内镜下黏膜切除术及黏膜剥离术治疗十二指肠非壶腹部病变的临床应用

蒋珍; 郑玉峰; 刘晓敏; 张腊梅

doi:10.16766/j.cnki.issn.1674-4152.002979

内镜下黏膜切除术及黏膜剥离术治疗十二指肠非壶腹部病变的临床应用

doi: 10.16766/j.cnki.issn.1674-4152.002979

河南科技大学第一附属医院消化内科，河南洛阳 471000

基金项目:

河南省卫健委联合共建项目 LHGJ20200581

详细信息

通讯作者:
蒋珍，E-mail: 1281733563@qq.com

中图分类号: R656.64
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出版历程
- 收稿日期: 2022-09-18

Endoscopic mucosal resection and submucosal dissection for clinical treatment of non-ampullary duodenal lesions

Department of Gastroenterology, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471000, China

摘要

摘要: 目的分析内镜分片黏膜切除术(EPMR)和黏膜剥离术(ESD)在治疗十二指肠非壶腹部病变(NADLs)中的安全性及疗效。方法选取2013年1月—2020年12月在河南科技大学第一附属医院内镜中心行手术治疗的78例NADLs患者为研究对象，按照手术方式分为EPMR组(24例)、ESD组(21例)及EPMR+ESD组(33例)。对比分析各组患者临床病例资料。结果 3组患者的病变部位、病变起源、病灶大小及病理类型差异均无统计学意义(均P>0.05)；手术时间分别为(59.4±4.3)min、(71.8±10.1)min、(34.4±5.8)min，差异有统计学意义(F=264.446，P < 0.05)；完全切除率分别为87.5%(21/24)、90.5%(19/21)、100.0%(33/33)，组间差异无统计学意义(χ²=4.400，P>0.05)；EPMR组2例发生围手术期穿孔(8.3%)，于内镜下治疗后恢复，ESD组发生术中穿孔3例(14.3%)、出血2例(9.5%)，予以内镜下电凝止血；EPMR+ESD组发生围手术期穿孔1例(3.0%)，予以钛夹夹闭治疗，3组患者均未发生感染、十二指肠狭窄等其他并发症。3组患者术后住院时间分别为(6.4±0.6)d、(6.4±0.8)d、(6.2±1.2)d，差异无统计学意义(F=0.945，P>0.05)；3组患者随访期内均未见复发。结论 EPMR、ESD治疗NADLs安全、有效，相较于单一方法，EPMR+ESD具有操作快捷的特点，临床应用前景广泛。
- 十二指肠病变 /
- 内镜分片黏膜切除术 /
- 内镜下黏膜下剥离术
Abstract: Objective To analyze the safety and efficacy of endoscopic piecemeal mucosal resection (EPMR) and endoscopic submucosal dissection (ESD) in the treatment of non-ampullary duodenal lesions (NADLs). Methods Seventy-eight patients with NADLs who underwent surgical treatment at the Endoscopy Center, the First Affiliated Hospital of Henan University of Science and Technology from January 2013 to December 2020 were selected, and divided into EPMR group (n=24), ESD group (n=21) and EPMR+ESD group (n=33) according to surgical modality. The clinical data of the three groups were analyzed comparatively. Results The differences in lesion site, lesion origin, lesion size and pathological type of NADLs were not statistically significant among the three groups (all P>0.05). The duration of surgery were (59.4±4.3) min, (71.8±10.1) min and (34.4±5.8) min, respectively, with statistically significant differences (F=264.446, P < 0.05). The complete resection rates in EPMR, ESD and EPMR+ESD groups were 87.5% (21/24), 90.5% (19/21) and 100.0% (33/33), respectively, with no significant differences among the groups (χ²=4.400, P>0.05). In the EPMR group, 2 cases (8.3%) of perioperative perforation were treated endoscopically and recovered; while in the ESD group, 3 cases (14.3%) of intraoperative perforation and 2 cases (9.5%) of bleeding were treated with bipolar electrocoagulation to stop the bleeding; in the EPMR+ESD group, 1 case (3.0%) of perioperative perforation was treated with titanium clips. No infection, duodenal stenosis or other complications occurred in any of the three groups. The average postoperative hospital stay was (6.4±0.6) d, (6.4±0.8) d and (6.2±1.2) d in the three groups, respectively, with no statistically significant difference (F=0.945, P>0.05). No recurrence was observed in any of the three groups during the follow-up. Conclusion Both EPMR and ESD are safe and effective for NADLs, compared to a single method, their combined use for NADLs requires a shorter operative time, which will have a wide clinical application prospect.
- Duodenal lesions /
- Endoscopic piecemeal mucosal resection /
- Endoscopic submucosal dissection
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图 1 EPMR术中操作

