修回日期: 2016-03-27
接受日期: 2016-04-06
在线出版日期: 2016-05-08
大肠息肉是指从大肠黏膜表面突起到肠腔的隆起状赘生物. 大肠息肉尤其是大肠腺瘤性息肉被认为是结直肠癌的癌前病变. 随着镜下治疗技术的不断发展, 内镜下治疗结肠息肉的方法越来越多, 但切除后的腺瘤性息肉复发率较高, 且仍具有恶变的危险, 故关于其切除术后的复发相关因素越来越受到医学工作者的关注与重视. 本文将对其复发相关因素的最新进展作简要综述.
核心提示: 大肠息目前最常见的治疗方式就是肉镜下治疗, 但是其术后复发率较高, 根据文献报道, 其复发与性别、年龄、饮食、烟酒嗜好、息肉数目、直径、类型、瘤变程度、家族史、幽门螺杆菌感染、胆囊疾病、代谢类疾病等因素密切相关. 本文总结了近几年来大肠息肉术后复发的常见因素, 以期对大肠息肉患者的随访观察提供依据, 为消化及内镜医生的临床工作提供指导.
引文著录: 蒋元烨, 曹勤. 大肠息肉切除术后复发相关因素研究的最新进展. 世界华人消化杂志 2016; 24(13): 2002-2009
Revised: March 27, 2016
Accepted: April 6, 2016
Published online: May 8, 2016
Colorectal polyps are growths projecting into the mucosal surface of the colon lumen. Colorectal polyps, especially colorectal adenomas, are considered precancerous lesions of colorectal cancer. With the continuous development of endoscopic technology, endoscopic treatment of colon polyps has been used widely. However, the recurrence rate is high, and the risk of recurrence and malignant transformation still exists. Therefore, more and more attention has been paid to the recurrence related factors after the resection of colorectal polyps. This article will review the latest progress in the research of factors related to recurrence after resection of colorectal polyps.
- Citation: Jiang YY, Cao Q. Latest progress in research of factors associated with recurrence after resection of colorectal polyps. Shijie Huaren Xiaohua Zazhi 2016; 24(13): 2002-2009
- URL: https://www.wjgnet.com/1009-3079/full/v24/i13/2002.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v24.i13.2002
大肠息肉(colorectal polyps)是指从大肠黏膜表面突起到肠腔的隆起状赘生物, 是结肠发病率最高的良性肿瘤. 这种传统意义上的"息肉"分为腺瘤性息肉和非腺瘤性息肉两类. 腺瘤性息肉上皮增生活跃, 多伴有上皮内瘤变, 可以恶变成腺癌; 非腺瘤性息肉一般不恶变, 但如伴有上皮内瘤变则也可恶变. 随着镜下治疗技术的不断发展, 内镜下治疗结肠息肉的方法越来越多, 但切除后的腺瘤性息肉复发率较高, 且仍具有恶变的危险. 腺瘤性息肉的复发过程复杂, 受到多种因素的影响, 目前关于复发的原因及机制尚不十分明确. 国外研究报道, 直肠腺瘤摘除后3-5年内的复发率在20%-50%[1,2]. 国内有研究报道, 1年内累计复发率为38.1%, 2年内累计复发率为78.2%[3]. Rosa等[4]研究发现首次内镜下腺瘤切除术后第8年腺瘤复发率达到高峰, 而继续随访发现此后复发率逐年降低. 本文就大肠息肉切除术后复发相关因素研究的最新进展作简要综述, 以期对大肠息肉患者的随访观察提供依据, 为消化及内镜医生的临床工作中提供指导.
Simunic等[5]研究发现, 男性大肠腺瘤患者内镜下治疗后再检出率高于女性患者, 其原因可能与体内雌激素及黄体酮比例有关, 随机对照试验证实雌激素受体对抑癌基因有潜在的调节作用[6]. Viel等[7]报道在单因素分析中男性患者大肠腺瘤内镜下治疗后再发的时间明显比女性患者延迟(HR = 0.63, 95%CI: 0.44-0.90). Regula等[8]通过对一项50148人参加的结肠镜筛査进行横断面分析, 结果表明男性是进展期腺瘤(直径>1 cm或伴有管状腺瘤、绒毛状腺瘤、混合型腺瘤及重度异型性)独立的危险因素, OR值为1.73, 95%CI: 1.52-1.98, P<0.001.
