内镜黏膜下剥离术后食管狭窄的防治研究进展

正华中科技大学同济医学院附属同济医院丁强田德安*,武汉430030     

食管癌内镜黏膜下剥离术后激素预防狭窄

目的 探讨激素对食管癌内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)后狭窄预防的疗效,同时评估激素的治疗方案,并确定狭窄的危险因素。方法 回顾性分析2018年3月至2022年8月于重庆医科大学附属第二医院因早期食管癌接受ESD治疗的56例患者,其食管黏膜周长缺损大于50%,但不累及全周。患者分为四组,包括单纯ESD组(n=13)、口服激素组(n=28)、激素注射组(n=10)和激素联合治疗组(n=5)。进行Logistic回归分析,以评估食管狭窄的危险因素。结果 单纯ESD组、口服激素组、激素注射组和激素联合治疗组的狭窄率分别为53.8%、17.9%、30.0%和20.0%。使用激素治疗患者的狭窄率明显低于单纯ESD组(20.9%vs 53.8%,P=0.035)。此外,口服激素组的狭窄率显著低于单纯ESD组(P=0.029)。多因素分析显示,食管黏膜周长缺损的程度是ESD后狭窄的重要危险因素(OR=20.67,95%CI:2.35～182.00,P=0.006)。使用激素(OR=0.14,95%CI:0.03～0.67,P=0.014)...     

组织工程学方法在预防食管早癌内镜黏膜下剥离术后管腔狭窄中的应用

<正>内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)能够对≥2cm消化道黏膜早癌进行整块切除,并获得准确的病理分期,目前已成为食管早癌及癌前病变的首选治疗方法。但对大面积食管黏膜早癌进行ESD可能存在一定的并发症,其中食管管腔狭窄是其中之一^[1-2]。     

老年食管早癌内镜黏膜下剥离术后狭窄的高危因素分析

[目的]分析食管早癌内镜黏膜下剥离术后狭窄的高危因素。[方法]选择行内镜黏膜下剥离术治疗的老年食管早癌患者239例,观察内镜黏膜下剥离术后狭窄发生情况。对患者性别、年龄、病变分型、操作时间、糖尿病史、高血压史、吸烟史、饮酒史、病灶部位、病变直径、病变形态、浸润深度、血小板淋巴细胞比值(PLR)、中性淋巴细胞比值(NLR)与术后狭窄的关系采用多因素Logistic回归分析。[结果]239例中术后狭窄37例(狭窄组),发生率为15.48%;202例属无狭窄组。经单因素分析表明,狭窄组与无狭窄组性别、年龄、病变分型、操作时间、糖尿病史、高血压史、吸烟史、饮酒史、病灶部位和浸润深度比较差异无统计学意义(P>0.05);狭窄组与无狭窄组病变直径、病变深度、PLR和NLR比较差异有统计学意义(P<0.05)。经多因素Logistic回归分析显示,病变直径>5 cm、病变深度m3+sm、高PLR和高NLR为影响术后狭窄高危因素。[结论]食管早癌内镜黏膜下剥离术后狭窄发生率较高,其中病变直径>5 cm、病变深度m3+sm、高PLR和高NLR为其高危因素。     

内镜黏膜下剥离术后食管狭窄的预防

内镜黏膜下剥离术（ESD）已成为食管早期肿瘤的标准治疗方法之一。随着治疗器械和操作技术的不断发展,ESD导致的出血及穿孔并发症也逐渐减少,但术后出现狭窄的概率仍较高。因此有必要分析ESD术后出现狭窄的原因,有针对性地提出预防措施,以此扩大食管ESD 的适应证,使大面积的食管浅表肿瘤能在内镜下被切除,且不引起食管狭窄。此文就目前各种预防ESD术后食管狭窄方法的机制及其优缺点作一综述。     

