专项(2009C03012-5);浙江省卫生厅科技项目(2007A093;2011KYA167;2012KYB232);国家公益性卫生行业专项基金(200802112)

摘　　要：目的总结内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)失败患者的临床及病理特征并探讨其失败的因素,以期指导临床操作及处理决策。方法回顾性分析41例接受ESD术并经术后病理明确为消化道黏膜或黏膜下病变(排除异位胰腺、平滑肌瘤、脂肪瘤等)的患者,按ESD成功与失败分组,对照研究性别、年龄、病变部位、病变形态、病变大小、手术时间、病理类型、抬举征、并发症等因素与ESD手术失败的关系。结果 41例行ESD术处理消化道黏膜或黏膜下病变的患者中,30例成功完整切除病变,11例ESD术失败(10例转外科手术切除,1例管状腺瘤残留随访);统计分析显示,ESD失败组与ESD成功组在性别、年龄、病变部位、形态、大小、病理类型、手术时间、并发症方面差异无统计学意义(P>0.05),而仅在病变抬举征方面差异有统计学意义(P<0.05)。根据Logistic回归分析,抬举征阴性为ESD手术失败的独立危险因素。11例ESD手术失败患者中,2例患者肿瘤浸润至黏膜下层,与肌层距离较近,粘连严重,其抬举征均为阴性;5例患者黏膜下层纤维化粘连,其抬举征均为阴性;1例患者术中迷走反射兴奋致心律显著下降;1例患者ESD术后病理证实肿瘤脉管浸润;另有2例患者其肌层内环肌束向上生长入黏膜下层,剥离困难,其抬举征均为中心区阴性。结论内镜下黏膜剥离术的失败仅与病变抬举征有关,抬举征阴性为ESD手术失败的独立危险因素。病变抬举征阴性与黏膜下层纤维化粘连、肿瘤浸润至黏膜下层和固有肌层肌束向黏膜层生长有关。Objective To study the risk factors of endoscopic submucosal dissection（ESD） by summarizing clinical and pathological characteristics of patients who underwent unsuccessful ESD procedure,for a better guidance to clinical pathways and treatment decision.Methods Forty-one patients,who had ESD procedure and were pathologically diagnosed as mucosal or submucosal lesions（excluding heterotopic pancreas liomyoma and lipomyoma） were retrospectively analyzed.They were divided into two groups according to ESD procedure being successful or not.Factors including sex,age,lesion location,type,size,procedure duration,pathology,lifting sign and complications were analyzed.Results Among all,thirty cases had successful and complete dissection while 11 cases failed（10 had surgery and the other one had adenoma residual and underwent close follow-up）.The analysis showed significant difference in lifting sign between the two groups（P0.05）.The logistic regression analysis showed that lifting sign was the only independent risk factor of ESD procedure.In those 11 unsuccessful cases,two failed due to adhesion caused by tumor infiltration into submucosa with negative lifting sign;five failed due to fibrosis adhesion with negative lifting sign;one suffered obvious vagovagal reflex;another one had vessel infiltration in post-ESD pathology;the other two had muscle bundle extending exceptionally from muscular layer into mucosal layer,crossing submucosa,which made the dissection of the lesions impossible.Conclusions Negative lifting sign was the only independent risk factor which may serve as indicator of an unsuccessful ESD procedure.And not only adhesion from fibration and tumor infiltration but also exceptional growth of muscle bundle from muscular layer into mucosal layer could result in negative lifting sign.

关 键 词：电外科手术 内窥镜检查 消化系统 黏膜 治疗失败 危险因素 回顾性研究 

分 类 号：R735[医药卫生—肿瘤]