结直肠息肉是肠黏膜上皮成熟异常, 或增生与死亡失衡所致, 其在各年龄段均可发病. 随着年龄的增加, 结直肠息肉的发病率, 以及多部位、多发性及较大息肉的发生率也随之增加[9,10]. Sato等[11]研究认为年龄是大肠腺瘤的危险因素之一. Barreda等[12]认为年龄>50岁为危险因素. Diamond等[13]研究发现大肠腺瘤好发生年龄在50岁以后, 每增加10岁, 大肠腺瘤的发生率也相应升高. Parente等[14]、高炳霞等[15]和张燕萍等[16]研究发现随着年龄的增加, 大肠腺瘤发生也逐渐增加. 闫彩文等[17]研究发现大肠腺瘤在50岁以上发病率显著增加, 50-60岁大肠腺瘤的发病率为20%-25%, 超过70岁的大肠腺瘤发生率增至50%. Yamaji等[18]认为性别及年龄是腺瘤性息肉切除术后再发的独立危险因素, 男性及年龄大者再发风险高. 但是国内也有部分报道认为年龄和性别并非腺瘤复发的独立危险因素[19-21].
纤维素对结直肠息肉的影响有较多报道, 研究[22]表明增加膳食中纤维素的摄入能降低大肠息肉及大肠癌发生的风险. 这与纤维素在大肠中经厌氧菌酵解可产生短链脂肪酸, 而后者具有诱导细胞分化、凋亡、抑制细胞增殖的作用相关. Platz等[23]研究发现, 不可溶性纤维(如蔬菜)在减少腺瘤样息肉的发生率上无明显作用, 而可溶性纤维(如水果)则可能有重要的保护作用. 日本的一项饮食因素与肿瘤死亡率的研究中发现高动物蛋白及高动物性食物(禽蛋、肉类、牛奶、鱼类等)的摄入与大肠肿瘤的发生呈明显正相关, 而植物性食物(蔬菜、水果、谷物)则呈负相关[24]. 马来西亚的学者也有类似的研究报道[25].
香烟中含有多环芳烃、杂环胺、芳香胺、亚硝胺等多种致癌物质. 现已证实吸烟与多种肿瘤相关. 究其原因, 一方面与香烟中的致癌物质可与DNA相结合形成DNA加合物, 干扰细胞复制, 影响DNA的修复; 另一方面与吸烟时烟草中的一氧化碳导致血液中碳氧血红蛋白的大量生成, 引起组织缺氧, 破坏DNA、脂质和蛋白质相关[26-28]. 吸烟者比不吸烟者更易出现息肉多发, 且更易发生腺瘤. 许多研究[29-32]资料均支持吸烟是大肠腺瘤发生的危险因素, 且吸烟年数、量与腺瘤发病危险性呈显著正相关. Martínez等[33]发现远端结直肠息肉的APC和KRAS基因突变与吸烟相关. 饮酒是大肠息肉发生的独立危险因素, 酒精摄入可增加大肠增生性息肉和腺瘤的发生[34], 其摄入量>51.3 g/d与直肠腺瘤的发病率有阳性联系[35-37]. Baron等[38]及Reid等[39]在研究中均发现吸烟及饮酒等不良生活嗜好均可诱发腺瘤复发, 增加腺瘤复发的风险, 导致男性患者的复发率偏高.
