Ahlenstiel Golo, Hourigan Luke F, Brown Gregor, Zanati Simon, Williams Stephen J, Singh Rajvinder, Moss Alan, Sonson Rebecca, Bourke Michael J
Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia.
Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia.
Gastrointest Endosc. 2014 Oct;80(4):668-676. doi: 10.1016/j.gie.2014.04.015. Epub 2014 Jun 7.
EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited.
To compare actual endoscopic with predicted surgical mortality.
Prospective, observational, multicenter cohort study.
Academic, high-volume, tertiary-care referral center.
Consecutive patients referred for EMR.
To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity.
Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003).
Nonrandomized study.
In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions.
结肠高级别黏膜内瘤变（AMN，即直径≥20mm的无蒂或侧向发育型病变）的内镜黏膜切除术（EMR）已成为越来越受欢迎的手术切除替代方案。然而，与手术相比，关于EMR安全性和死亡率的数据有限。
比较实际内镜下死亡率与预测的手术死亡率。
前瞻性、观察性、多中心队列研究。
学术性、高容量三级医疗转诊中心。
连续接受EMR治疗的患者。
EMR。主要观察指标：为预测假设的手术死亡率，计算每位患者由生理和手术部分组成的英国和爱尔兰结直肠外科学会评分。然后将预测的手术死亡率与EMR的实际结果进行比较。通过使用结直肠生理和手术严重程度评分来计算死亡率和发病率，对一个未选择的亚队列进行验证。
在1050例接受EMR治疗的AMN患者中，包括预测死亡率大于5%的患者（占队列的13.8%），术后30天内无死亡发生。使用英国和爱尔兰结直肠外科学会评分预测的手术死亡率为3.3%（P <.0001）。这表明EMR相对于手术具有显著优势。通过对390例患者使用结直肠生理和手术严重程度评分来计算死亡率和发病率进行验证，预测的手术死亡率为3.2%（P =.0003）。
非随机研究。
在这项关于结肠AMN的EMR大型多中心研究中，预测的手术死亡率显著高于实际内镜下死亡率。鉴于内镜治疗比手术创伤小、费用低，且可作为门诊治疗，对于大多数此类病变患者，应将其视为一线治疗方法。