内镜黏膜下剥离术治疗食管早癌及食管癌前病变的临床疗效和手术前后病理差异分析

[目的]探讨内镜下黏膜剥离术(ESD)治疗食管早癌及癌前病变的临床疗效,并分析手术前后病理标本的差异。[方法]55例术前经胃镜活检标本检确诊为食管早癌或癌前病变,均经ESD治疗,观察其临床表现特征、术前及术后病理特点的差异等。[结果]55例均顺利完成ESD;4例术中并发出血,均成功内镜下止血,无穿孔、迟发性出血和操作相关死亡发生;2例术后出现食管创面狭窄,予以内镜下球囊扩张后狭窄缓解。ESD术后病理：炎症2例,低级别上皮内瘤变16例,高级别上皮内瘤变26例,早癌8例,浸润癌2例,巴雷特食管1例。所有患者水平切缘均阴性。相比较ESD前的钳夹活检,有28处标本病理结果发生变化。术前钳取活检总正确率为49.09%(9/20)。其中,轻度不典型增生诊断正确率53.84%(14/26),重度不典型增生诊断正确率45.00%(6/14),早癌诊断正确率80.00%(4/5)。对高级别上皮内瘤变和早癌的低估率为67.56%(25/37)。术前术后病理差异有统计学意义。[结论]ESD是治疗食管早癌及癌前病变的有效方法,可以提高病理诊断的正确率。从患者安全角度出发,怀疑食管早癌的患者,应该积极微创手术治...     

食管憩室合并食管早癌行内镜黏膜下剥离术治疗一例

食管憩室与食管早癌都较少见,但均不罕见,而二者合并出现则极为罕见。本例食管早癌发生于食管憩室,经内镜黏膜下剥离术完全切除。     

食管全周浅表癌内镜黏膜下剥离术后长期保留胃管对食管狭窄的预防及治疗作用

为探讨食管全周浅表癌行内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）后长期保留胃管对食管狭窄预防及治疗的影响,回顾性分析2018年1月—2021年12月在南京医科大学第一附属医院行ESD的食管全周浅表癌患者,术后置入胃管患者15例（胃管置入组）,无胃管置入患者23例（无胃管置入组）,比较两组患者基础情况、病变位置、病理分期、术后并发症、食管狭窄程度（进水情况）、疼痛情况、住院次数及医疗费用等资料。结果显示,两组患者在年龄、性别、病变位置及术后病理分期的构成方面差异无统计学意义（P>0.05）。与无胃管置入组相比,胃管置入组患者可进水率较高（11/15比6/23,P<0.05）,发生疼痛次数较少［（7.3±3.1）次比（10.7±3.6）次,t=3.00,P<0.05］,ESD后至食管支架置入前及置入后的住院次数和医疗总费用均明显低于无胃管置入组（P<0.05）。ESD后迟发性出血率、穿孔率以及首次狭窄出现时间,两组差异均无统计意义（P>0.05）。研究结果初步表明食管全周病变患者行ESD后长期保留胃管可减轻食管狭窄程度,具有较良好的安全性。     

自体皮片移植术预防食管环周早癌内镜黏膜下隧道剥离术后食管狭窄的临床研究

目的 评价自体皮片移植术预防食管环周早癌内镜黏膜下隧道剥离术（ESTD）后食管狭窄的安全性和有效性。方法 2018年1月至2018年3月,5例食管环周早癌患者于解放军总医院接受ESTD联合自体皮片移植术。术后通过内镜随访,观察皮片生长情况,有无食管狭窄及并发症发生情况。结果 5例患者均成功实施了食管环周早癌ESTD和自体皮片移植术。无食管穿孔、出血、创面感染和支架移位等并发症发生。平均移植皮片成活率为86.0%。4例患者术后平均随访9.5个月,未发生食管狭窄;1例患者术后发生食管狭窄并进行了球囊扩张,术后随访8个月内未再发生狭窄。结论 自体皮片移植术可能是预防食管环周早癌ESTD术后食管狭窄的一种安全且有效的方法。     

