摘要
回顾性分析2017年8月-2023年8月该院行内镜下切除治疗的66例胃SMTs患者的临床资料,根据所用手术器械不同,分为:圈套器组(采用圈套器行内镜下切除,n = 33)和传统切除组(采用传统一次性黏膜切开刀行内镜下切除,n = 33)。比较两组患者手术时间、整体切除率、不良反应发生率、手术费用、住院费用和术后住院时间等。
圈套器组病变直径为8.00(6.00,14.00)mm,传统切除组病变直径为8.00(7.50,10.00)mm,两组患者比较,差异无统计学意义(P > 0.05);圈套器组手术时间为26.00(19.00,30.50)min,明显短于传统切除组的33.00(22.50,49.50)min,差异有统计学意义(P < 0.05);两组患者整体切除率均为100.0%;两组患者均未发生术中穿孔,两组患者术中出血、腹痛和发热等不良反应发生率比较,差异均无统计学意义(P > 0.05);圈套器组手术费用为(8 642.18±1 078.56)元,明显少于传统切除组的(13 266.45±2 160.80)元,差异有统计学意义(P < 0.05);
黏膜下肿物(submucosal tumors,SMTs)是一类来源于黏膜下方各层的隆起性病变,其组织病理类型复杂多样,多为良性,但也有部分存在恶性潜
回顾性分析2017年8月-2023年8月本院行内镜下切除术(包括ESD和EFR)治疗的66例胃SMTs患者的临床资料,根据所用手术器械不同,分为:圈套器组(采用圈套器代黏膜切开刀行内镜下切除治疗,n = 33)和传统切除组(采用传统一次性黏膜切开刀行内镜下切除治疗,n = 33)。两组患者一般资料比较,差异无统计学意义(P > 0.05),具有可比性。见
组别 | 性别 例(%) | 年龄/岁 | 既往史 例(%) | ||||
---|---|---|---|---|---|---|---|
男 | 女 | 高血压 | 糖尿病 | 冠心病 | 腹部手术史 | ||
圈套器组(n = 33) | 14(42.4) | 19(57.6) | 55.21±11.06 | 10(30.3) | 2(6.1) | 2(6.1) | 6(18.2) |
传统切除组(n = 33) | 11(33.3) | 22(66.7) | 53.09±11.90 | 7(21.2) | 2(6.1) | 2(6.1) | 9(27.3) |
t/ |
0.5 |
1.1 |
0.7 |
0.0 |
0.0 |
1.4 | |
P值 | 0.447 | 0.269 | 0.398 | 1.000 | 1.000 | 0.228 |
组别 | 病变直径/mm | 病变深度 例(%) | 病变部位 例(%) | |||||
---|---|---|---|---|---|---|---|---|
黏膜下层 | 固有肌层 | 胃底 | 胃体 | 贲门 | 胃窦 | 胃角 | ||
圈套器组(n = 33) | 8.00(6.00,14.00) | 7(21.2) | 26(78.8) | 10(30.3) | 22(66.7) | 0(0.0) | 1(3.0) | 0(0.0) |
传统切除组(n = 33) | 8.00(7.50,10.00) | 7(21.2) | 26(78.8) | 12(36.4) | 16(48.5) | 2(6.1) | 2(6.1) | 1(3.0) |
t/ |
-0.2 |
0.0 | ||||||
P值 | 0.790 | 1.000 |
0.38 |
注: 1)为
纳入标准:年龄≥18岁;病变直径≤20 mm;行超声内镜检查术(endoscopic ultrasonography,EUS),证实病变起源于黏膜下层或固有肌层;无消化道外浸润或转移征象;病例资料完整;患者和家属知情同意,并签署手术知情同意书。排除标准:采用其他器械(尼龙绳、牙线和套扎器等)辅助治疗者;浆膜外生长的SMTs;病理结果不明者;凝血功能差[国际标准化比值 > 1.5和(或)血小板 < 50 000];严重心律失常或肺功能不全,无法耐受麻醉和内镜切除手术;存在严重影响生存率的恶性肿瘤;未签署知情同意书或拒绝行内镜治疗者。
采用全身麻醉。传统切除组手术方法(

A

B

C

D




图1 传统ESD切除SMTs的操作过程
Fig.1 The procedure of conventional ESD for cutting SMTs
A:内镜下观察SMTs;B:同一病灶的EUS显示,肿瘤起源于固有肌层;C:用黏膜切开刀标记病变范围;D:黏膜下注射含肾上腺素、美兰和甘油果糖的注射液;E:用黏膜切开刀分离瘤体周边结缔组织和肌层;F:瘤体剥离后的创面;G:用金属夹封闭创面;H:切除后的标本。
E F G H