腺瘤性息肉的数目、直径、类型及腺瘤的瘤变程度等因素在腺瘤复发过程中发挥着重要作用, 这些危险因素的重要性得到了国内外部分研究结果的支持[5,40-42]. Terpstra等[43]研究发现腺瘤直径≥1 cm时, 其正常黏膜增长速度也可能加快, 可能导致腺瘤更易复发. 直径>1 cm的腺瘤的正常黏膜增殖速度加快, 这能对直径>1 cm的腺瘤较高复发率进行部分解释. 绒毛状结构与管状结构相比, 前者使腺瘤表面积增加, 其提高腺瘤复发的机制与直径较大的腺瘤更易复发的机制相似[44]. 我国5个医疗中心的统计结果显示, 进展性大肠腺瘤摘除后1、5年的再发率分别高达59.46%和78.07%[45]. Laiyemo等[46]报道首次肠镜息肉切除后在低危人群中进展期腺瘤的累积再发率为3.6%, 而在高危人群中为38.9%, 其还对基线肠镜中4年内有随访记录的患者进行远期随访发现4年内再发腺瘤的人群比未再发腺瘤的人群远期再发腺瘤的概率大(45.6% vs 24.5%, P<0.001). Saini等[47]认为3个或以上腺瘤及高级别内瘤变腺瘤患者为术后腺瘤高复发率人群, 其RR值分别为2.52及1.84. Viel等[7]报道在单因素分析中腺瘤的数量显著缩短腺瘤再发的时间(HR = 1.20, 95% CI: 1.06-1.35), 而多因素分析中仅有息肉的数目与腺瘤的高再发率有关, 而息肉的部位、大小及人口学特征并非腺瘤再发的相关风险因素. Chung等[48]研究发现基线肠镜检查中高危人群(进展期腺瘤或腺瘤≥3枚)术后随访5年累积再发率显著高于低危人群(腺瘤≤2枚且直径<1.0 cm), 分别为57.3%及45.8%(P<0.001), 再发进展期腺瘤的概率在两组中分别为12.2%及2.0%, 差异具有显著性, 其中息肉数目≥3枚及直径≥1.0 cm为独立的危险因素.
1.6.1 家族史: 有研究[49-51]发现, 在有大肠癌家族史的人群中, 大肠腺瘤的发病率以及腺瘤癌变的风险也高于普通人群. 美国胃肠病学会2008年结直肠癌筛查指南建议: 普通人群从50岁开始, 每10年进行一次结肠镜检查; 一级亲属有大肠癌病史人群从40岁开始每5年进行一次结肠镜检查, 或者比患大肠癌的一级亲属诊断时年龄提前10年开始, 每5年进行一次结肠镜检查[52].
1.6.2 幽门螺杆菌: 关于幽门螺杆菌(Helicobacter pylori, H. pylori)与大肠息肉间因果关系的研究在不断发生变化, 早先国内外一些研究并不认为H. pylori与大肠息肉之间具有相关性, 但目前有研究认为H. pylori感染与大肠息肉的发生具有相关性. H. pylori感染可导致肠道内分泌异常, 诱导血浆胃泌素17及环氧合酶2表达, 营养肠黏膜, 刺激肠黏膜增生, 促进息肉生长[53]. Selgrad等[54]研究发现, 大肠息肉患病率在H. pylori感染组占63.4%, 而且H. pylori感染多发生在增生性息肉和低级别上皮内瘤变腺瘤患者中, H. pylori是大肠肿瘤发展的危险因素[54,55]. H. pylori也可通过释放抗原, 引起全身免疫反应及肠黏膜损害, 致息肉形成.
1.6.3 胆囊疾病: 许多研究将胆囊疾病史尤其是有胆囊切除史作为大肠息肉发生的危险因素. 胆系疾病可能是内脏自主神经病变的一个标志, 内脏自主神经病变会导致胆囊排空功能障碍和肠道传输时间延长. 有学者认为, 胆囊炎发病后, 胆汁中胆酸浓度较前增高, 而胆汁酸的代谢产物则增强了对结肠的致癌作用[56]. 高爽等[57]研究发现, 结直肠息肉组胆囊息肉样病变的发生率明显高于非结直肠息肉组, 提示结直肠息肉与胆囊息肉样病变有关系. Vinikoor等[58]的研究结果表明, 胆囊切除术后会增加结直肠腺瘤性息肉的复发几率. 国外曾有学者对胆系疾病与大肠息肉进行荟萃分析报道[59], 42543例结肠腺瘤患者中, 28281例患者中有胆系疾病或曾行胆囊切除术.