注：A~B为分点黏膜下注射含亚甲蓝和甘油果糖的生理盐水使黏膜抬起，使用圈套器分片切除病灶；C为创面使用钛夹封闭处理。

Figure 1. Intraoperative procedure of EPMR

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图 2 ESD术中操作

注：A为于病变基底部黏膜下注射含亚甲蓝和甘油果糖的生理盐水，黏膜抬举后沿标记点外侧进行环周黏膜预切开；B~C为黏膜下层完整剥离病变。

Figure 2. Intraoperative procedure of ESD

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图 3 EPMR+ESD术中操作

注：A为于病变基底部黏膜下注射含亚甲蓝和甘油果糖的生理盐水，黏膜抬举征阳性；B为使用圈套器分片切除病灶；C为黏膜下层完整剥离病变；D为创面使用金属钛夹封闭处理；E为剥离标本回收。

Figure 3. Intraoperative procedure of EPMR+ESD

下载: 全尺寸图片幻灯片

表 1 3组十二指肠非壶腹部病变患者各指标比较[例(%)]

Table 1. Comparison of various indicators among the 3 groups of patients with NADLs[cases (%)]

项目	EPMR组(n=24)	ESD组(n=21)	EPMR+ESD组(n=33)	χ²值	P值
病变部位
球部	15(62.5)	9(42.9)	18(54.4)	4.309	0.366
降部	5(20.8)	10(47.6)	9(27.3)
交界部	4(16.7)	2(9.5)	6(18.2)
病变起源
黏膜层	20(83.3)	18(85.7)	21(63.6)	4.508	0.105
黏膜下层	4(16.7)	3(14.3)	12(36.4)
并发症
有	2(8.3)	5(23.8)	1(3.0)	6.159	0.046
无	22(91.7)	16(76.2)	32(97.0)
完全切除
是	21(87.5)	19(90.5)	33(100.0)	4.400	0.095
否	3(12.5)	2(9.5)	0
病理类型
高级别上皮内瘤变	15(62.5)	14(66.7)	19(57.5)	9.189	0.452
低级别上皮内瘤变	6(25.0)	4(19.0)	10(30.3)
绒毛状管状腺瘤	2(8.3)	0	2(6.1)
Brunner腺瘤	1(4.2)	0	0
淋巴管瘤	0	2(9.5)	0
平滑肌瘤	0	1(4.8)	2(6.1)

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表 2 3组十二指肠非壶腹部病变患者疗效指标评价

Table 2. Evaluation of the efficacy indexes of non-ampullae lesions in duodenum in 3 groups

组别	例数	病灶大小(x ± s，cm)	手术时间(x ± s，min)	住院时间(x ± s，d)	完全切除[例(%)]
EPMR组	24	2.0±0.9	59.4±4.3	6.4±0.6	21(87.5)
ESD组	21	2.1±0.4	71.8±10.1^b	6.4±0.8	19(90.5)
EPMR+ESD组	33	2.0±0.7	34.4±5.8^bc	6.2±1.2	33(100.0)
统计量		2.995^a	264.446^a	0.945^a	4.400^d
P值		0.056	<0.001	0.393	0.095
注：^a为F值，^d为χ²值。与EPMR组比较，^bP<0.05；与ESD组比较，^cP<0.05。

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