| Objective:In recent years,endoscopic resection has become an important treatment for various gastrointestinal diseases.Gastrointestinal stromal tumor(GIST)is a common submucosal tumor with malignant potential in the gastrointestinal tract,but there is still some controversy about the efficacy of endoscopic resection of GIST.In addition,there is still a lack of unified opinions on the standard treatment of endoscopic resection during the perioperative period,especially perioperative prophylactic antibiotic therapy.This study is divided into two parts.In the first part,a retrospective study was conducted to evaluate the safety and efficacy of endoscopic resection of gastric GIST.In the second part,a prospective randomized controlled trial was conducted to evaluate the necessity of perioperative prophylactic antibiotic therapy in endoscopic submucosal dissection(ESD)and related endoscopic resection.Methods:The first part of this study included a total of 240 patients,and the clinical data and follow-up data of patients were collected,sorted out and analyzed.The second part included a total of 308 patients who were randomly assigned to group A(prophylactic antibiotic treatment group)and group B(no prophylactic antibiotic treatment group)in a1:1 ratio,and the patients were blinded.Then,the clinical symptoms such as fever,abdominal pain,chest pain or discomfort,and white blood cell(WBC),erythrocyte sedimentation rate(ESR),hypersensitive C-reactive protein(hs-CRP),procalcitonin(PCT),blood culture results were analyzed at 24 hours and 72 hours after ESD and related endoscopic resection in the two groups.Results:Among the 240 patients in the first part,92(38.33%)were males and 148(61.67%)were females.Five resection techniques were used,of which endoscopic submucosal dissection(182/240,75.83%)and endoscopic full thickness resection(50/240,20.83%)were the main resection methods.The maximum diameter of the resected tumors was 0.2～6.5 cm,of which 99.17%(238/240)were≤5.0 cm.A total of 43patients(17.92%)had bleeding and 101 patients(42.08%)had perforation.The piecemeal resection rate of tumors was 2.92%(7/240).Postoperative pathological risk stratification was mainly at very low risk(165/240,68.75%)and low risk(67/240,27.92%).A total of193 patients(including six patients whose tumors were piecemeal resected)were followed,and no tumor residue,recurrence or metastasis were found.The second part included a total of 308 patients,with 154 patients in group A and group B,respectively.The most common operation site was stomach(121/308,39.29%),followed by esophagus(96/308,31.17%).In terms of operation technique,a total of 53 cases(17.21%)of all patients used endoscopic tunnel technique,253 cases(82.14%)did not use endoscopic tunnel technique.The total operation time of 308 patients was 18～343 min,of which 128 patients(41.56%)had an operation time≥120 min.There were 10 patients(3.25%)had bleeding,and 20patients(6.49%)had perforation.A total of 33 patients(10.71%)with fever had blood culture collected within 24 hours after operation,and the results were all negative.Overall analysis showed that there were no significant differences in fever,abdominal pain,chest pain or discomfort,WBC,ESR,hs-CRP,and PCT between group A and group B at 24hours and 72 hours after operation(P>0.05).After analysis of subgroups with different operation sites,different operation methods,intraoperative perforation and operation time greater than or equal to 120 min.It was found that except for the esophageal treatment group,the WBC of group B was higher than that of group A at 72 hours after operation(7.28×10~9/L vs 6.09×10~9/L,P=0.016),and there was no significant difference between group A and group B in other subgroups(P>0.05).Conclusions:Under the operation of experienced endoscopists,endoscopic resection of gastric GIST with a diameter of≤5.0 cm is a safe and effective treatment with a low risk of serious complications and recurrence rate.Piecemeal resection during the procedure may not affect the patient’s prognosis.On the premise of good preoperative preparation and endoscopic operation,prophylactic antibiotic therapy after ESD and related endoscopic resection has no obvious clinical benefit and is not recommended for routine use.Fever after ESD and related endoscopic resection may not be related to bacteremia.Part Ⅰ:Efficacy of Endoscopic Resection of Gastric Gastrointestinal Stromal TumorsObjective: Endoscopic resection has gradually become one of the treatment methods for GIST with the development and progress of endoscopic minimally invasive treatment.However,there are still some controversies in the endoscopic treatment for GIST.The aim of this study was to evaluate the efficacy and safety of endoscopic resection of gastric GIST,so as to provide evidence for the treatment of gastric GIST by endoscopy.Methods: This retrospective single-center study included 240 patients with gastric GIST who underwent endoscopic treatment at the Gastrointestinal Endoscopy Center from January 2010 to December 2019.The clinical medical records and follow-up data of the patients were collected and analyzed.Results: Among the 240 patients,92(38.33%)were males and 148(61.67%)were females.The mean age was 55.32 ± 9.40 years.Five resection techniques were used,of which endoscopic submucosal dissection and endoscopic full thickness resection were the main resection methods,with 182 cases(75.83%)and 50 cases(20.83%),respectively.The maximum diameter of tumors