探讨导致食管浅表肿瘤内镜黏膜下剥离术(ESD)困难(手术时间≥90 min、非治愈性切除、穿孔并发症)的独立危险因素。

回顾分析2015年7月至2019年6月苏北人民医院消化科诊断食管早期癌或癌前病变而行ESD治疗的452位患者病例资料，包括患者性别、年龄、病灶部位、内镜大体形态，病灶长径、周径、手术时期、术前病理、术后病理、手术时间以及穿孔并发症。先通过单因素分析寻找影响ESD手术时间、非治愈性切除及穿孔的因素，对其中有统计学意义的因素再纳入Logistic回归分析寻找导致ESD手术困难的独立危险因素。

452例患者平均年龄(66.47±7.59)岁，平均手术时间(72.7±32.9)min，术后病理为鳞状上皮高级别上皮内瘤变212例，鳞状细胞癌240例，治愈性切除率375/452(83.1%)，发生穿孔并发症9例。单因素分析显示患者病灶大体形态、病灶长径、病灶周径、病变部位、术者经验与ESD手术困难有关(P<0.05)。经多因素分析显示病灶呈Ⅱa＋Ⅱc/Ⅱc是手术时间≥90 min(OR＝2.689，P＝0.003)、非治愈性切除(OR＝2.238，P＝0.009)及穿孔并发症(OR＝1.928，P＝0.042)的独立危险因素。病灶长径>2 cm是手术时间≥90 min(OR＝5.917，P<0.001)的独立危险因素，病灶周径为1/3～2/3周是手术时间≥90 min(OR＝2.733，P＝0.019)的独立危险因素，病灶周径≥2/3周是手术时间≥90 min(OR＝26.502，P<0.001)、非治愈性切除(OR＝4.174，P<0.001)的独立危险因素；病变位于食管上段(OR＝2.609，P＝0.016)、及术者经验(OR＝1.897，P＝0.045)是手术时间≥90 min的独立危险因素。

病变形态呈Ⅱa＋Ⅱc/Ⅱc、病灶长径>2 cm、病灶周径>1/3周、病变位于食管上段及术者经验是造成食管ESD困难的独立危险因素。

To investigate risk factors associated with difficult endoscopic submucosal dissection(ESD)for superficial esophageal lesions(operating time≥90 min, non-curative resection, esophageal perforation).

The medical records of 452 patients with single esophageal lesion who received ESD at Department of Gastroenterology, Subei People′s Hospital of Jiangsu Province from July 2015 to June 2019 were retrospectively reviewed, including gender, age, lesion site, endoscopic gross morphology, lesion diameter, circumference, operative period, preoperative pathology, postoperative pathology, operating time and perforation complication.The factors associated with ESD operating time, non-curative resection and perforation were analyzed by univariate analysis.Statistically significant factors were then included in Logistic regression analysis to look for independent risk factors leading to difficulties in ESD surgery.

The mean age of the patients was(66.47±7.59)years, and the mean operating time was(72.7±32.9)min.A total of 212 cases of high-grade intraepithelial neoplasia and 240 cases of squamous cell carcinoma were diagnosed by postoperative pathology.The rate of curative resection was 83.1%(375/452). Complications of perforation occurred in 9 cases.The lesions gross morphology, length, circumference, location and experience of operator were risk factors of difficult ESD for superficial esophageal lesions by univariate analysis.Multivariate analysis showed that typeⅡa+ Ⅱc/Ⅱc was an independent risk factor for operating time≥90 min(OR=2.689, P=0.003), non-curative resection(OR=2.238, P=0.009)and perforation(OR=1.928, P=0.042). Lesion length(>2 cm)was an independent risk factor for operating time≥90 min(OR=5.917, P<0.001). Circumferential lesion size(1/3-2/3 esophageal circumference)was an independent risk factor for operating time≥90 min(OR=2.733, P=0.019), and≥2/3 circumference was an independent risk factor for operating time≥90 min(OR=26.502, P<0.001)and non-curative resection(OR=4.174, P<0.001). The lesion located in the upper esophagus(OR=2.609, P=0.016)and the operator′s experience(OR=1.897, P=0.045)were independent risk factors for operating time≥90 min.

TypeⅡa+ Ⅱc/Ⅱc lesions, the lesion length(>2 cm), circumferential lesion size(>1/3 esophageal circumference), the lesion located in the upper esophagus and the operator′s experience were independent risk factors for difficult esophageal ESD procedures.