Klein Amir, Ahlenstiel Golo, Tate David J, Burgess Nicholas, Richardson Arthur, Pang Tony, Byth Karen, Bourke Michael J
Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.
University of Sydney, Sydney, Australia.
Endoscopy. 2017 Jul;49(7):659-667. doi: 10.1055/s-0043-105484. Epub 2017 Apr 4.
Adenomas of the duodenum and ampulla are uncommon. For lesions ≤ 20 mm in size and confined to the papillary mound, endoscopic resection is well supported by systematic study. However, for large laterally spreading lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite substantial associated morbidity and mortality. We aimed to compare actual endoscopic outcomes of such lesions and costs with those predicted for surgery using validated prediction tools. Patients who underwent endoscopic resection of LSL-D/P were analyzed. Two surgeons assigned the hypothetical surgical management. The National Surgical Quality Improvement Program (NSQIP), and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were used to predict morbidity, mortality, and length of hospital stay. Actual endoscopic and hypothetical surgical outcomes and costs were compared. A total of 102 lesions were evaluated (mean age of patients 69 years, 52 % male, mean lesion size 40 mm). Complete endoscopic resection was achieved in 93.1 % at the index procedure. Endoscopic adverse events occurred in 18.6 %. Recurrence at first surveillance endoscopy was seen in 17.7 %. For patients with ≥ 2 surveillance endoscopies (n = 55), 90 % were clear of disease and considered cured (median follow-up 27 months). Compared with hypothetical surgical resection, endoscopic resection had less morbidity (18 % vs. 31 %; = 0.001) and shorter hospital stay (median 1 vs. 4.75 days; < 0.001), and was less costly than surgery (mean $ 11 093 vs. $ 19 358; < 0.001). In experienced centers, even extensive LSL-D/P can be managed endoscopically with favorable morbidity and mortality profiles, and reduced costs, compared with surgery.
十二指肠和壶腹腺瘤并不常见。对于大小≤20毫米且局限于乳头隆起的病变，系统研究充分支持内镜切除术。然而，对于十二指肠或乳头的大型侧向扩散性病变（LSL-D/P），尽管存在大量相关的发病率和死亡率，手术仍经常进行。我们旨在比较此类病变的实际内镜治疗结果和成本与使用经过验证的预测工具预测的手术结果和成本。对接受LSL-D/P内镜切除术的患者进行了分析。两名外科医生指定了假设的手术治疗方案。使用国家外科质量改进计划（NSQIP）以及用于计算死亡率和发病率的朴茨茅斯生理和手术严重程度评分（P-POSSUM）来预测发病率、死亡率和住院时间。比较了实际内镜治疗和假设手术治疗的结果及成本。共评估了102个病变（患者平均年龄69岁，男性占52%，平均病变大小40毫米）。初次手术时93.1%的病变实现了内镜完全切除。内镜不良事件发生率为18.6%。首次监测内镜检查时复发率为17.7%。对于接受≥2次监测内镜检查的患者（n = 55），90%无疾病且被认为治愈（中位随访27个月）。与假设的手术切除相比，内镜切除的发病率更低（18%对31%；P = 0.001），住院时间更短（中位1天对4.75天；P < 0.001），且成本低于手术（平均11093美元对19358美元；P < 0.001）。在经验丰富的中心，与手术相比，即使是广泛的LSL-D/P也可通过内镜治疗，具有良好的发病率和死亡率特征，且成本降低。
