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中华胃肠内镜电子杂志 ›› 2026, Vol. 13 ›› Issue (02) : 93 -100. doi: 10.3877/cma.j.issn.2095-7157.2026.02.004

论著

基于新分型探讨伴有瘢痕的早期食管肿瘤再次内镜黏膜下剥离术的安全性及难度预测
毛丽娟1, 黄奕婷2, 丁永刚3, 张婷1, 金甜1, 李文杰1, 卢晓云1, 王耀辉4, 张其德1,()   
  1. 1210029 南京,南京中医药大学附属医院 江苏省中医院消化内镜中心
    2210029 南京,南京中医药大学
    3215003 苏州 中国中医科学院西苑医院苏州医院消化科
    4210029 南京,南京中医药大学附属医院 江苏省中医院病理科
  • 收稿日期:2026-02-05 出版日期:2026-05-15
  • 通信作者: 张其德
  • 基金资助:
    江苏省中医院重点病种建设项目(YZJ2407); 江苏省卫生健康委老年健康面上项目(LKM2022003); 刘沈林全国名中医传承工作室

Safety and predictive value for operative difficulty of a new classification in re-treatment of scar-associated early esophageal tumors by endoscopic submucosal dissection

Lijuan Mao1, Yiting Huang2, Yonggang Ding3, Ting Zhang1, Tian Jin1, Wenjie Li1, Xiaoyun Lu1, Yaohui Wang4, Qide Zhang1,()   

  1. 1Digestive Endoscopy Center, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
    2Nanjing University of Chinese Medicine, Graduate student, Nanjing 210029, China
    3Department of Gastroenterology, Xiyuan Hospital, Chinese Academy of Traditional Chinese Medicine, Suzhou Hospital, Suzhou 215003, China
    4Department of Pathology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
  • Received:2026-02-05 Published:2026-05-15
  • Corresponding author: Qide Zhang
引用本文:

毛丽娟, 黄奕婷, 丁永刚, 张婷, 金甜, 李文杰, 卢晓云, 王耀辉, 张其德. 基于新分型探讨伴有瘢痕的早期食管肿瘤再次内镜黏膜下剥离术的安全性及难度预测[J/OL]. 中华胃肠内镜电子杂志, 2026, 13(02): 93-100.

Lijuan Mao, Yiting Huang, Yonggang Ding, Ting Zhang, Tian Jin, Wenjie Li, Xiaoyun Lu, Yaohui Wang, Qide Zhang. Safety and predictive value for operative difficulty of a new classification in re-treatment of scar-associated early esophageal tumors by endoscopic submucosal dissection[J/OL]. Chinese Journal of Gastrointestinal Endoscopy(Electronic Edition), 2026, 13(02): 93-100.

目的

基于瘢痕-内镜黏膜下剥离术(Scar-ESD)分型,探讨伴有瘢痕的早期食管肿瘤再次ESD的安全性,并评价该分型对手术难度的预测价值。

方法

回顾性收集2017年2月至2024年2月经江苏省中医院消化内镜中心再次行食管ESD且伴有既往治疗瘢痕的早期食管肿瘤患者资料,分析其安全性、剥离速率、术中辅助方法、肌层损伤、标本破损率和治疗效果等。

结果

纳入47例患者,平均年龄(65.51±6.68)岁,男女比例为2.6∶1;Scar-ESD分型中病灶不伴有瘢痕的A0型14例(29.79%)、伴有瘢痕的A1型16例(34.04%)、A2型11例(23.40%)、A3型6例(12.77%)。中位手术时长A0组17.50 (15.00,23.75)min,明显少于非A0组32.00 (26.00,45.00)min(P<0.05);中位剥离速率A0型与非A0型(A1/A2/A3型)组间比较均无明显差异(P>0.05);术中使用辅助牵引法的共14例(29.79%,P<0.05),全部为非A0型患者,其中A1/A2型各为5例、A3型为4例;术中存在肌层损伤22例(46.81%),A1/A2型发生率最高(各8例)、A3型5例(组间比较P<0.05);标本破损6例(12.77%),A1/A2/A3型为1∶3∶2(组间比较P=0.05)。各型均无术中术后穿孔及迟发性出血,两组整块切除率均为100%,R0切除率与治愈性切除率均为87.23%。

结论

伴有瘢痕的早期食管肿瘤再次行ESD安全有效,Scar-ESD分型中A2/A3型存在较高的标本破损趋势、A1/A2型易发生术中肌层损伤、非A0型可考虑术中牵引辅助剥离;该分型利于预测手术难度、辅助方法、标本损伤状况等,值得临床推广。

Objective

Based on the Scar-ESD (Scar-endoscopic submucosal dissection) classification, this study aims to explore the safety of re-ESD for early esophageal tumors with scars and evaluate the predictive value of this classification for the operative difficulty.

