广西医学

目的分析胃黏膜病变活检病理结果与内镜黏膜下剥离术（ESD）后病理结果差异，以及病理升级的危险因素。方法回顾性分析314例因诊断胃黏膜病变接受ESD治疗患者的临床资料。根据术前活检病理结果，将患者分为非典型增生（AH）组（n=42）、低级别上皮内瘤变（LGIN）组（n=156）、高级别上皮内瘤变（HGIN）组（n=98）和早期胃癌（EGC）组（n=18）；根据活检病理与术后病理符合情况，将患者分为未升级组和升级组。统计不同类型胃黏膜病变术后病理升级情况，并采用多因素Logistic回归模型分析病理升级的危险因素。结果活检病理结果及ESD后病理结果的总体一致率为51.27%（161/314），升级率为42.04%（132/314）。AH组升级率为61.90%（26/42），升级为LGIN及HGIN的比例分别为50.00%（21/42）、11.90%（5/42）； LGIN组升级率为43.59%，升级为HGIN、EGC的比例分别为39.74%（62/156）、3.85%（6/156）；38.78%（38/98）的HGIN升级为EGC。多因素Logistic回归分析结果显示，病变色泽发红及虫噬样改变是AH术后病理升级的独立危险因素（P<0.05）；病变形态呈凹陷型、病变大小>1.5 cm、活检数量仅1块、黏膜结节状隆起是LGIN术后病理升级的独立危险因素（P<0.05）；合并糜烂/溃疡是HGIN术后病理升级的独立危险因素（P<0.05）。结论胃黏膜病变ESD前后病理结果存在一定差异性。活检病理提示为AH的病变存在色泽发红或虫噬状改变时，需要密切随访或者行内镜切除；活检病理提示为LGIN的病变，如存在病变大小>1.5 cm、单块活检、黏膜结节状隆起、形态为凹陷型等情况，应注意病变被低估的情况，需要考虑行内镜切除；当合并糜烂/溃疡的病变活检病理提示HGIN时，需要警惕病理升级为胃癌可能，应综合评估其大小及浸润深度，谨慎选择ESD或外科手术治疗。

bmucosal resection (ESD) for gastric mucosal lesions, and the risk factors for pathological upgrading. Methods A retrospective analysis was conducted on the clinical data of 314 patients diagnosed as gastric mucosal lesions receiving ESD. Patients were divided into atypical hyperplasia (AH) group (42 cases), low⁃grade intraepithelial neoplasia (LGIN) group (156 cases), high⁃grade intraepithelial neoplasia (HGIN) group (98 cases), or early gastric cancer (EGC) group (18 cases) according to preoperative biopsy pathological results. According to the coincidence between biopsy pathology and postoperative pathology, the patients were assigned to non⁃upgraded group or upgraded group. The pathological upgrading of different types of gastric mucosal lesions after surgery was statistically analyzed, and the risk factors for pathological upgrading were analyzed by employing multivariate Logistic regression model. Results The overall consistency rate between the results of biopsy pathology and pathological results after ESD was 51.27% (161/314), and the upgrading rate was 42.04% (132/314). The upgrading rate of the AH group was 61.90% (26/42), and the upgrading proportions to LGIN and HGIN were 50.00% (21/42) and 11.90% (5/42), respectively. The upgrading rate of the LGIN group was 43.59%, and the upgrading proportions to HGIN and EGC were 39.74% (62/156) and 3.85% (6/156), respectively; furthermore, 38.78% (38/98) of HGIN patients were upgraded to EGC. Multivariate Logistic regression analysis results revealed that redness and insect⁃like changes were independent risk factors for pathological upgrading after AH surgery (P<0.05), depressed lesion shape, lesion size >1.5 cm, number of biopsy only 1, mucosal nodular uplift were independent risk factors for postoperative pathological upgrading of LGIN (P<0.05); in addition, combined erosion/ulcer was an independent risk factor for postoperative pathological upgrading of HGIN (P<0.05). Conclusion There are some differences in pathological results of gastric mucosal lesions before and after ESD. When the lesions suggested as AH by biopsy have redness or insect⁃like changes, close follow⁃up or endoscopic resection is needed. When the lesions suggested as LGIN by biopsy exhibit the size >1.5 cm, single biopsy, mucosal nodular uplift and depressed shape exist, attention should be paid to the underestimated lesion, and endoscopic resection should be considered. When the biopsy pathology of the lesion with erosion/ulcer indicates HGIN, it is necessary to be alert to the possibility of pathological upgrading to gastric cancer. The size and invasion depth of the lesion should be comprehensively evaluated, and ESD or surgical treatment should be carefully selected.