糖皮质激素预防食管内镜黏膜下剥离术后狭窄的临床观察

目的评估口服醋酸泼尼松和口服醋酸泼尼松联合局部注射曲安奈德预防食管早期癌及癌前病变内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）术后食管狭窄的疗效和安全性。方法回顾性分析2014年12月—2019年2月在东南大学附属中大医院就诊的52例食管早期癌或癌前病变患者的病例资料,其中对照组20例（ESD术后未采取任何预防狭窄的措施）,口服组17例,口服联合局部注射组15例。主要观察：狭窄率、难治性狭窄率、ESD术后内镜下扩张次数、ESD术后首次内镜下扩张距ESD完成的间隔时间;以及是否有手术和糖皮质激素相关不良事件,是否有内镜下扩张的不良反应。结果对照组、口服组和口服联合局部注射组ESD术后狭窄率分别为85.0%（17/20）、47.1%（8/17）和46.7%（7/15）,ESD术后难治性狭窄率分别为75.0%（15/20）、23.5%（4/17）和20.0%（3/15）,内镜下扩张次数分别为3.50（2.25,6.00）次,0.00（0.00,2.50）次和0.00（0.00,2.00）次,ESD术后首次内镜下扩张距ESD完成的间隔时间分别为（27.7±9.4）d、（110.1±46.0）d和（147.4±9.4）d,上述四个指标口服组和口服联合局部注射组均明显低于或少于对照组（P＜0.05）,并且口服组与口服联合局部注射组比较,ESD术后狭窄率、难治性狭窄率和内镜下扩张次数方面差异均无统计学意义（P＞0.05）,但ESD术后首次内镜下扩张距ESD完成的间隔时间方面差异有统计学意义（P＜0.01）。仅对照组有2例发生穿孔,其余患者均未发生ESD、糖皮质激素、内镜下扩张相关的严重不良事件。结论口服泼尼松或者口服泼尼松联合局部注射曲安奈德均可有效且安全地预防食管ESD术后的狭窄,且口服联合局部注射激素可延长ESD术后首次内镜下扩张距ESD完成的间隔时间,有利于患者术后的心理恢复和生活质量的提高。     

内镜黏膜下隧道法剥离术治疗早期食管癌伴黏膜下层纤维化的临床观察

目的评价内镜黏膜下隧道法剥离术（endoscopic submucosal tunnel dissection,ESTD）治疗早期食管癌伴黏膜下层纤维化的效果和安全性。方法2015年6月—2018年2月间,在江苏省苏北人民医院消化内科采用ESTD或内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗,术后病理证实病灶＜1/3食管管周,且伴有黏膜下层纤维化的早期食管癌病例87例纳入回顾性分析,按纤维化程度分成轻度纤维化60例（ESTD 31例、ESD 29例）和重度纤维化27例（ESTD 16例、ESD 11例）,比较同一纤维化程度时两种手术方式的剥离速度、整块切除率、完全切除率,以及出血、肌层损伤、穿孔、颈部皮下气肿和术后狭窄的发生率。结果对于伴有轻度黏膜下层纤维化的早期食管癌患者,ESTD的整块切除率[96.8%（30/31）比82.8%（24/29）,P＜0.05]和完全切除率[96.8%（30/31）比75.9%（22/29）,P＜0.05]明显高于ESD,固有肌层损伤发生率明显低于ESD[6.5%（2/31）比17.2%（5/29）,P＜0.05],剥离速度、术中出血发生率、穿孔发生率、术后狭窄发生率与ESD比较差异均无统计学意义（P均＞0.05）,两种手术方式均无术后迟发性出血和颈部皮下气肿发生。对于伴有重度黏膜下层纤维化的早期食管癌患者,ESTD的剥离速度快于ESD[（12.3±2.8）mm2/min比（7.1±3.2）mm2/min],整块切除率、完全切除率、术后狭窄发生率与ESD相近,术中出血发生率[12.5%（2/16）比54.5%（6/11）]、固有肌层损伤发生率[18.8%（3/16）比54.5%（6/11）]、穿孔发生率[6.3%（1/16）比27.3%（3/11）]、颈部皮下气肿发生率[6.3%（1/16）比27.3%（3/11）]低于ESD,两种手术方式均无术后迟发性出血发生。术后12个月2例行ESD和1例行ESTD患者局部复发,术后24个月1例行ESTD患者发生异时癌。结论ESTD能安全、有效切除伴有黏膜下层纤维化的早期食管癌。对于伴有轻度黏膜下层纤维化者,ESTD的优势主要体现在治疗效果方面;对于伴有重度黏膜下层纤维化者,ESTD的优势主要体现在治疗安全性方面。     

