内镜黏膜下剥离术治疗早期食管癌及癌前病变的临床评价

目的初步探讨内镜黏膜下剥离术（ESD）治疗早期食管癌及癌前病变的应用价值及安全性。方法2009年2月至2012年7月在南京医科大学第一附属医院接受ESD治疗的176例早期食管癌及癌前病变的病例，对其手术及治疗情况、近远期并发症、术后随访疗效等多个指标进行回顾比较。结果176例患者中，低级别上皮内瘤变56例，病灶长度1～10cm，平均4．3em，ESD平均手术时间62min。高级别上皮内瘤变80例，病灶长度1～10cm，平均5．0em，ESD平均手术时间72min。早期食管癌病例40例，病灶长度1-11em，平均5．7cm，ESD平均手术时间86min。术后出现胸骨后疼痛80例（45．5％），出血2例（1．1％），穿孔3例（1．7％），食管狭窄15例（8．5％），腹痛17例（9．6％），发热15例（8．5％），均未发生其他并发症。125例病例进行了随访，中位随访时间14个月（1～39个月）。病灶术后病理示，低级别上皮内瘤变的56例患者中，54例一次性完整切除病灶，3．6％（2／56）边缘有残留；高级别上皮内瘤变的80例患者中，76例一次性完整切除病灶，5．0％（4／80）切缘有残留；食管早期癌的40例患者中，37例为一次性完整切除，7．5％（3／40）切缘见残留。所有病理基底均未见残留，且术后病理提示所有患者病变范围均未突破黏膜下层。病灶局灶复发3例（1．7％）。101例进行了术后2个月的胃镜复查，创面愈合率100％（101／101）。79例完成了术后6个月的胃镜复查，其中2例局灶复发，1例发现贲门病变，创面愈合率100％（79／79）。52例完成了术后12个月的胃镜复查，1例局灶复发，创面愈合率100％（52／52）。结论ESD能够一次性完整切除病灶，有利于病理诊断，并且病灶复发率低、并发症少、创伤小，是诊断及治疗早期食管癌及癌前病变的安全有效的方法。

Cfinical evaluation of endoscopic submucosal dissection for patients with early esophageal cancer andprecancerous lesion

Objective To explore the application value and safety of endoscopic submucosal dissection （ESD） in the treatment of early esophageal cancer and precancerous lesion. Methods One hundred and seventy-six patients with early esophageal cancer and precancerous lesion who underwent ESD were selected from February 2009 to July 2012. Multiple indicators such as the circumstances of surgery and treatment,long-and short-term complications, efficacy of postoperative follow-up, and so on were compared retrospectively. Results Among the 176 cases, the lengths of the lesions of 56 eases with low-grade intraepithelial neoplasia（ LEIGN ） , 80 cases with high-grade intraepithelial neoplasia （ HGIEN ） and 40 cases with early esophageal cancer were respectively 1 ～ 10 cm, 1 N 10 cm, 1 ～ 11 em;the average diameters of the three groups were respectively 4. 3cm, 5.0cm and 5.7cm; and the average operation time of ESD were respectively 62 rain,72 rain and 86 min. Retrosternal pain in 80 patients （45.5%）, bleeding in 2 cases （ 1. 1% ）, perforation in 3 cases （ 1.7% ）, esophageal stricture in 15 cases （ 8.5% ）, bellyache in 17cases （9. 6% ）and fever in 15 cases（ 8. 5% ）were observed after operation, and no other complications occurred. One hundred twenty-five cases were followed up, with a median follow-up time of 14 months（ 1-39 months）. Postoperative pathology showed that the cases with one-time complete resection of the three groups were 54, 76 and 37 ; the cases with residual lesions at incisal edge were respectively 2 （ 3.6% ）, 4 （ 5.0% ）, 3 （7. 5% ）. No residual lesions were found at basal layer, and postoperative pathology showed that no lesionsinfiltrated into submucosa. Local recurrence occurred in 3 cases （1.7%）. One hundred and one cases received gastroscopy review 2 months after operation, with healing rate of 100% （101/101）. Seventy-nine cases received gastroscopy review 6 months after operation with 2 cases of local recurrence, 1 case of cardiac lesion,wound healing rate of 100% （79/79）. Fifty-two cases received gastroscopy review 12 months after operation with 1 case of local recurrence, wound healing rate of 100% （52/52）. Conclusions ESD can excise early esophageal cancer and precancerous lesion as en bloc, provide complete pathologic data and reduce the recurrence and complication incidence and wound. ESD is a safe and effective diagnostic and therapeutic method for early esophageal cancer and precancerous lesion.