糖皮质激素的不同给药方式预防食管内镜黏膜下剥离术后狭窄的效果

Effect of different administration modes of glucocorticoid on the prevention of stenosis after endoscopic submucosal dissection of esophagus

摘要:

目的 研究口服醋酸泼尼松、局部注射曲安奈德和口服醋酸泼尼松联合局部注射曲安奈德预防早期食管癌及癌前病变行内镜黏膜下剥离术（ESD）后狭窄的疗效及安全性。方法 回顾性分析2014年9月－2021年5月于该院就诊的早期食管癌及癌前病变行ESD的87例患者的临床资料，分为对照组、局部注射曲安奈德组（局部注射组）、口服醋酸泼尼松组（口服组）和口服醋酸泼尼松联合局部注射曲安奈德组（口服联合局部注射组）。其中，对照组11例，未采取预防术后狭窄的措施，局部注射曲安奈德组10例，口服醋酸泼尼松组29例，口服醋酸泼尼松联合局部注射曲安奈德组37例。对比分析4组患者术后狭窄率、难治性狭窄率、狭窄后内镜下球囊扩张治疗次数、首次内镜下球囊扩张与ESD的间隔时间、是否有激素应用不良反应和球囊扩张并发症等。结果 对照组、局部注射组、口服组和口服联合局部注射组术后狭窄发生率分别为81.82%（9/11）、70.00%（7/10）、41.38%（12/29）和40.54%（15/37），难治性狭窄发生率分别为63.64%（7/11）、50.00%（5/10）、24.14%（7/29）和24.32%（9/37），内镜下球囊扩张次数分别为（4.09±1.76）、（3.90±2.33）、（1.86±0.88）和（1.76±0.95）次，首次内镜下球囊扩张与ESD的间隔时间分别为（31.09±3.56）、（33.40±2.95）、（117.93±5.54）和（138.24±7.22）d。上述4个指标中，对照组和局部注射组术后狭窄发生率和难治性狭窄发生率明显高于口服组及口服联合局部注射组，术后内镜下球囊扩张次数明显多于口服组及口服联合局部注射组，内镜下首次球囊扩张与ESD的间隔时间明显短于口服组及口服联合局部注射组，差异均有统计学意义（P < 0.05）。组间两两比较，对照组与局部注射组狭窄发生率和难治性狭窄发生率比较，差异均无统计学意义（P > 0.05），内镜下球囊扩张次数和术后首次球囊扩张与ESD的间隔时间比较，差异均有统计学意义（P < 0.05）；口服组与口服联合局部注射组的狭窄发生率、难治性狭窄发生率和内镜下球囊扩张次数比较，差异均无统计学意义（P > 0.05），术后首次球囊扩张与ESD的间隔时间比较，差异有统计学意义（P < 0.05）。仅对照组发生1例迟发性出血，其余均无手术、球囊扩张及激素相关严重不良事件发生。结论 口服及口服联合局部注射糖皮质激素在预防食管ESD术后狭窄方面安全、有效，单纯局部注射糖皮质激素预防食管ESD术后狭窄效果有限，但可减少术后球囊扩张次数，延长首次内镜下球囊扩张与ESD的间隔时间；口服联合局部注射较单纯口服糖皮质激素可明显延迟术后发生狭窄的时间，改善患者生活质量。

Abstract:

Objective To study the efficacy and safety of oral prednisone acetate, local triamcinolone acetonide injection and oral prednisone acetate combined with local triamcinolone acetonide injection in the prevention of stricture after endoscopic submucosal dissection (ESD) in the treatment of early esophageal cancer and precancerous lesions.Methods We retrospectively analyzed the data of 87 patients who underwent endoscopic submucosal dissection in the treatment of early esophageal cancer and precancerous lesions from September 2014 to May 2021. The patients were divided into control group, local injection of triamcinolone acetonide, oral prednisone acetate group, oral prednisone acetate combined with local injection of triamcinolone acetonide groups, including control group in 11 cases, did not take measures to prevent postoperative stenosis, there were 10 patients in the local injection of triamcinolone acetonide group, 29 patients in the oral prednisone acetate group, and 37 patients in the oral prednisone acetate combined with local injection of triamcinolone acetonide group. Contrast analysis of four groups of patients with postoperative stricture rate, rate of refractory stricture, the times of treatment of esophageal stricture with endoscopic balloon dilation, the interval between the first endoscopic balloon dilation treatment and ESD, and whether there were adverse effects of hormone and balloon dilation complications.Results The incidence of postoperative stricture was 81.82% (9/11) in the control group, 70.00% (7/10) in the local injection of triamcinolone acetonide group, 41.38% (12/29) in the oral prednisone acetate group, and 40.54% (15/37) in the oral prednisone acetate combined with local injection of triamcinolone acetonide group. The rates of refractory stricture were 63.64% (7/11), 50.00% (5/10), 24.14% (7/29), 24.32% (9/37), respectively. The times of balloon dilation under endoscopy were (4.09 ± 1.76) times, (3.90 ± 2.33) times, (1.86 ± 0.88) times, (1.76 ± 0.95) times, The interval between the first balloon dilation treatment and ESD was (31.09 ± 3.56) d, (33.40 ± 2.95) d, (117.93 ± 5.54) d, (138.24 ± 7.22) d, respectively. With the index of the four, in the control group and the local injection group, the incidence of postoperative stricture, refractory stricture and the times of endoscopic balloon dilation were significantly higher than that of oral group, and oral combined with local injection group, and the interval between the first endoscopic balloon dilation treatment and ESD surgery was significantly shorter than that of oral group, and oral combined with local injection group, the difference was statistically significant (P < 0.05). Pairwise comparison between the control group and the local injection group showed no significant difference in the incidence of stricture and refractory stricture (P > 0.05). The comparison of the times of endoscopic balloon dilation and the interval between the first balloon dilation and ESD surgery were statistically significant (P < 0.05). In the oral group and oral combined with local injection group, there were no significant difference in the incidence of stricture, the incidence of refractory stricture and the times of endoscopic balloon dilatation (P > 0.05), but there was significant difference in the interval between the first postoperative balloon dilatation and ESD surgery (P < 0.05). Only 1 case of delayed bleeding occurred in the control group, and no serious adverse events related to surgery, balloon dilation or hormone occurred in the rest.Conclusion Oral administration and oral combined with local injection of glucocorticoid are safe and effective in preventing postoperative stricture of esophageal submucosal dissection. Local injection of glucocorticoid alone has limited effect in preventing postoperative stricture of esophageal ESD, but can reduce the times of postoperative endoscopic balloon dilation and prolong the interval between the first endoscopic balloon dilation and ESD. Compared with oral glucocorticoid alone, oral administration combined with local injection of glucocorticoid can significantly delay the interval of postoperative stricture and improve patients’ postoperative quality of life.