离体猪食管模型同步临床病例在食管内镜黏膜下剥离术学习曲线中的作用探讨

Application of isolated pig esophagus model to synchronous clinical cases in learning curve of esophagus endoscopic submucosal dissection

摘要:

目的 探讨间断应用离体猪食管模型同步临床病例在食管内镜黏膜下剥离术（ESD）学习曲线中的作用。方法 记录该科于2017年1月－2019年12月行离体猪食管ESD及在此期间连续行食管ESD的早期食管癌患者的资料。采用单因素方差分析、非参数秩和检验和χ²检验进行统计学分析。结果 共纳入36例次离体猪食管ESD。第1年（2017年）的剥离熟练度明显较第2和3年（2018年和2019年）低（17.2、5.6和5.8 min/cm²，P < 0.05）；第1年（2017年）的肌层损伤明显较第2和3年（2018年和2019年）多（中位数为2.0、0.0和0.0次/例，P < 0.05）。共实施了25例临床患者食管ESD，第1年（2017年）的剥离熟练度明显较第2和3年（2018年和2019年）低（39.3、16.6和12.7 min/cm²，P < 0.05）。整块切除率为100.0%，R0切除率为96.0%，治愈性切除率为92.0%，只有早期1例较大病变发生了穿孔，总的穿孔率为4.0%，无迟发性出血发生。结论 内镜医生独立掌握食管ESD技术至少需要16例ESD（8例离体猪食管+8例临床患者）积累。对于初学者，每个月至少2例食管ESD可能是技术不至于生疏的一个合理载量。

Abstract:

Objective To investigate the role of continuous application of isolated pig esophagus model and synchronous clinical cases in esophageal endoscopic submucosal dissection (ESD) learning curve.Methods The data of isolated pig esophagus model ESD specimen size, dissection time and muscularis propria injury were recorded from January 2017 to December 2019. The data of clinical early esophageal carcinoma continuous ESD cases were collected. One-Way Anova, nonparametric rank sum test and Chi square test were used for statistical analysis.Results In total, we practiced ESD in 36 cases of pig esophagus in vitro. In the first year (2017), the dissection proficiency was significantly lower than that of the second and third year (2018, 2019) (17.2 min/cm² vs 5.6 and 5.8 min/cm², P < 0.05). The muscularis propria injury in the first year (2017) was significantly more than that of the second and third years (2018, 2019) (2.0 vs 0.0 and 0.0, P < 0.05). In total, we performed esophageal ESD in 25 clinical patients. The first year (2017), the dissection proficiency was significantly lower than that of the second and third year (2018, 2019) (39.3 min/cm², vs 16.6 and 12.7 min/cm², P < 0.05), the whole resection rate was 100.0%, the R0 resection rate was 96.0%, and the curative resection rate was 92.0%. Only one case of large ESD had perforation in the early stage, and the total perforation rate was 4.0%, no case of delayed bleeding.Conclusion Endoscopists need to accumulate at least 16 cases of ESD (8 cases of isolated pig esophagus + 8 cases of clinical patients) to master the esophageal ESD technology independently, and for beginners, at least 2 cases of esophageal ESD per month may not be a reasonable load for technical sparsity.