Prevention of esophageal strictures after endoscopic submucosal dissection

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have recently been accepted as less invasive methods for treating patients with early esophageal cancers such as squamous cell carcinoma and dysplasia of Barrett’s esophagus. However, the large defects in the esophageal mucosa often cause severe esophageal strictures, which dramatically reduce the patient’s quality of life. Although preventive endoscopic balloon dilatation can reduce dysphagia and the frequency of dilatation, other approaches are necessary to prevent esophageal strictures after ESD. This review describes several strategies for preventing esophageal strictures after ESD, with a particular focus on anti-inflammatory and tissue engineering approaches. The local injection of triamcinolone acetonide and other systemic steroid therapies are frequently used to prevent esophageal strictures after ESD. Tissue engineering approaches for preventing esophageal strictures have recently been applied in basic research studies. Scaffolds with temporary stents have been applied in five cases, and this technique has been shown to be safe and is anticipated to prevent esophageal strictures. Fabricated autologous oral mucosal epithelial cell sheets to cover the defective mucosa similarly to how commercially available skin products fabricated from epidermal cells are used for skin defects or in cases of intractable ulcers. Fabricated autologous oral-mucosal-epithelial cell sheets have already been shown to be safe.     

Q法自牵引技术在大范围早期食管癌内镜 黏膜下剥离术中的应用研究（含视频）

目的初步报告Q法自牵引辅助内镜黏膜下剥离术(Q-ESD)应用于大范围早期食管癌(EEC)的临床效果。方法回顾性分析2015年1月至2018年12月间在福建省立医院接受ESD治疗的82例大范围EEC(单发病灶>1/2周径或纵径长度>5 cm)患者病例资料,按治疗方案不同分为传统ESD组(n=44)和Q-ESD组(n=38),比较两组操作面积、操作时间、操作速度、整块切除率、完整切除率、并发症情况。结果82例病灶均于内镜下成功整块切除。Q-ESD组和传统ESD组在操作面积[779.8(329.9~2552.5)mm^2比875.7(417.8~1914.8)mm^2,U=155,P=0.636]、操作时间[63(41~177)min比59(42~169)min,U=171,P=0.167]、完整切除率[94.7%(36/38)比93.2%(41/44),χ^2=0.086,P=0.769]方面比较差异无统计学意义。但Q-ESD组操作速度快[14.9(5.4~20.8)mm^2/min比9.0(5.0~19.5)mm^2/min,U=142,P=0.035],固有肌层损伤发生率低[7.9%(3/38)比27.3%(12/44),χ^2=5.123,P=0.023],术后狭窄发生率低[5.3%(2/38)比20.5%(9/44),χ^2=4.051,P=0.044]。除传统ESD组有1例穿孔外,未发生其他不良事件。结论Q-ESD是治疗大范围EEC安全有效的可选策略。     

Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer: A meta-analysis

AIM: To compare endoscopic submucosal dissection(ESD) and endoscopic mucosal resection(EMR) for early gastric cancer(EGC).METHODS: Computerized bibliographic search was performed on PubMed/Medline, Embase, Google Schol-ar and Cochrane library databases. Quality of each included study was assessed according to current Co-chrane guidelines. Primary endpoints were en bloc re-section rate and histologically complete resection rate. Secondary endpoints were length of procedure, post-treatment bleeding, post-procedural perforation and re-currence rate. Comparisons between the two treatment groups across all the included studies were performed by using Mantel-Haenszel test for fixed-effects mod-els(in case of low heterogeneity) or DerSimonian and Laird test for random-effects models(in case of high heterogeneity).RESULTS: Ten retrospective studies(8 full text and 2 abstracts) were included in the meta-analysis. Overall data on 4328 lesions, 1916 in the ESD and 2412 in the EMR group were pooled and analyzed. The mean operation time was longer for ESD than for EMR(stan-dardized mean difference 1.73, 95%CI: 0.52-2.95, P =0.005) and the "en bloc " and histological complete re-section rates were significantly higher in the ESD group [OR = 9.69(95%CI: 7.74-12.13), P 0.001 and OR = 5.66,(95%CI: 2.92-10.96), P 0.001, respectively]. As a consequence of its greater radicality, ESD provided lower recurrence rate [OR = 0.09,(95%CI: 0.05-0.17), P 0.001]. Among complications, perforation rate was significantly higher after ESD [OR = 4.67,(95%CI, 2.77-7.87), P 0.001] whereas the bleeding incidences did not differ between the two techniques [OR = 1.49(0.6-3.71), P = 0.39].CONCLUSION: In the endoscopic therapy of EGC, ESD showed a superior efficacy but higher complication rate with respect to EMR.     