Methods

A retrospective analysis was conducted on the data of patients with early esophageal tumors accompanied by scars from previous treatments who underwent re-ESD at the Digestive Endoscopy Center of Jiangsu Provincial Hospital of Chinese Medicine from February 2017 to February 2024.The safety, dissection rate, intraoperative auxiliary methods, muscular layer injury, specimen damage rate, and treatment outcomes were analyzed.

Results

A total of 47 patients were included, with a mean age of 65.51±6.68 years and a male-to-female ratio of 2.6∶1.According to the Scar-ESD classifications, 14 cases (29.79%) were type A0 (without scars), 16 cases (34.04%) were type A1 (with scars), 11 cases (23.40%) were type A2 (with scars), and 6 cases (12.77%) were type A3 (with scars).The median operative time in the A0 group was 17.50 (15.00; 23.75) min, which was significantly shorter than that in the non-A0 group [32.00 (26.00; 45.00)min, P<0.05].The median dissection rate showed no significant difference between the A0 group and the non-A0 group (A1/A2/A3) (P>0.05).Intraoperative traction assistance was used in 14 cases (29.79%) of the non-A0 group (P<0.05), specifically in 5 cases of A1, 5 cases of A2, and 4 cases of A3.Intraoperative muscular layer injury occurred in 22 cases (46.81%), with the highest incidence in types A1 (8 cases) and A2 (8 cases), followed by A3 (5 cases) (P<0.05).Specimen damage occurred in 6 cases (12.77%), with a ratio of 1∶3∶2 in A1/A2/A3 (P=0.05).There were no intraoperative or postoperative perforations or delayed bleeding in all types.The en bloc resection rate was 100% in both the A0 and non-A0 groups.The R0 resection rate and curative resection rate were both 87.23% (41/47).

Conclusion

Re-ESD for early esophageal tumors with scars is safe and effective.Types A2/A3 in the Scar-ESD classification has a higher tendency of specimen damage, types A1/A2 is prone to intraoperative muscular layer injury, and non-A0 types may consider intraoperative traction assistance for dissection.The Scar-ESD classification helps predict the operative difficulty, the need for intraoperative auxiliary methods, and specimen damage risk, which provides high clinical utility.

图1 瘢痕-内镜黏膜下剥离术(Scar-ESD)分型示意图注:A:A0型(瘢痕与病变之间有正常黏膜);B:A1型(瘢痕与病变之间有交叉重叠,重叠面积小于病变面积70%);C:A2型(瘢痕位于病变内部);D:A3型(病变位于瘢痕内部)[10]
图2 瘢痕-内镜黏膜下剥离术(Scar-ESD)A1分型治疗过程注:A:既往ESD术后旁病灶,卢戈氏碘液染色后呈不染区;B:剥离过程中见疤痕处纤维化(箭头表示瘢痕处);C:ESD术后创面,疤痕处局灶可见肌层损伤(箭头所示);D:ESD术后标本,碘染后可见病灶境界清楚,完整切除
图3 瘢痕-内镜黏膜下剥离术(Scar-ESD)A2分型治疗过程注:A:病灶中央可见疤痕;B:剥离过程中可见疤痕处与肌层粘连;C:ESD术后创面,箭头表示瘢痕处;D:ESD术后标本固定,可见多处局部标本破洞
图4 瘢痕-内镜黏膜下剥离术(Scar-ESD)A3分型(外院ESD未成功,改EMR分片切除)治疗过程注:A:NBI下可见瘢痕茶色区(箭头所示),呈B1型上皮内乳头样毛细血管袢;B:环周切开可见黏膜下层瘢痕与肌层粘连;C:内镜下精准肌层剥离术(EPMD);D:ESD术后标本,碘染色后可见病变完整切除(箭头表示两处病变)
表1 患者一般资料情况[例(%)]
表2 临床疗效分析[例(%)]
表3 病变瘢痕与分型关系差异分析(例)
表4 辅助方法、肌层损伤-多重分析比较(例)
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