Endoscopic Mucosal Resection Outcomes and Prediction of Submucosal Cancer From Advanced Colonic Mucosal Neoplasia
Endoscopic Mucosal Resection Outcomes and Prediction of Submucosal Cancer From Advanced Colonic Mucosal Neoplasia
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DOI：
10.1053/j.gastro.2011.02.062
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发表时间：
2011-06-01
期刊：
影响因子：
29.4
通讯作者：
Byth, Karen
中科院分区：
文献类型：
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作者：
Moss, Alan;Bourke, Michael J.;Byth, Karen
背景与目的：大的无蒂结肠息肉通常采用手术治疗，具有显著的发病率和潜在的死亡率。关于内镜黏膜切除术（EMR）的前瞻性、意向性、多中心研究很少。我们研究了内镜标准是否可以预测侵袭性疾病并指导最佳治疗策略。方法：澳大利亚结肠内窥镜（ACE）切除研究小组对所有因尺寸为20 mm或更大的无蒂结直肠息肉而转诊进行EMR的患者进行了一项前瞻性、多中心、观察性研究（n = 479，平均年龄，68.5岁;平均病变尺寸，35.6 mm）。我们分析了病变特征和手术、临床和组织学结局的数据。根据随访结肠镜检查结果，多元逻辑回归分析确定了EMR疗效和腺瘤复发的独立预测因素。研究结果：粘膜下浸润的危险因素如下：巴黎分类0-IIa + c形态、非颗粒表面和Kudo凹陷模式V型。最常见的病变（0-IIa颗粒）的粘膜下浸润率较低（1.4%）。在89.2%的患者中，EMR在单次治疗中完全切除息肉是有效的;缺乏疗效的风险因素包括既往尝试EMR（比值比[ OR]，3.8; 95%置信区间，1.77-7.94; P = .001）和回盲瓣受累（OR，3.4; 95%置信区间，1.20-9.52; P = .021）。有效EMR后复发的独立预测因素是病灶大小大于40 mm（OR，4.37; 95%置信区间，2.43-7.88; P <0.001）和使用氩等离子凝固术（OR，3.51; 95%置信区间，1.69-7.27; P = 0.0017）。EMR没有导致死亡; 83.7%的患者避免了手术。结论：内镜治疗大的无蒂结肠息肉是安全有效的。内窥镜评估可识别含有粘膜下癌的风险增加的病变。第一次EMR是患者结局的重要决定因素-之前的尝试是缺乏疗效的重要风险因素。
BACKGROUND & AIMS: Large sessile colonic polyps usually are managed surgically, with significant morbidity and potential mortality. There have been few prospective, intention-to-treat, multicenter studies of endoscopic mucosal resection (EMR). We investigated whether endoscopic criteria can predict invasive disease and direct the optimal treatment strategy. METHODS: The Australian Colonic Endoscopic (ACE) resection study group conducted a prospective, multicenter, observational study of all patients referred for EMR of sessile colorectal polyps that were 20 mm or greater in size (n = 479, mean age, 68.5 y; mean lesion size, 35.6 mm). We analyzed data on lesion characteristics and procedural, clinical, and histologic outcomes. Multiple logistic regression analysis identified independent predictors of EMR efficacy and recurrence of adenoma, based on findings from follow-up colonoscopy examinations. RESULTS: Risk factors for submucosal invasion were as follows: Paris classification 0-IIa + c morphology, nongranular surface, and Kudo pit pattern type V. The most commonly observed lesion (0-IIa granular) had a low rate of submucosal invasion (1.4%). EMR was effective at completely removing the polyp in a single session in 89.2% of patients; risk factors for lack of efficacy included a prior attempt at EMR (odds ratio [ OR], 3.8; 95% confidence interval, 1.77-7.94; P = .001) and ileocecal valve involvement (OR, 3.4; 95% confidence interval, 1.20-9.52; P = .021). Independent predictors of recurrence after effective EMR were lesion size greater than 40 mm (OR, 4.37; 95% confidence interval, 2.43-7.88; P < .001) and use of argon plasma coagulation (OR, 3.51; 95% confidence interval, 1.69-7.27; P = .0017). There were no deaths from EMR; 83.7% of patients avoided surgery. CONCLUSIONS: Large sessile colonic polyps can be managed safely and effectively by endoscopy. Endoscopic assessment identifies lesions at increased risk of containing submucosal cancer. The first EMR is an important determinant of patient outcome-a previous attempt is a significant risk factor for lack of efficacy.