超细内镜引导下自膨式金属支架置入在恶性结直肠梗阻中的应用

目的　评估超细内镜引导下置入自膨式金属支架治疗恶性结直肠梗阻的有效性和安全性，探讨适用超细内镜的病例特点。方法　回顾性分析2018年1月至2022年10月在北京大学第三医院接受内镜下金属支架置入治疗的107例恶性结直肠梗阻患者的资料。根据所使用的内镜类型是常规结肠镜还是超细内镜，将患者分为常规组（n=80）和超细组（n=27）。比较两组间病变部位、病变中心在屏幕的最佳位置、导丝插入时间和整体操作时间及并发症发生率等指标。将上述P<0.2的自变量及其他具有临床意义的临床和影像特征纳入二元logistic回归，分析影响恶性结直肠梗阻患者使用超细内镜的相关因素。结果　超细组的直肠乙状结肠梗阻率［74.1%（20/27）比46.3% （37/80）］和远处转移率［88.9%（24/27）比 67.5%（54/80）］均比常规组更高。两组病变中心在屏幕的最佳位置差异有统计学意义（χ2=4.14，P=0.042）。超细组插入导丝的时间明显短于结肠镜组［4.0（2.0，7.0）min 比 8.5（5.0，14.3）min， Z=-3.22，P=0.001］，但整体操作时间差异无统计学意义［（28.3±12.6）min 比（23.4±11.5）min，t=-1.79，P=0.077］。常规组有2例支架放置失败，而超细组均成功。两组均未发生出血、穿孔所致急性腹膜炎等需要紧急治疗的并发症。多因素logistic回归分析显示，存在远处转移（OR=6.775，95%CI：1.084~42.346，P=0.041）、狭窄肠腔在屏幕外1/2（OR=3.097，95%CI：1.406~6.822， P=0.005）适合使用超细内镜；而梗阻部位位于降结肠更倾向于不使用超细内镜（降结肠比直肠乙状结肠：OR=0.073，95%CI：0.009~0.602，P=0.015）。结论　超细内镜用于疑难恶性结肠梗阻患者可明显缩短导丝插入时间，提高结直肠支架置入的成功率，特别是存在远处转移、常规结肠镜下狭窄肠腔位于屏幕外1/2的病例，而病变位于降结肠更倾向于不使用超细内镜。

Self‑expanding metallic stent placement guided by ultra‑fine endoscope for malignant colorectal obstruction

Objective　To evaluate the efficacy and safety of self‑expanding metallic stent (SEMS) placement guided by ultra‑fine endoscope for malignant colorectal obstruction. Methods　Data of 107 patients with malignant colorectal obstruction treated by colorectal SEMS implantation under endoscopy in Peking University Third Hospital from January 2018 to October 2022 were retrospectively analyzed. According to the type of endoscope, patients were divided into the conventional colonoscope group (n=80) and the ultra‑fine endoscope group (n=27). Lesion location, the best location of lesion at the screen, the time of inserting guidewire, the time of overall operation and complication incidence were compared. The independent variables with P <0.2 and some special clinical and imaging features were included in the binary logistic regression for multivariate analysis to determine the influencing factors for using ultra‑fine endoscope. Results　The rectosigmoid obstruction in the ultra‑fine group was significantly higher than that in the conventional group [74.1% (20/27) VS 46.3% (37/80)]. More patients in the ultra‑fine endoscopy group had abdominal lymph nodes and distant metastasis [88.9% (24/27) VS 67.5% (54/80)]. There was significant difference in the best location of lesion at the screen （χ2=4.14，P=0.042）. The time of inserting the guidewire in the ultra‑fine group was significantly shorter than that in the conventional group [4.0 (2.0, 7.0) min VS 8.5 (5.0, 14.3) min, Z=-3.22, P=0.001]. However, there was no significant difference in the overall operation time (28.3±12.6 min VS 23.4±11.5 min, t=-1.79, P=0.077). Two stent placements failed in the conventional group and all stent placements succeeded in the ultra‑fine endoscope group. There was no severe complication such as hemorrhage or acute peritonitis caused by perforation in either group. Logistic regression analysis showed that the presence of distant metastasis (OR=6.775, 95%CI: 1.084‑42.346, P=0.041) and narrow lumen located at the outside 1/2 of the screen (OR=3.097, 95%CI: 1.406‑6.822, P=0.005) were influencing factors for the usage of ultra‑fine endoscopy. On the other hand, ultra‑fine endoscopy was not recommended for patients with lesions located at the descending colon (descending colon VS rectosigmoid: OR=0.073, 95%CI:0.009‑0.602, P=0.015). Conclusion　Ultra‑fine endoscopy can significantly shorten the time of guidewire insertion and improve the success rate of SEMS placement, especially for those with abdominal lymph node and distant metastasis, and whose narrow lumen located at the outside 1/2 of the screen. Ultra‑fine endoscopy is not recommended for patients with lesions located at the descending colon.