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某内窥镜转诊中心接收反抗性结直肠病变患者行内镜下粘膜切除术的治疗成果

发布日期:2014-1-29 12:40:46 文章来源:GIE 作者次数:1487

    接收日期:2011111;接受发表:2012229;在线发表:201264

    研究背景

    随着人们疾病意识的不断提高、内窥镜技术和医疗影像技术不断进步,广基扁平型病变的辨别越发准确及时。“反抗性息肉(DP)”指的是经结肠镜辨别且无法由标准套圈息肉切除术切除的病灶。对反抗性息肉进行影像归档与组织取样已成为普遍做法,且越来越多的病人被建议尝试根治型结肠镜切除术。

    研究目的

    评估现行“反抗性息肉(DP)”的本质和其内镜下切除的治疗成果。

    研究设计

    回顾性研究

    研究环境

    三级转诊中心

    患者及干预治疗

    无法行标准套圈息肉切除术的结直肠息肉病人被转入一家三级治疗中心,并由该中心的一名内窥镜专家为其负责,并尝试进行根治性内窥镜切除术。自20076月开始,追溯性选取所有符合上述病征定义的反抗性息肉病征。从20076月至200910月,为某内窥镜转诊中心内的一位内窥镜专家搜集该病征的电子内窥镜报告资料库。资料覆盖病人的年龄与性别、息肉位置和组织病理、切除方式、辅助消融的使用、不良事件、及随访期间残留性/复发性肿瘤的情况。内镜下切除术采用经亚甲蓝着色的不同数量的普通生理盐水,行粘膜下注射。采用配合标准及微小套圈,配合单纯电凝电流。

    主要测量指标

    完全切除、并发症、复发

    结果

    本研究共涉及274例被推荐尝试内镜下切除术的转入病人(50.4%女性,平均年龄65(标准偏差12)岁),共计315枚反抗性息肉病征。绝大部分的DP病征出现在结肠右侧(226枚,72%)。息肉平均估计尺寸为23mm(范围从8100mm,标准偏差13)。其中29DP息肉因外观(n=3)、位置(n=9)、无法提离(n=10)等因素、或因EMR治疗术后组织病理检查发现粘膜下侵袭(n=7),而无法进行内镜下切除术,因而需要采取手术。286DP息肉(91%)在单次切除后,实现内镜下完全根除(R0)。对其中153枚息肉(53.5%)进行整块切除,对132枚息肉(46%)进行零碎切除。 组织病理检查显示,其中178枚为管状腺瘤(56.5%)、62枚为锯齿状腺瘤(20%)、27枚为管状绒毛腺瘤(9%)、10枚为增生型息肉(3%)、以及14枚腺癌(4.5%)。其中69DP息肉(24%),在对病灶残留肿瘤组织行辅助消融后,实现内镜下完全根除(R0)。在249例病人中,29例病人(11.6%)发生与治疗相关的不良事件。9例病人发生急性出血(其中1人需要入院治疗并重新进行内窥镜手术)。1例病人发生微穿孔,对其进行了夹扣封闭并辅以抗生素。18例病人(7.2%)出现迟发性出血(在术后1-6天),其中8人需要住院、4人需要行结肠镜止血。在258名随访病人中,135人进行结肠镜复查,共发现36人(27%)在之前EMR治疗的位置上出现残留性/复发性肿瘤组织。所有残留性/复发性肿瘤组织均在进一步的内镜下切除或消融戳时下成功根除。

    局限性

    一项回顾性设计。

    结论

    反抗性息肉(DP)主要由包括锯齿状腺瘤在内的广基型及扁平型腺瘤组成。大部分的DP息肉能够通过治疗型结肠镜,行辅助根除及消融治疗,予以根除。该方法能够达到较高的内镜下完全根除率,且不良反应率较低。且由于在切除部分发生局部残留性/复发性肿瘤的几率较高,因此有必要进行后续的结肠镜复查。

    缩写词:APC,氩离子凝固术;DP,反抗性息肉;R0,内镜下完全根除。

     


    Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center

    Received 1 November 2011; accepted 29 February 2012. published online 04 June 2012.

    Background

    Flat and sessile lesions are being identified more frequently because of increased awareness, improved endoscopic skills, and enhanced imaging. The defiant polyp (DP) is a lesion identified at colonoscopy that defies resection by the standard snare polypectomy technique. Increasingly, the DP undergoes photodocumentation and tissue sampling, and the patient is referred for an attempt at curative colonoscopic resection.

    Objective

    To evaluate the current nature of the DPs and outcomes of their endoscopic resection.

    Design

    Retrospective study.

    Setting

    Tertiary referral center.

    Patients and Interventions

    Patients with colorectal polyps not amenable to standard snare polypectomy were referred to a single endoscopist at a tertiary center for an attempt at curative endoscopic resection. The indication DP was applied prospectively, as defined previously, beginning in June 2007. An electronic endoscopy report database was searched for this indication from June 2007 to October 2009 for a single endoscopist at an endoscopy referral center. Data pertaining to patient age and sex, polyp site and histopathology, resection technique, use of adjunctive ablation, adverse events, and residual/recurrent neoplasia at follow-up were culled. Submucosal injection of varying quantities of normal saline solution tinted with methylene blue dye was used for endoscopic resection. Standard and mini-snares were used with pure coagulation current.

    Main Outcome Measurements

    Complete resection, complications, recurrence.

    Results

    This study included 274 patients (50.4% women, age 65 [standard deviation 12] years) with a total of 315 DPs who were referred for attempted endoscopic resection. The majority of DPs were located in the right side of the colon (226; 72%). The mean size was estimated at 23 mm(range 8-100 mm; standard deviation 13). In 29 DPs (10%), surgery was required because endoscopic resection was deemed unsuitable because of the unfavorable appearance (n = 3), the location (n = 9), or the inability to lift (n = 10) or because of submucosal invasion on post-EMR histopathology (n = 7). Complete endoscopic eradication (R0) was achieved in a single session in 286 DPs (91%). En bloc resection was performed in 153 polyps (53.5%) and piecemeal resection in 132 (46%). Histopathology revealed 178 tubular adenomas (56.5%), 62 serrated adenomas (20%), 27 tubulovillous adenomas (9%), 10 hyperplastic polyps (3%), and 14 adenocarcinomas (4.5%). Adjunctive ablation of focal residual neoplastic tissue was applied in 69 DPs (24%) to achieve R0. Procedure-related adverse events were recorded in 29 of 249 patients (11.6%). Acute bleeding occurred in 9 patients (1 required hospitalization and repeat endoscopy). There was 1 microperforation managed with clip closure and antibiotics. Delayed bleeding (1-6 days post-procedure) was observed in 18 patients (7.2%), of whom 8 required hospitalization and 4 colonoscopy for hemostasis. Among the patients who underwent follow-up surveillance colonoscopy (135 of 258 patients), residual/recurrent neoplastic tissue at the site of the previous EMR was identified in 36 (27%). Residual/recurrent neoplasia was successfully eradicated with further endoscopic resection or ablation.

    Limitations

    A retrospective design.

    Conclusions

    DPs consist predominantly of sessile and flat adenomas including serrated adenomas. Most DPs can be successfully eradicated at dedicated therapeutic colonoscopy by using adjunctive resection and ablation techniques. The R0 rate is high and the adverse event rate is low. A relatively high rate of local residual/recurrent neoplasia at the resection site underscores the importance of follow-up colonoscopy.

    Abbreviations:  APC, argon plasma coagulation, DP, defiant polyp, R0, complete endoscopic eradication

     

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