ranged from 0.2 to 6.5 cm,with a median of 1.5 cm,and 99.17%(238/240)were less than or equal to 5.0 cm.A total of 43 patients(17.92%)had bleeding,including 40 cases(16.67%)of minor bleeding and 3 cases(1.25%)of major bleeding.Perforation occurred in 101 patients(42.08%),of which 51 patients(21.25%)were active perforation and 50 patients(20.83%)were passive perforation.The time to start a liquid diet ranged from 1 to 9 days after endoscopic resection,with a median of 3 days.The length of hospital stay after endoscopic resection ranged from 1 to12 days,with a median of 6 days.The en bloc resection rate was 97.08%(233/240),and the piecemeal resection rate was 2.92%(7/240).In the postoperative pathological risk stratification,68.75%(165/240)were at very low risk,27.92%(67/240)were at low risk,2.92%(7/240)were at intermediate risk,and 0.42%(1/240)was at high risk.A total of193 patients after a median follow-up time of 30 months(range 1~127 months),no tumor residual,recurrence,or metastasis were found.After a median follow-up of 22 months(range 1~101 months),the six patients who had undergone piecemeal resection did not find tumor residual,recurrence,or metastasis.Conclusions: Under the operation of experienced endoscopists,endoscopic resection of gastric GIST with a diameter of ≤ 5.0 cm is a safe and effective treatment with a low risk of serious complications and recurrence rate.Piecemeal resection during the procedure may not affect the patient’s prognosis.Part Ⅱ: Randomized Controlled Trial of Prophylactic Antibiotic Therapy after Endoscopic Submucosal Dissection and Related ResectionObjective: Currently,ESD and related endoscopic resection have been used for minimally invasive treatment of various gastrointestinal diseases,but there is no unified opinion on the treatment of perioperative prophylactic antibiotics in ESD and related endoscopic resection.This study conducted a prospective randomized controlled trial of prophylactic antibiotic therapy after ESD and related endoscopic resection.The purpose was to evaluate the necessity of prophylactic use of antibiotics after ESD and related endoscopic resection.Methods: This study was a prospective,single-center,single-blind,parallel,randomized controlled trial.Patients were enrolled from the Gastrointestinal Endoscopy Center according to the inclusion and exclusion criteria,and randomly assigned to group A(prophylactic antibiotic treatment group)and group B(no prophylactic antibiotic treatment group)in a ratio of 1:1,the patients were blinded.Then,the clinical symptoms such as fever,abdominal pain,chest pain or discomfort,and WBC,ESR,hs-CRP,PCT,blood culture results were analyzed at 24 hours and 72 hours after ESD and related endoscopic resection in the two groups.Results: A total of 308 patients were included in this study,with 154 patients in group A and group B,respectively.The operation sites included esophagus in 96 cases(31.17%),stomach in 121 cases(39.29%),intestine in 78 cases(25.32%),and multiple sites in 13cases(4.22%).A total of 53 cases(17.21%)of all patients used endoscopic tunnel technique,253 cases(82.14%)did not use endoscopic tunnel technique,and 2 cases(0.65%)used both techniques.The total operation time of 308 patients was 18~343 min,and the median operation time was 108 min,of which 128 patients(41.56%)had an operation time ≥ 120 min.There were 10 patients(3.25%)with bleeding,including 6patients with intraoperative bleeding and 4 patients with postoperative bleeding.There were 20 patients(6.49%)with intraoperative perforation.A total of 33 patients(10.71%)with fever had blood culture collected within 24 hours after operation,including 12 cases in group A and 21 cases in group B,and the results of blood culture were all negative.Overall analysis showed that there were no significant differences in fever,abdominal pain,chest pain or discomfort,WBC,ESR,hs-CRP,and PCT between group A and group B at 24 hours and 72 hours after operation(P > 0.05).After subgroup analysis of operation site and operation technique,it was found that the WBC in group B was higher than that in group A at 72 hours after esophageal endoscopic treatment(7.28×109/L vs6.09×109/L,P = 0.016),and there was no significant difference between group A and group B in other subgroups(P > 0.05).After analysis of patients with intraoperative perforation and operation time ≥ 120 min,there were no significant differences in fever,abdominal pain,chest pain or discomfort,WBC,ESR,hs-CRP,and PCT at 24 hours and72 hours after operation between group A and group B(P > 0.05).Conclusions: On the premise of good preoperative preparation and endoscopic operation,prophylactic antibiotic therapy after ESD and related endoscopic resection has no obvious clinical benefit and is not recommended for routine use.Fever after ESD and related endoscopic resection may not be related to bacteremia.prophylactic antibiotic therapy may help reduce WBC at 72 hours after esophageal endoscopic treatment,but there is no significant improvement in clinical symptoms and ESR,hs-CRP,PCT after operation.Moreover,prophylactic antibiotic therapy did not significantly improve the clinical symptoms,WBC,ESR,hs-CRP,and PCT after endoscopic resection of gastric and intestinal lesions.Prophylactic antibiotics did not significantly improve the clinical symptoms,WBC,ESR,hs-CRP and PCT after treatment with endoscopic tunnel technology and non endoscopic tunnel technology. |
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