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比较带帽内镜切除术与多环黏膜切除术內镜下分次切除早期Barretts 食管瘤的随机试验

发布日期:2014-1-29 12:40:12 文章来源:GIE(July,2011) 作者次数:1288
     
    背景
    內镜切除术是高级别上皮内瘤和Barretts 食管早期癌的一种重要治疗手段。带帽內镜切除术要求粘膜下层隆起并在帽中设置圈套器,这样使得它在技术很难达到要求。然而多环黏膜切除术(MBM)使用的是一种改良的静脉曲张圈套结扎器,它不要求粘膜下层隆起和装置圈套器。
    目的
    对带帽內镜切除术(ER-cap)与多环黏膜切除术(MBM)在內镜下分次切除早期Barretts 瘤进行比较。
    设计
    随机对照试验
    环境
    第三医疗和社区卫生中心(Tertiary-care and community-care centers)
    患者
    本研究纳入行內镜下分次切除Barretts瘤的84例患者,其中64例男性,平均年龄为70岁。
    干涉
    运用带帽內镜切除术(ER-cap)或多环黏膜切除术(MBM)实施內镜下分次切除操作,切除对象均为42例。
    主要评价指标
    安全性,有效性,手术时间,成本。
    结果
    多环黏膜切除术(MBM)与带帽內镜切除术(ER-cap)相比较,它的手术时间(34对50分,P =0.2)明显短,成本花费(240对322欧元,P< .01)也明显低。多环黏膜切除(MBM)的切割的样本长宽均小于带帽內镜切除(ER-cap)的,分别为18 ×13 mm ,20 × 15 mm,且P <0.01。然而二者切割的样本最大厚度,被切除的粘膜下层均没统计学差异。手术中均未发生临床相关的出血事件,但4例患者发生穿孔,其中3例是带帽內镜切除术引起,1例是多环黏膜切除术引起(P无统计学意义)。
    局限性
    由于参加操作的內镜医生之间经验水平不同而产生的潜在性偏差。
    结论
    多环黏膜切除术(MBM)与带帽內镜切除术(ER-cap)相比,它在內镜下分次切除更快速更便宜。还有多环黏膜切除术(MBM)不要求粘膜下层隆起,而且明显它与更多穿孔发生无相关性。尽管多环黏膜切除术(MBM)会产生略小的样本,但是由于两种技术切除深度没有什么不同,所以它的临床相关性可能会受到限制。因此多环黏膜切除术(MBM)是內镜下分次切除早期Barretts瘤的首选方法。
     
    缩写: APC为氩离子凝固, BE为Barretts食管, CI为置信区间, ER为內镜下切割术, HGIN为高级别上皮内瘤, IQR为为内距, MBM多环黏膜切除术RFA为射频消融。
     
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    Abstract
     
    Endoscopic resection (ER) is an important treatment for high-grade intraepithelial neoplasia and early cancer in Barretts esophagus. ER-cap requires submucosal lifting and positioning of a snare in the cap, making it technically demanding and laborious. Multiband mucosectomy (MBM) uses a modified variceal band ligator and requires no submucosal lifting or positioning of a snare
     
    To compare ER-cap and MBM for piecemeal ER of early Barretts neoplasia.
    Design
    Randomized, controlled trial.
    Setting
    Tertiary-care and community-care centers.
    Patients
    This study involved 84 patients (64 men; median age 70 years) undergoing piecemeal ER of Barretts neoplasia.
    Intervention
    Piecemeal ER was performed by using ER-cap (n = 42) or MBM (n = 42).
    Main Outcome Measurements
    Safety, efficacy, procedure time, costs.
    Results
    Procedure time (34 vs 50 minutes; P = .02) and costs (€240 vs €322; P < .01) were significantly less with MBM compared with ER-cap. MBM resulted in smaller resection specimens than ER-cap (18 ×13 mm vs 20 × 15 mm; P < .01). Maximum thicknesses of specimens and resected submucosa were not significantly different. There were no clinically relevant bleeding episodes. Four perforations occurred, 3 with ER-cap, 1 with MBM (P = not significant).
    Limitations
    Potential bias because of different levels of experience among participating endoscopists.
    Conclusion
    Piecemeal ER with MBM is faster and cheaper than with ER-cap. Despite the lack of submucosal lifting, MBM appears not to be associated with more perforations. Although MBM results in slightly smaller specimens, the clinical relevance of this may be limited because depth of resections does not differ between both techniques. MBM may thus be preferred for piecemeal ER of early Barretts neoplasia.
    Abbreviations: APC, argon plasma coagulation, BE, Barretts esophagus, CI, confidence interval, ER, endoscopic resection, HGIN, high-grade intraepithelial neoplasia, IQR, interquartile range, MBM, multiband mucosectomy, ns, not significant, RFA, radiofrequency ablation
     
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