摘要
目的比较内镜下切除和腹腔镜手术治疗肿瘤最大径为2~5 cm胃间质瘤的临床疗效,分析肿瘤表面情况、生长方式、病变起源等因素对手术方式选择的影响,为胃间质瘤患者提供更安全、有效的治疗方法。方法回顾性分析2012年1月至2019年11月因胃间质瘤在郑州大学第一附属医院行内镜下切除(内镜下切除组137例)或腹腔镜手术治疗(腹腔镜手术组164例)的301例患者的基本临床资料,包括患者的年龄、性别,肿瘤表面有无凹陷(肿瘤表面黏膜局部下陷深度>5 mm)、是否不规则(肿瘤表面表现为非半球形或非椭圆形)、有无溃疡,肿瘤部位、形状、病变起源、生长方式(腔内生长或腔内外生长)、危险度分级(极低危、低危、中危、高危),肿瘤是否整块切除,手术时间、是否出血、禁食时间、留置胃管时间、住院时间、术后住院时间、术后并发症和随访情况。统计学方法采用独立样本t检验、卡方检验、Fisher确切概率法和Wilcoxon秩和检验。结果内镜下切除组137例胃间质瘤患者中,行内镜黏膜下剥离术85例(62.0%),内镜黏膜下挖除术9例(6.6%),内镜下全层切除术42例(30.7%),隧道法内镜黏膜下肿物切除术1例(0.7%)。内镜下切除组和腹腔镜手术组患者性别构成、年龄、病变部位、肿瘤大小、危险度分级比较差异均无统计学意义(均P>0.05)。极低危、低危、中危、高危胃间质瘤患者中分别有1、49、26、2例肿瘤表面有凹陷、溃疡、不规则,不同危险度分级肿瘤表面有无凹陷、是否不规则、有无溃疡的比例差异有统计学意义(Z=-2.55,P=0.011)。内镜下切除组肿瘤完整切除率低于腹腔镜手术组[86.1%(118/137)比100.0%(164/164)],差异有统计学意义(χ^(2)=24.28,P<0.001),但内镜下切除组手术时间、禁食时间、留置胃管时间、住院时间和术后住院时间均短于腹腔镜手术组,且住院总费用低于腹腔镜手术组[分别为90.0 min(62.5 min,150.0 min)比119.5 min(80.0 min,154.2 min)、3 d(3 d,4 d)比5 d(4 d,7 d)、3 d(2 d,4 d)比4 d(2 d,6 d)、11 d(10 d,14 d)比16 d(12 d,20 d)、7 d(6 d,9 d)比9 d(7 d,11 d)、(38211.6±10221.0)元比(59926.1±17786.1)元],差异均有统计学意义(Z=-2.46、-7.12、-4.44、-6.89、-5.92,t=-13.24;均P<0.05)。内镜下切除组术后腹痛和术后其他较重并发症(休克、呼吸衰竭、肺栓塞、胃轻瘫等)发生率均低于腹腔镜手术组[16.8%(23/137)比27.4%(45/164)、0.7%(1/137)比4.9%(8/164)],差异均有统计学意义(χ^(2)=4.84、Fisher确切概率法,P=0.028、0.043);两组术中出血,术后出血、发热、穿孔发生率比较差异均无统计学意义(均P>0.05)。内镜下切除组呈腔内生长、起源于固有肌层病变的手术相关并发症发生率均低于腹腔镜手术组[分别为19.5%(25/128)比32.6%(45/138)、12.6%(12/95)比31.4%(37/118)],差异均有统计学意义(χ^(2)=5.86、10.42,P=0.016、0.001)。内镜下切除组和腹腔镜手术组术后肿瘤复发率比较[0(0/137)比2.4%(4/164)]差异无统计学意义(Fisher确切概率法,P=0.129)。结论对于肿瘤最大径为2~5 cm的胃间质瘤,内镜下切除安全、有效,优于腹腔镜手术治疗,但对于肿瘤表面有凹陷、溃疡、不规则、呈腔内外生长倾向的病变建议选择腹腔镜手术。
Objective To compare the clinical efficacy of endoscopic resection and laparoscopic surgery in the treatment of gastric gastrointestinal stromal tumor(GIST)with a maximum diameter of 2 to 5 cm,and to analyze the influence of factors such as tumor surface,growth pattern and lesion origin on the choice of resection method,so as to provide a safer and more effective treatment for patients with gastric GIST.Methods From January 2012 to November 2019,at the First Affiliated Hospital of Zhengzhou University,the clinical data of 301 patients with gastric GIST who underwent endoscopic resection(137 cases in the endoscopic resection group)or laparoscopic surgery(164 cases in the laparoscopic surgery group)were retrospectively analyzed,including age,gender,whether there was depression on the tumor surface(the local subsidence depth of the mucosa on the tumor surface was>5 mm),whether the tumor surface was irregular(non-hemispherical or non-elliptical tumor surface),whether there was combined ulcer,location,shape,origin of the lesion,growth pattern(intralumina growth or combined intraluminal and extraluminal growth),risk classification(very low risk,low risk,medium risk,high risk),whether the tumor was en bloc resection,operation time,whether bleeding or not,fasting time,indwelling time of gastric tube,time of hospitalization,time of postoperative hospital stay,postoperative complications and follow-up.Independent sample t test,chi-square test or Fisher′s exact test and Wilcoxon rank sum test were used for statistical analysis.Results Among the 137 patients with gastric GIST in the endoscopic resection group,85 cases(62.0%)underwent endoscopic submucosal dissection,9 cases(6.6%)underwent endoscopic submucosal excavation,42 cases(30.7%)underwent endoscopic full-thickness resection,and 1 