The effects of oral steroid duration on stricture prevention after extensive endoscopic submucosal dissection for superficial esophageal cancer

BackgroundEsophageal stricture is a major complication of endoscopic submucosal dissection (ESD) in patients with superficial esophageal cancer (SEC). Oral steroids have been used to prevent esophageal stricture in patients with more than 75% of the esophageal circumference resected. However, there are no established guidelines regarding the optimal duration of steroid use. This retrospective observational study aimed to compare the incidence of esophageal stricture according to the period of prophylactic oral steroid use and to identify the risk factors for esophageal stricture.MethodsEighty-one patients who were prescribed prophylactic steroid after undergoing ESD for SEC with more than 75% of esophageal circumference resected were enrolled. Patients were classified into the four-week steroid group (n=72) or eight-week steroid group (n=9) to compare the incidence of esophageal stricture. In addition, the patients were subdivided into those who developed esophageal stricture (n=24) and those who did not (n=57) to identify the risk factors for esophageal stricture.ResultsTwenty patients (27.8%) in the four-week oral steroid group and four patients (44.4%) in the eight-week oral steroid group developed esophageal stricture (P=0.44). The univariable analysis identified tumor size, longitudinal length of semi-circumferential resection, and proportion of circumferential resection as risk factors of esophageal stricture. The multivariable analysis identified the proportion of circumferential resection as an independent risk factor. After adjusting for the proportion of circumferential resection, the incidence of stricture was marginally higher in the eight-week steroid group [P=0.05; odds ratio (OR): 5.69; 95% confidence interval (CI): 1.01–32.15].ConclusionsEight weeks of oral steroid prophylaxis does not reduce the risk of stricture after extensive ESD more than four weeks of oral steroid prophylaxis. The proportion of circumferential resection is the strongest risk factor for stricture in patients with SEC undergoing ESD.     

Outcome after endoscopic submucosal dissection for early gastric cancer in Korea

Endoscopic treatment,such as endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD),has been established as one of the treatment options for selected cases with early gastric cancer(EGC).Most studies on this topic have been carried out by researchers in Japan.Recently,the experience in EMR/ESD for EGC outside Japan is increasingly reported.In Korea,gastric cancer is the most common malignant disease,and the second leading cause of cancer death.Currently,EMR for EGC is widely performed i...     

Disseminated nocardiosis during systemic steroid therapy for the prevention of esophageal stricture after endoscopic submucosal dissection

An 85‐year‐old man underwent endoscopic submucosal dissection for a large superficial esophageal epithelial neoplasm, which required removal of 95% of the circumference of the esophageal mucosa. Steroids were given orally to prevent esophageal stricture starting on day 3 postoperatively. In the 6th week of steroid treatment, he developed high fever without other symptoms. Chest computed tomography revealed a nodular lesion in the lung. Sputum sample showed Gram‐positive, branching, filamentous bacteria, and a diagnosis of nocardiosis was suspected. Brain magnetic resonance imaging revealed multiple focal lesions which indicated dissemination of nocardiosis. Trimethoprim‐sulfamethoxazole was immediately started, which led to the disappearance of pulmonary and cerebral nocardiosis with alleviation of fever. Recently, oral steroid treatment has been widely used for the prevention of esophageal stricture. However, the present case indicates the risk of life‐threatening infection and the importance of close monitoring of this treatment.     

Endoscopic submucosal dissection vs endoscopic mucosal resection for superficial esophageal cancer

AIM:To investigate the effectiveness of endoscopic submucosal dissection(ESD)and endoscopic mucosal resection(EMR)in treating superficial esophageal cancer(SEC).METHODS:Studies investigating the safety and efficacy of ESD and EMR for SEC were searched from the databases of Pubmed,Web of Science,EMBASE and the Cochrane Library.Primary end points included the en bloc resection rate and the curative resection rate.Secondary end points included operative time,rates of perforation,postoperative esophageal stricture,bleeding and local recurrence.The random-effect model and the fixed-effect model were used for statistical analysis.RESULTS:Eight studies were identified and included in the meta-analysis.As shown by the pooled analysis,ESD had significantly higher en bloc and curative resection rates than EMR.Local recurrence rate in the ESD group was remarkably lower than that in the EMR group.However,operative time and perforation rate for ESD were significantly higher than those for EMR.As for the rate of postoperative esophageal stricture and procedure-related bleeding,no significant difference was found between the two techniques.CONCLUSION:ESD seems superior to EMR in the treatment of SEC as evidenced by significantly higher en bloc and curative resection rates and by obviously lower local recurrence rate.