A

B

C

D




图2 采用圈套器行内镜下切除术切除SMTs的操作过程
Fig.2 The procedure of endoscopic resection using snares for cutting SMTs
A:内镜下观察SMTs;B:同一病灶的EUS显示,肿瘤起源于固有肌层;C:用圈套器标记病变范围;D:用圈套器套取瘤体表面黏膜;E:用圈套器分离瘤体周边结缔组织及肌层;F:吸引瘤体,收紧圈套器后高频电切除;G:用金属夹封闭创面;H:切除后的标本。
E F G H
按照内镜术中出血(endoscopic resection bleeding,ERB)三级五分
传统切除组术后病理类型包括:神经内分泌瘤、平滑肌瘤、间质瘤和脂肪癌。其中,间质瘤占57.6%(19/33),且均为极低危险
组别 | 间质瘤 | 平滑肌瘤 | 神经内分泌瘤 | 脂肪瘤 | 钙化纤维性肿瘤 |
---|---|---|---|---|---|
圈套器组(n = 33) | 13(39.4) | 13(39.4) | 6(18.2) | 0(0.0) | 1(3.0) |
传统切除组(n = 33) | 19(57.6) | 9(27.3) | 3(9.1) | 2(6.1) | 0(0.0) |
P值 |
0.20 |
注: †采用Fisher确切概率法。
圈套器组手术时间明显短于传统切除组[ 26.00(19.00,30.50)min vs 33.00(22.50,49.50)min],差异有统计学意义(P = 0.036);两组患者整块切除率均为100.0%;圈套器组手术费用为(8 642.18±1 078.56)元,明显少于传统切除组的(13 266.45±2 160.80)元,差异有统计学意义(P = 0.000);圈套器组住院费用为(19 346.36±3 769.12)元,明显少于传统切除组的(26 204.03±3 269.38)元,差异有统计学意义(P = 0.000);圈套器组术后住院时间为4.00(3.00,5.00)d,明显短于传统切除组的5.00(4.00,6.00)d,差异有统计学意义(P = 0.005)。见
组别 | 手术时间/min | 金属夹/个 | 手术费用/元 | 住院费用/元 | 术后住院时间/d |
---|---|---|---|---|---|
圈套器组(n = 33) | 26.00(19.00,30.50) | 6.00(6.00,8.00) | 8 642.18±1 078.56 | 19 346.36±3 769.12 | 4.00(3.00,5.00) |
传统切除组(n = 33) | 33.00(22.50,49.50) | 7.00(6.00,9.50) | 13 266.45±2 160.80 | 26 204.03±3 269.38 | 5.00(4.00,6.00) |
t/Z值 | -2.10 | -1.13 |
-11.0 |
-7.9 | -2.78 |
P值 | 0.036 | 0.257 | 0.000 | 0.000 | 0.005 |
注: †为t值。
圈套器组有2例固有肌层深层病变行EFR的患者,传统切除组有5例,黏膜缺损均于内镜下通过金属夹完全闭合,未发生腹膜炎。术中出血分级为ERB-c1的两组均有25例,圈套器组出血分级为ERB-c2的3例,传统切除组有5例。66例患者术后均未出现严重不良反应。圈套器组有2例发热,1例为低热,另1例为中等度热;传统切除组也有2例发热,均为低热,两组患者发热发生率比较,差异无统计学意义(P > 0.05)。传统切除组与圈套器组术后腹痛发生率(9.1%和9.1%)比较,差异无统计学意义(P > 0.05)。两组患者均未发生术中穿孔。见
组别 | 术中出血 | 发热 | 腹痛 | ||||
---|---|---|---|---|---|---|---|
ERB-0级 | ERB-c1级 | ERB-c2级 | 无发热 | 低热 | 中热 | ||
圈套器组(n = 33) | 5(15.2) | 25(75.8) | 3(9.1) | 31(93.9) | 1(3.0) | 1(3.0) | 3(9.1) |
传统切除组(n = 33) | 3(9.1) | 25(75.8) | 5(15.2) | 31(93.9) | 2(6.1) | 0(0.0) | 3(9.1) |
Z值 | 0.99 | -0.03 | |||||
P值 | 0.321 | 0.975 |
0.99 |
注: †采用Fisher确切概率法。
近年来,随着消化内镜检查和EUS的快速发展,胃SMTs的检出率大幅度提
ESAKI
出血和穿孔是内镜下切除病变的常见不良事件,起源于深层的肿物,在内镜下切除更容易出现穿孔等并发
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