1.6.4 代谢疾病: 胰岛素抵抗是代谢综合征的关键, Keku等[60]研究显示空腹血浆胰岛素水平升高和胰岛素样生长因子1(insulin-like growth factor 1, IGF-1)[61]是结直肠腺瘤的危险因素, 胰岛素可作用于腺瘤癌序列中由初期的正常黏膜细胞凋亡减少, 促进大肠腺瘤的发展[60]. 国外多项研究[62,63]发现, 高体质量指数(body mass index, BMI)会增加大肠息肉的患病风险, 尤其是在腺瘤性息肉和增生性息肉方面. 王娜等[64]研究提示BMI≥28 kg/m2的肥胖人群, 其患大肠腺瘤的危险度为正常人的2.48倍; 而肥胖男性的患病风险显著高于女性, 其患大肠腺瘤的危险度是正常人的4.10倍. Lee等[65]报道肥胖症患者易发生肠息肉, 从分子学角度分析其原因可能为胰岛素及IGF-1可刺激非晚期息肉向晚期息肉发展. 高脂血症可影响结直肠腺瘤的发生, 尤其是高甘油三酯血症及高密度脂蛋白降低作用更为明显[66]. Sun等[67]研究发现高甘油三酯血症是大肠腺瘤的危险因素.
但是代谢疾病与患者年龄、性别和基础疾病等多种因素有关, 并且对结直肠腺瘤发生和发展的影响是长期作用的结果, 二者之间的关系十分复杂, 对回顾性研究的结果进行解读十分困难, 因此对于代谢水平与大肠息肉或腺瘤性息肉的是否相关这一问题尚需要更多的高质量的研究.
1.6.5 漏诊: 研究表明, 肠道准备不充分的人群(包括肠道准备欠佳和准备差)腺瘤再检出率较肠道准备充分的人群显著升高, Ahn等[68]在一项前瞻性研究中同一天对149位被检者连续行2次肠镜检查发现息肉、腺瘤及进展期腺瘤的漏诊率分别为16.8%、17.0%及5.4%, 其中第一次肠镜中息肉越小或数目越多越容易被漏诊, 直径≤5 mm的息肉漏诊率高达22.9%, 第一次肠镜检查发现1枚、2枚、3枚及3枚以上息肉的患者漏诊率分别为14%、28%、44%及66%. van Rijn等[69]通过六项研究共465例患者的meta分析发现息肉的总体漏诊率为22%, 对于直径≥10 mm的腺瘤性息肉, 漏诊率约为2.1%, 5-10 mm的腺瘤漏诊率可达到13%, 当腺瘤的直径≤5 mm时, 漏诊的息肉可达到26%. 近几年的国外文献报道[70,71]结肠镜检查时漏诊的腺瘤约为12%-47%. 大部分学者认为足够长的退镜时间可有效的降低腺瘤的漏诊率, 美国结直肠癌多学会工作组、美国消化内镜协会、美国胃肠病协会工作组等一致建议肠镜检查退镜时间不少于6 min以确保肠镜检查高质量[72].
Aslam等[73]提出一个富含矿物的来源于红色海洋藻类提取物大西洋红藻, 可作为化学预防结肠息肉形成的膳食补充. Bobe等[74]通过在息肉预防试验中饮食摄入黄酮醇研究发现, 白介素-6可以作为一个防止高风险腺瘤复发的潜在指标及作为一个预防结肠癌膳食中摄入黄酮醇的反应指标. Huang等[75]研究发现阿托伐他汀通过甲羟戊酸和异戊二烯化通路能诱导体外细胞凋亡. 阿托伐他汀虽然不能有效地防止小鼠模型息肉形成, 但能有效地减缓裸鼠模型肿瘤的生长, 降低的肿瘤的生长可以说明增加的细胞凋亡. 部分研究发现结直肠腺瘤患者的肠道黏膜处于持续性慢性炎症状态, 故非甾体类抗炎药的应用可能在预防患者术后复发中发挥一定的作用[76]. 由于上述药物胃肠道和心血管的不良反应较明显或医疗成本较高, 并不适合用于一般危险度人群的预防[77,78]. 另外, 补充钙剂和维生素D、纤维素饮食及其肠道代谢物短链脂肪酸可能也具有一定的预防大肠癌的作用[79-81]. 但目前尚缺乏直接的临床试验对上述药物长期使用的安全性和疗效作相关评价.