case(0.7%)underwent submucosal tunnel endoscopic resection.There were no significant differences in gender,age,lesion location,tumor size,and risk classification between the endoscopic resection group and the laparoscopic surgery group(all P>0.05).The tumor surface was depressed,with ulcer or irregular in 1,49,26,and 2 cases of patients with gastric GIST of very low risk,low risk,medium risk and high risk,respectively.There was statistically significant difference in the proportion of depression,irregularity and ulcer on the tumor surface at different risk levels(Z=-2.55,P=0.011).The complete tumor resection rate of the endoscopic resection group was lower than that of the laparoscopic surgery group(86.1%,118/137 vs.100.0%,164/164),and the difference was statistically significant(χ^(2)=24.28,P<0.001).However the operation time,fasting time,the indwelling time of gastric tube,time of hospitalization,and the time of postoperative hospital stay of the endoscopic resection group were shorter than those of the laparoscopic surgery group,and the total hospitalization cost was lower than that of the laparoscopic surgery group(90.0 min(62.5 min,150.0 min)vs.119.5 min,(80.0 min,154.2 min);3 d(3 d,4 d)vs.5 d(4 d,7 d);3 d(2 d,4 d)vs.4 d(2 d,6 d);11 d(10 d,14 d)vs.16 d(12 d,20 d);7 d(6 d,9 d)vs.9 d(7 d,11 d);(38211.6±10221.0)yuan vs.(59926.1±17786.1)yuan),and the differences were statistically significant(Z=-2.46,-7.12,-4.44,-6.89 and-5.92,t=-13.24;all P<0.05).The incidence of postoperative abdominal pain and other severe postoperative complications(including shock,respiratory failure,pulmonary embolism,gastroparesis,etc.)of the endoscopic resection group were all lower than those of the laparoscopic surgery group(16.8%,23/137 vs.27.4%,45/164;0.7%,1/137 vs.4.9%,8/164),and the differences were statistically significant(χ^(2)=4.84,Fisher′s exact test,P=0.028 and 0.043).There were no significant differences in the incidence of intraoperative bleeding,postoperative bleeding,fever and perforation between the two groups(all P>0.05).The incidence of operation-related complications of lesions with intraluminal growth and originating from muscularis propria in the endoscopic resection group were lower than those of the laparoscopic surgery group(19.5%,25/128 vs.32.6%,45/138;12.6%,12/95 vs.31.4%,37/118),and the differences were statistically significant(χ^(2)=5.86 and 10.42,P=0.016 and 0.001).There was no significant difference in the postoperative tumor recurrent rate between the endoscopic resection group and the laparoscopic surgery group(0,0/137 vs.2.4%,4/164;Fisher’s exact test,P=0.129).Conclusions Endoscopic treatment is safe and effective for gastric GIST with a maximum diameter of 2 to 5 cm,which is superior to laparoscopic surgery.However,laparoscopic surgery is recommended for tumor with depressed,ulcerative,or irregular surface and combined intraluminal and extraluminal growth.
作者
贺德志
魏珂乐
岳来福
刘冰熔
李建生
韩艳妙
徐海莉
宋李娟
赵梦月
王文玲
He Dezhi;Wei Kele;Yue Laifu;Liu Bingrong;Li Jiansheng;Han Yanmiao;Xu Haili;Song Lijuan;Zhao Mengyue;Wang Wenling(Department of Gastroenterology,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,China)
出处
《中华消化杂志》
CAS
CSCD
北大核心
2022年第4期240-246,共7页
Chinese Journal of Digestion
基金
河南省教育厅科学技术研究重点项目(22B320018)。
关键词
胃间质瘤
内镜切除
腹腔镜
伊马替尼
Gastric gastrointestinal stromal tumor
Endoscopic resection
Laparoscopes
Imatinib
