【作者】 邱钰；

【导师】 施瑞华；

【作者基本信息】 东南大学 ， 临床医学（专业学位）， 2020， 硕士

【摘要】 研究背景:随着消化道内镜诊疗技术的不断发展,目前对于食管早癌或癌前病变,推荐采用内镜下治疗,例如内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）等,具备创伤小,住院时间短,术后并发症少等优势。但ESD术后常见的并发症为食管狭窄,会影响患者吞咽功能,从而降低患者的生活质量。对于大于3/4食管周径的ESD,术后狭窄率高达83.3-94.1%^[1]。内镜下扩张（endoscopic dilation,ED）是目前公认的治疗食管ESD术后狭窄的有效方法,但其复发率高,且反复的扩张治疗会引起穿孔、出血等并发症^[2]。因此,探求预防食管ESD术后狭窄有效且安全的方法,对于目前消化道内镜治疗的发展是非常必要的。近年来,糖皮质激素逐渐被临床用于预防食管ESD术后狭窄,其主要有两种给药方式:口服醋酸泼尼松和局部注射曲安奈德。目前国内外多项研究显示的结果差异很大^[3-9]。基于这些现有的研究和我们自身的经验,我们开展了一项回顾性研究,以评估口服及口服结合局部注射糖皮质激素在预防食管ESD术后狭窄方面的有效性及安全性。目的:评估并比较口服醋酸泼尼松片、口服醋酸泼尼松结合局部注射曲安奈德对于预防食管早癌及癌前病变内镜黏膜下剥离术后食管狭窄的疗效。方法:回顾性分析2014年12月至2019年2月至东南大学附属中大医院就诊的52名食管早癌或癌前病变患者资料,分为对照组（A组,n=20）、口服激素组（B组,n=17）、口服结合局部注射组（C组,n=15）。比较3组患者的背景信息、狭窄率、内镜下扩张次数、ESD术后第一次扩张间隔时间、不良事件发生情况。结果:三组患者的背景信息在年龄、性别、病变部位、病变周径、病变长度、病变深度、术后病理等方面差异无统计学意义（P>0.05）。三组狭窄率差异存在统计学意义[85.0%（17/20）比47.1%（8/17）比46.7%（7/15）,X²=7.559,P<0.01],两两比较,B组和C组狭窄率均低于A组,且均有统计学意义（P<0.05）,而B组与C组比较狭窄率无统计学差异（P>0.05）。ESD术后随访期间,3组患者的内镜下扩张次数差异有统计学意义[（4.2±2.9）次比（1.4±2.2）次比（1.1±1.3）次,F=9.90,P<0.01],两两比较,B组和C组扩张次数均少于A组,且均有统计学意义（P<0.01）,而B组与C组比较扩张次数差异无统计学意义（P=0.74）。3组患者ESD术后第一次内镜下扩张时间差异有统计学意义[（27.7±9.4）天比（110.1±46.0）天比（147.4±9.4）天,F=89.4,P<0.001)],两两比较,B组和C组扩张间隔时间均长于A组（P<0.001）,且C组扩张间隔时间长于B组（P<0.001）。对照组有2例病人发生穿孔,经积极治疗后均好转,其余患者均未发生严重ESD术或激素相关不良事件。结论:口服泼尼松或者口服泼尼松结合局部注射曲胺奈德均可有效且安全地预防食管ESD术后的狭窄,值得进一步推广并且探讨最有效且安全的口服时间和剂量。两者之间比较,虽然口服结合局部注射激素在降低狭窄率和减少扩张次数方面无明显优势,但可延长ESD术后第一次扩张的间隔时间,有利于患者术后的心理恢复及生活质量的提高。更多还原

【Abstract】 Research Background:At present,endoscopic techniques are recommended for early esophageal neoplasm or precancerous lesions,such as endoscopic submucosal dissection（ESD）,which possesses the advantages of minor injury,shorter duration of hospital stay and less postoperative complications.However,the common complication after ESD is esophageal stricture,which affects the swallowing function and reduces the quality of life of patients.For patients with mucosal defect larger than 3/4 circumference of esophagus,the stenosis rate after ESD,is as high as 83.3%^[1].Endoscopic bougie dilatation（EBD）is currently recognized as an effective method for the treatment of esophageal stricture after ESD,but its recurrence rate is high,and repeated dilatation treatment will cause perforation,bleeding and other complications^[2].Therefore,exploring more effective and safer methods of prevent esophageal stricture after ESD is very necessary for the development of endoscopic therapy at present.In recent years,corticosteroids have been gradually used to prevent esophageal stricture after ESD.There are two main ways of administration:oral prednisolone acetate and local injection of triamcinolone acetonide.At present,many studies at home and abroad show that the results are rather different^[3-9].Based on these existing studies and our own experience,QIU Yu conducted a study to retrospectively compare the effectiveness and safety of oral and oral combined with local injection of corticosteroids in preventing esophageal stenosis after ESD.Purpose:To evaluate and compare the efficacy and safety of oral prednisone acetate and oral prednisone acetate combined with local injection of triamcinolone acetonide in the prevention of esophageal stricture after endoscopic submucosal dissection（ESD）for early esophageal neoplasm and precancerous lesions.Methods:The data of 52 patients with early esophageal cancer or precancerous lesions from December 2014 to February 2019 in Zhongda Hospital Affiliated to Southeast University were analyzed retrospectively.They were divided into control group（group A,n=20）,oral steroid group（group B,n=17）and oral combined with local injection group（group C,n=15）.The background information,stenosis rate,endoscopic dilatation times,time interval of first dilation after ESD and adverse events of the three groups were compared.Results:There was no significant difference in age,sex,lesion location,lesion circumference,lesion length,lesion depth and post-operative pathology among the three groups（P>0.05）.The difference of stenosis rate among the three groups was statistically significant[85.0%（17/20）VS 47.1%（8/17）VS 46.7%(7/15,X²=7.559,P<0.01].In pairwise comparison,the stenosis rate in group B and group C was significantly lower than that in group A,and there was no statistical difference in stenosis rate between group B and group C（P>0.05）.During follow-up period after ESD,the difference of endoscopic dilatation times among the three groups was statistically significant（4.2±2.9 VS 1.4±2.2 VS 1.1±1.3,P<0.01）.In pairwise comparison,the times of endoscopic dilatation in group B and group C was significantly less than that in group A（P<0.01）,but there was no significant difference between group B and group C（P=0.74）.There was significant difference in the time interval of the first endoscopic dilation after ESD among the three groups（27.7±9.4d VS 110.1±46.0d VS 147.4±9.4d,P<0.001）.In pairwise comparison,the first dilation interval in group B and group C was longer than that in group A（P<0.001）,and the first dilation interval in group C was longer than that in group B（P<0.001）.Two patients in control group developed perforation after ESD but they were treated actively and recovered finally.No ESD or steroid-related severe adverse events occurred in other patients of the three groups.Conclusion:Both of oral prednisone and oral prednisone combined with local injection of triamcinolone acetonide after ESD can effectively and safely prevent esophageal stricture after ESD,which is worth further promoting and exploring the most proper time and dose of oral administration.Although oral administration combined with local injection of corticosteroids has no obvious advantage in reducing stenosis rate and the times of dilatation,it can prolong the time interval of the first dilation after ESD,which is beneficial to the psychological recovery and the improvement of quality of life of patients after operation.更多还原