Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, San5, Wonchondong, Yoengtongku, Keongkido, Suwon 443-721, South Korea.
Surg Endosc. 2012 Sep;26(9):2456-64. doi: 10.1007/s00464-012-2211-x. Epub 2012 Mar 8.
Endoscopic submucosal dissection (ESD) enables en bloc resection of larger gastric neoplasms. However, the procedure is associated with a high incidence of perforation. Perforations during ESD are divided into macro- and microperforations. Although both types of perforations could cause widespread tissue injury and secondary sepsis, very little is known concerning the risk factors for perforations according to the type of perforation. Thus, this study was performed to evaluate the risk factors for macro-, micro-, and all perforations (both) during ESD.
823 gastric lesions (gastric adenoma or early gastric cancer) in 729 patients treated by ESD were enrolled, and their records were reviewed retrospectively. Risk factors were evaluated, focusing on age, sex, gastric neoplasm-related factors (12 locations, resected size, gross type of lesions, presence of ulceration, presence of fibrosis, pathologic diagnosis, and depth of invasion), and ESD procedure-related factors (type of knife, immediate bleeding during ESD, en bloc resection, procedure time, and the number of ESD cases experienced by the endoscopist).
Of the 823 gastric lesions, the rates of all perforation, macroperforation, and microperforation were 9.6%, 7.5%, and 2.1%, respectively. Risk factors for all perforations on multivariate analysis were location of tumor in upper portion, presence of fibrosis, and long procedure time (>2 h). Risk factors for macroperforations were the same as all perforations. Risk factors for microperforations on multivariate analysis were old age (≥81 years), depth of invasion (muscularis mucosa), and long procedure time (>2 h).
The risk factors for perforations during ESD could differ according to the type of perforation. Therefore, although macroperforation did not develop during ESD, it would be necessary to consider the possibility of microperforation in case of old age, long procedure time, and (deep) depth of invasion.
内镜黏膜下剥离术（ESD）能够整块切除较大的胃肿瘤。然而，该操作与穿孔的高发生率相关。ESD 过程中的穿孔分为大穿孔和小穿孔。尽管这两种类型的穿孔都可能导致广泛的组织损伤和继发感染，但对于根据穿孔类型的穿孔危险因素，人们知之甚少。因此，本研究旨在评估 ESD 过程中大穿孔、小穿孔和所有穿孔（两者）的危险因素。
回顾性分析了 729 例接受 ESD 治疗的 823 例胃病变（胃腺瘤或早期胃癌）患者的记录。评估了危险因素，重点关注年龄、性别、胃肿瘤相关因素（12 个部位、切除大小、病变大体类型、溃疡存在、纤维化存在、病理诊断和浸润深度）和 ESD 操作相关因素（刀类型、ESD 过程中即刻出血、整块切除、操作时间和内镜医生的 ESD 操作例数）。
823 例胃病变中，所有穿孔、大穿孔和小穿孔的发生率分别为 9.6%、7.5%和 2.1%。多因素分析显示，所有穿孔的危险因素为肿瘤位于上部、纤维化存在和操作时间长（>2 小时）。大穿孔的危险因素与所有穿孔相同。多因素分析显示，小穿孔的危险因素为年龄较大（≥81 岁）、浸润深度（黏膜肌层）和操作时间长（>2 小时）。
ESD 过程中穿孔的危险因素可能因穿孔类型而异。因此，尽管 ESD 过程中未发生大穿孔，但在高龄、操作时间长和（深部）浸润深度的情况下，仍有发生小穿孔的可能，需要考虑这种可能性。
