Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study
Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study
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DOI：
10.1016/j.gie.2008.09.027
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发表时间：
2009-06-01
影响因子：
7.7
通讯作者：
Seol, Sang Young
中科院分区：
文献类型：
--
作者：
Chung, Ii-Kwun;Lee, Jun Haeng;Seol, Sang Young
背景资料：内镜粘膜下剥离术（ESD）的引入能够获得早期大型胃肠道肿瘤的细胞块标本。ESD的缺点是其技术上的困难，因此，这与较高的并发症发生率相关，并且需要先进的内窥镜技术和较长的手术时间。目的：由在韩国至少有3年EMR经验的专家内窥镜医师评估ESD的治疗结果。设计：一项回顾性多中心研究患者：2006年1月至2007年6月，952例患者中的1000例早期胃癌（502名男性，450名女性;平均年龄62.1岁，范围43-90岁）在韩国6所与韩国ESD研究小组（KESG）相关的大学医院接受ESD治疗。我们采用典型的顺序（标记、切口和粘膜下剥离）进行ESD手术。主要结果测量：整块切除率、并发症发生率和手术时间。预定因素（各种内镜和最终病理特征）。结果：整块切除率为95.3%，完全整块切除率为87.7%，垂直不完全切除率为1.8%，分段切除率为4.1%，延迟出血率为15.6%，大出血率为0.6%，穿孔率为1.8%，手术并发症发生率为0.6%，1.2%和0.2%。平均手术时间为47.8 ± 38.3分钟。整体切除率在病变部位上有显著差异（胃上部vs中部vs下部，分别为88.6% vs 95.2% vs 96.0%; P = 0.02），存在瘢痕（96.0%vs89.5%; P = 0.002）和组织学类型（低级别腺瘤vs高级别腺瘤vs分化型早期胃癌vs未分化型早期胃癌，95.8% vs 94.6% vs 96.2% vs 83.8%; P = .007）。迟发性出血的发生率在不同部位有显著差异（胃上部与胃下部，分别为28.6%与13.8%; P = 0.003），肿瘤的大小（> 40 mm vs < 20 mm，分别为28.6% vs 13.7%; P = .009），复发性病变（分别为29.4%与15.1%; P = 0.024）和肉眼可见型（平坦与升高，分别为18.8%与12.4%; P = 0.047）。与手术时间较长相关的因素是位置（胃上部与胃下部，分别为64.8与44.1分钟; P <0.001），肿瘤的大小（> 40 mm vs < 20 mm，分别为67.1 vs 42.0分钟; P < .001），溃疡的存在（54.6 vs 46.8分钟; P <0.045）和瘢痕的存在（69.2 vs 45.0分钟; P <0.001）。结论：ESD是治疗早期胃肿瘤的有效和安全的治疗方法。内窥镜医生必须接受对先进的内窥镜技术的需求，以便在大病变、瘢痕病变、未分化癌症或胃上部病变的情况下进行ESD。对于胃上部有较大或复发性病变的患者，内镜医生需要更多的经验来减少并发症;这些病变也需要更多的时间来完成ESD手术。（Gastrointest Endosc 2009;69：1228-35.）
Background: The technique of endoscopic submucosal dissection (ESD) was introduced to be able to obtain ell bloc specimens of large early GI neoplasms. The drawback of ESD is its technical difficulty, which, consequently, is associated with a higher rate of complication and which requires advanced endoscopic techniques and a long procedure time.Objective: To assess the therapeutic Outcome of ESD by expert endoscopists who have at least 3 years' experience of EMR in Korea.Design: A retrospective, multicenter studyPatients: From January 2006 to June 2007, 1000 early gastric cancers in 952 patients (502 men, 450 women; mean age 62.1 years, range 43-90 years) were treated by using ESD at 6 Korean ESD study group (KESG)-related university hospitals in Korea.Intervention: We performed ESD procedures with typical sequences (marking, incision, and submucosal dissection).Main Outcome Measurements: The rate of en bloc resection, incidence of complication, and length of procedure. Predetermined factors (various endoscopic and final pathologic features) for these outcomes.Results: The rates of en bloc resection, complete en bloc resection, vertical incomplete resection, and piecemeal resection were 95.3%, 87.7%, 1.8%, and 4.1%, respectively The rates of delayed bleeding, significant bleeding, perforation, and surgery related to complication were 15.6%, 0.6%, 1.2%, and 0.2%, respectively. The mean procedure time was 47.8 +/- 38.3 minutes. The rates of en bloc resection differed significantly in relation to the location of the lesions (upper portion vs middle portion vs lower portion of the stomach, 88.6% vs 95.2% vs 96.0%, respectively; P = .02), presence of a scar (no vs yes, 96.0% vs 89.5%, respectively; P = .002), and histologic type (low-grade adenoma vs high-grade adenoma vs differentiated early gastric cancer vs undifferentiated early gastric cancer, 95.8% vs 94.6% vs 96.2% vs 83.8%, respectively; P = .007). The rates of delayed bleeding differed significantly in relation to location (upper portion vs lower portion of the stomach, 28.6% vs 13.8%, respectively; P = .003), the size of the tumor (> 40 mm vs < 20 mm, 28.6% vs 13.7%, respectively; P = .009), recurrent lesion (29.4% vs 15.1%, respectively; P = .024), and macroscopic type (flat vs elevated, 18.8% vs 12.4%, respectively; P = .047). Factors related to the longer procedure time were location (upper portion vs lower portion of the stomach, 64.8 vs 44.1 minutes, respectively; P < .001), the size of the tumor (> 40 mm vs < 20 mm, 67.1 vs 42.0 minutes, respectively; P < .001), the presence of ulcer (54.6 vs 46.8 minutes; P < .045), and the presence of a scar (69.2 vs 45.0 minutes; P < .001).Conclusions: ESD is an effective and safe therapy in the management of early gastric neoplasms. Endoscopists have to accept the need for advanced endoscopic techniques for performing ESD in the case of large lesions, scar lesions, undifferentiated cancers, or for the lesions in the upper portion of the stomach. Endoscopists require more experience to decrease complications in patients who have a large or recurrent lesion in the upper portion of the stomach; these lesions also take more time to complete the ESD procedure. (Gastrointest Endosc 2009;69:1228-35.)