对于大肠腺瘤术后如何随访, 2012年美国结直肠癌多学会工作组(United States Multi-Society Task Force, MSTF)在大肠息肉切除后随访指南共识意见中提出: 高危人群(包括进展期腺瘤及腺瘤数目≥3枚)内镜下治疗后建议每3年复查一次结肠镜, 低危人群(1枚或2枚管状腺瘤不伴有高级别上皮内瘤变)内镜下治疗后建议每5-10年复查一次结肠镜, 基本与2006年指南相同, 但其强调多发腺瘤数目在10枚以上者结肠镜随访间隔因<3年[82]. 国内外目前尚无统一的随访策略, 目前国内学者大多要求腺瘤患者的随访要较国外推荐的随访策略更加密切, 随访间期更短. 如何才能确定更加符合国内人群的随访指南, 制定个体化的随访策略, 是否可以对腺瘤性息肉患者进行更细致的危险分层, 是否可以制定一个评分标准, 既能使患者少受肠道准备及行结肠镜检查时的痛苦, 节省医疗资源, 又可以使患者受益最佳, 从而制定更合理的随访方案, 是国内学者需要面对的一项重大任务.
大肠息肉, 尤其是大肠腺瘤性息肉被认为是结直肠癌的癌前病变. 随着镜下治疗技术的不断发展, 内镜下治疗结肠息肉的方法越来越多, 但切除后的腺瘤性息肉复发率较高, 且仍具有恶变的危险, 故关于其切除术后的复发相关因素的研究越来越受到医学工作者的关注与重视, 但目前此类研究尚缺乏.
石振东, 副主任医师, 沈阳医学院附属铁法煤业集团总医院老年病科VIP病房; 宁守斌, 主任医师, 中国人民解放军空军总医院消化内科
目前国内外尚无统一的息肉术后随访策略, 如何才能确定更加符合国内人群的随访指南, 制定个体化随访策略, 既能使患者少受肠道准备及行结肠镜检查的痛苦, 节省医疗资源, 又可以使患者受益最佳, 制定更合理的随访方案, 是国内学者需要面对的一项重大任务.
Bobe等通过在息肉预防试验中饮食摄入黄酮醇研究发现, 白介素-6可以作为一个防止高风险腺瘤复发的潜在指标, 但是缺乏更大样本的研究, 目前也仍未有简易方便确切可以预测大肠息肉术后复发情况的指标.
本文对近年来国内外对大肠息肉切除术后复发的相关研究进行系统梳理、回顾及总结, 内容较为全面.
大肠息肉尤其是腺瘤性息肉被认为是癌前病变, 切除后的腺瘤性息肉复发率较高, 且仍具有恶变的危险. 本文对大肠息肉切除术后复发相关因素研究的最新进展进行了综述, 对临床工作具有一定的指导意义.
大肠息肉: 是指从大肠黏膜表面突起到肠腔的隆起状赘生物, 是结肠发病率最高的良性肿瘤. 传统意义上的"息肉"分为腺瘤性息肉和非腺瘤性息肉两类. 腺瘤性息肉上皮增生活跃, 多伴有上皮内瘤变, 可以恶变成腺癌; 非腺瘤性息肉一般不恶变, 但如伴有上皮内瘤变则也可恶变.
本文可读性较好, 有一定的临床使用实用价值.
编辑:郭鹏 电编:都珍珍
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