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  • Title: [Application of dental floss traction-assisted endoscopic submucosa dissection to rectal neuroendocrine neoplasm].
    Author: Shi Q, Sun D, Zhong YS, Xu MD, Li B, Cai SL, Qi ZP, Ren Z, Zhang H, Yong YY, Yao LQ, Zhou PH.
    Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2019 Apr 25; 22(4):377-382. PubMed ID: 31054553.
    Abstract:
    Objective: To evaluate the safety and efficacy of dental floss traction-assisted endoscopic submucosal dissection (DFS-ESD) for rectal neuroendocrine neoplasm (NEN). Methods: A retrospective cohort study was performed. Clinical data of rectal NEN patients undergoing ESD at Endoscopy Center of Zhongshan Hospital, Fudan University from January 2016 to December 2017 were retrospectively analyzed. Inclusion criteria: 1) age of 18 to 80 years old; 2) maximal diameter of lesions <1.5 cm; 3) tumor locating in the submucosa without invasion into the muscularis propria; 4) no enlarged lymph nodes around bowel and in abdominal cavity; 5) ESD requested actively by patients. A total of 37 patients were enrolled, including 23 male and 14 female cases with mean age of (56.0±11.3) years. All the lesions were single tumor of stage T1, and the mean size was 0.8±0.2(0.5-1.2) cm. Postoperative pathology revealed all samples as neuroendocrine tumors (NET). Seventeen patients received DFS-ESD treatment (DFS-ESD group) and 20 patient received conventional ESD treatment (conventional ESD group). In DFS-ESD group, after the mucosa was partly incised along the marker dots, the endoscopy was extracted, and the dental floss was tied to one arm of the metallic clip. When the endoscope was reinserted, the hemoclip was attached onto the incised mucosa; another hemoclip was attached onto normal mucosa opposite to the lesion in the same way. The submucosa was clearly exposed with the traction of dental floss and the resection could proceed. The conventional ESD group received the traditional ESD operation procedure. The operation time, modified operation time (remaining time after excluding the assembly time of dental floss traction in DFS-ESD group), en bloc resection rate, R0 resection rate, morbidity of operative complication, recurrence and metastasis were compared between two groups. Results: The average tumor size was (0.8±0.2) cm in DFS-ESD group and (0.7±0.2) cm in conventional ESD group (t=0.425, P=0.673). According to postoperative pathological grading of rectal neuroendocrine neoplasm, 13 were G1 and 4 were G2 in DFS-ESD group, while 17 cases were G1 and 3 cases were G2 in conventional ESD group without significant difference (P=0.680). There were no significant differences in baseline data between in the two groups (all P>0.05). All the basal resection margins were negative, the en bloc resection rate was 100% and the R0 resection rate was 100%. Pathological results showed tumor tissue close to the burning margin in 5 cases of conventional ESD group and in 2 cases of DFS-ESD group (P=0.416). The operation time was (17.9±6.6) minutes in conventional ESD group and (14.7±3.3) minutes in DFS-ESD group (t=1.776, P=0.084). The modified operation time of DFS-ESD group was (11.9±2.8) minutes, which was significantly shorter than (17.9±6.6) minutes in conventional ESD group (t=3.425, P=0.002). The hospital stay was (2.3±0.6) days and (2.0±0.5) days in conventional ESD group and DFS-ESD group, respectively, without significant difference (t=1.436, P=0.160). No patient was transferred to surgery, and no delayed bleeding or perforation occurred in either group. There was no recurrence or primary tumor-related death, and all the patients recovered well during a follow-up period of 14(1-24) months. Conclusion: Dental floss traction-assisted ESD for rectal neuroendocrine neoplasm can simplify operation and ensure negative basal margin. 目的： 评估牙线悬吊牵引法在内镜黏膜下剥离术（ESD）治疗直肠神经内分泌肿瘤（NEN）的安全性和有效性。 方法： 采用回顾性队列研究方法，分析2016年1月至2017年12月期间，在复旦大学附属中山医院内镜中心接受ESD治疗的直肠NEN患者资料。病例入选标准：（1）年龄在18~80岁之间；（2）病变最大直径<1.5 cm；（3）肿瘤位于黏膜下层，且未侵犯固有肌层；（4）未见肠周或腹腔肿大淋巴结；（5）积极要求内镜治疗。根据上述标准，共37例直肠NEN患者被纳入本研究，其中男23例，女14例，年龄（56.0±11.3）岁；均为单发肿瘤；病变平均最大直径（0.8±0.2）（0.5~1.2）cm，分期均为T1期，术后病理类型均为神经内分泌瘤（NET）。17例采用牙线悬吊牵引辅助ESD治疗（牵引组），20例采用传统ESD治疗（非牵引组）。牵引组在切开边缘并适当剥离后，在直肠腔内伸出一个固定好牙线的金属夹，夹住切开的黏膜边缘；再另用一个金属夹，将用于牵引的牙线固定到病变的对侧正常黏膜，轻拉牙线，将黏膜拉起，显露肿瘤与正常组织的边界后，进行病变的剥离。非牵引组手术参照传统ESD操作流程。比较牵引组与非牵引组的手术时间、校正手术时间（牵引组中，排除牙线牵引装置组装时间后的手术时间）、完整切除率和治愈性切除率、手术并发症发生率以及肿瘤复发和转移情况。 结果： 牵引组与非牵引组患者的病变最大径分别为（0.7±0.2）cm和（0.8±0.2）cm，差异无统计学意义（t=0.425，P=0.673）。牵引组G1期13例，G2期4例；非牵引组术后病理G1期17例，G2期3例；差异也无统计学意义（P=0.680）。两组基线资料比较差异均无统计学意义（均P>0.05）。两组患者术后基底切缘均为阴性，均达到完整切除和治愈性切除。牵引组和非牵引组分别有2例和5例提示肿瘤紧贴烧灼缘，但差异无统计学意义（P=0.416）。牵引组和非牵引组手术时间分别为（14.7±3.3）min和（17.9±6.6）min，差异无统计学意义（t=1.776，P=0.084）。但排除牙线牵引装置的制备时间（3.0±0.9）min后，牵引组的校正手术时间为（11.9±2.8）min，短于非牵引组，差异有统计学意义（t=3.425，P=0.002）。牵引组和非牵引组住院时间分别为（2.0±0.5）d和（2.3±0.6）d，差异无统计学意义（t=1.436，P=0.160）。两组患者术后均未发生迟发型出血或迟发型穿孔等并发症，也没有因并发症或内镜手术困难而中转外科手术患者。中位随访14（1~24）个月，患者均恢复良好，无明显不适或复发。 结论： 牙线悬吊牵引辅助行ESD治疗直肠NEN，可简化手术，以确保基底切缘的阴性。.
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