【作者】 何怡；

【导师】 王雷；

【作者基本信息】 南京大学 ， 临床医学（消化内科）（专业学位）， 2020， 硕士

【摘要】 背景:内镜全层切除术(EFTR)和保留浆膜层切除术(ESSD)是两种固有肌层起源肿瘤的内镜下治疗方式。EFTR手术过程中因造成胃壁穿孔可能导致胃内容物外渗、腹腔感染等其他不良反应。然而,ESSD通过浆膜下层与固有肌层间注射剥离能够在保留胃浆膜层的前提下进行瘤体切除,隔绝了胃腔与腹膜腔间贯通,一定程度上降低了渗漏性腹膜炎的发生。目前尚无关于这两种内镜手术的临床比较研究。目的:通过倾向性匹配评分(PSM)比较ESSD和EFTR在治疗固有肌层起源肿瘤的疗效及临床并发症对比。方法:此为一项单中心回顾性研究。收集2016年10月至2019年1月在南京大学医学院附属鼓楼医院行胃固有肌层起源间质瘤ESSD或者EFTR治疗的患者。收集两组患者的基线资料(性别、年龄、瘤体部位、病变大小)、手术时间、术中及术后并发症、住院时间及费用情况。为使研究更有说服力,我们采用了倾向性匹配评分(PSM)对两组患者的基线资料(性别、年龄、瘤体部位、病变大小)进行控制匹配,并对得到的两组数据进行进一步结果分析。所有统计学数据均使用SPSS25.0软件进行统计学分析。对于研究中符合正态分布的数值变量采用t检验,数值表示为mean(SD),对于不符合正态分布的数值变量采用非参数检验,数值表示为median(Q1,Q3)。研究中的分类变量采用卡方检验。P值<0.05认为有统计学意义。结果:共计22例患者行ESSD治疗,男女比例:0.69:1,平均年龄:54.9岁,76例患者行EFTR治疗,男女比例:0.68:1,平均年龄:57.2岁。经PSM倾向匹配后共计得到21对患者资料。同EFTR组相比,ESSD组的平均手术时间较EFTR组短(46.4±21.2min vs 71.1±36.7 min,P=0.010)。两组病人置入胃肠减压管的事件发生率(23.8%vs 81%,P<0.001)及拔出胃肠减压管时间(0(0,0.5)vs 2(1.0,3.0),P<0.001)具有统计差异性。ESSD组患者和EFTR组患者具有大致相同的预后。根据对患者术后指标记录,EFTR组较ESSD组患者术后体温、血常规中白细胞、中性粒细胞计数均有升高且差异具有统计学意义(P<0.05)。EFTR组患者术后出现腹痛、胃肠道不适人数高于ESSD组(P<0.05)。ESSD组术后抗生素使用时间及平均住院费用低于EFTR组(P<0.05),术后住院时间无明显统计学差异(p=0.086)。两组患者均未出现大出血、术后迟发性出血或转至外科手术治疗。术后病理提示所有患者均为完整切除。结论:两种内镜治疗方法均安全可靠。相比较而言,ESSD手术创伤性低、保持了消化道器官完整性具有良好的术中、术后结果。更多还原

【Abstract】 Background: Endoscopic full-thickness resection(EFTR)and Endoscopic subserosal dissection(ESSD)are different endoscopic method in dealing with gastric cavity tumors originating from the muscularis propria layer.EFTR may cause abdominal cavity infection and other adverse events.However,ESSD can resect the lesion without damage the serosa and isolating the gastric cavity from the abdominal cavity.At present,there is no clinical comparative study on the two kinds of endoscopic surgery.Objective: This study is aimed to compare effectiveness and complications using propensity score matching method(PSM)between ESSD and EFTR in GISTs which originating from the muscularis propria layer.Methods: This is a single-center retrospective study.We collected the clinical data of the patients which had treated in our hospital by ESSD or EFTR between October2016 and January 2019.Baseline information such as age,gender,tumor location,lesion size,operation time,intraoperative and postoperative complications were collected.Propensity score-matched(PSM)method was used to control baseline information which allowed for more reliable statistical results.All statistical data were analyzed by spss25.0 software.T-test was used for the numerical variables conforming to the normal distribution,and the value is expressed as mean(SD).Nonparametric test is used for the numerical variables not conforming to the normal distribution,and the value is expressed as median(Q1,Q3).Chi-square test was used for classification variables.P < 0.05 was considered statistically significant.Results: 22 patients,ratio of male to female: 0.69:1,mean age 54.9 years received ESSD and 76 patients,ratio of male to female: 0.68:1,mean age 57.2 years received EFTR,in total,21 pairs were balanced.Compared with the EFTR group,the average operation time was shorter in the ESSD group(46.4±21.2min vs 71.1±36.7 min,P =0.010).Furthermore,the rate of incidence(23.8% vs 81%,p<0.001)and pullout time of gastrointestinal decompression tube indwelling(0(0,0.5)vs 2(1.0,3.0),P<0.001)were statistically different.Two groups had similar postoperative prognosis.According to the post-operative inflammatory index record,the temperature,WBC and neutrophil count of EFTR group were significantly higher than those of ESSD group(P < 0.05).The incidence of abdominal pain and gastrointestinal discomfort in EFTR group was higher than that in ESSD group(P < 0.05).The postoperative antibiotic use time and average hospitalization cost of ESSD group were lower than those of EFTR group(P < 0.05),and there was no significant difference in postoperative hospitalization time(P = 0.086).None of the patients had intraoperative hemorrhage or transferred to surgical treatment.According to the pathological results after operation,complete resection of tumor was achieved in all patients.Conclusion: Both endoscopic resection method is minimally invasive and safe.However,ESSD is a less invasive method,which can maintain the integrity of digestive tract organs and associated with a better intraoperative and postoperative outcome.更多还原