早期胃癌内镜黏膜下剥离术后出血的危险因素分析

doi:10.3969/j.issn.1004-583X.2021.12.006

摘要/Abstract

摘要：

目的系统分析早期胃癌内镜黏膜下剥离(ESD)术后出血的危险因素。方法回顾性分析2017年1月至2021年2月于河北医科大学第二医院行内镜黏膜下剥离术且术后病理为早期胃癌的患者共计281例。依据是否出现术后出血分为对照组及术后出血组。收集既往史、住院病历、病理结果、内镜报告等资料。统计并分析患者性别、年龄、术前是否服用抗血小板药物、是否合并高血压、是否合并糖尿病、是否合并缺血性血管病、肿瘤部位、内镜下大体分型、组织学类型、肿瘤直径、手术时间、是否合并溃疡、是否合并脉管癌栓、是否为整块切除、是否为完全切除、是否出现术后出血及术后出血时间等信息,通过单因素及多因素Logstic回归分析早期胃癌患者ESD术后出血的危险因素。结果 281例早期胃癌患者中共有16例发生术后出血(5.69%),出血时间为术后第1~9日。ESD术后24小时内出血8例(50.0%),48小时内出血10例(62.5%)。其中1例于术后48小时内连续出血2次,失血性休克1例,均于内镜下止血成功。术前服用抗血小板药物(OR值为0.051, 95%CI 0.011~0.230, P<0.01)、手术时间≥2 h(OR值为0.048, 95% CI 0.009~0.263, P<0.01)、合并溃疡(OR值为0.038, 95% CI 0.007~0.193, P<0.01)是早期胃癌患者ESD术后出血的独立危险因素。结论手术时间≥2 h、术前应用抗血小板药物、合并溃疡是早期胃癌患者ESD术后出血的独立危险因素。

关键词: 胃肿瘤, 内镜黏膜下剥离术, 术后出血

Abstract:

Objective To systematically analyze the risk factors of postoperative hemorrhage of endoscopic submucosal dissection (ESD) in early gastric cancer (EGC). Methods A total of 281 EGC patients who underwent ESD treated in the second Hospital of Hebei Medical University from January 2017 to February 2021 were analyzed retrospectively. These patients were divided into control group and postoperative bleeding group on the basis of occurrence of postoperative hemorrhage. The previous history, inpatient medical records, pathologic diagnosis, report on endoscopy were collected, and the key observation was sex, age, whether or no preoperative antiplatelet therapy, whether with hypertension, diabetes, ischemic angiopathy; tumor location, endoscopic classification, histological classification, tumor diameter, operation time; whether complicated by ulcer, vascular tumor thrombus; whether block resection or complete resection; whether or no postoperative bleeding, as well as the postoperative bleeding time, ect. The risk factors for postoperative hemorrhage of ESD in EGC patients were analyzed by univariate and multivariate Logstic regression. Results There were 16 cases with postoperative bleeding (5.69%, 16/281) in out of 281 EGC patients, with bleeding time was from day 1 to day 9 postoperation; of which 8 cases (50.0%, 8/16) had postoperative bleeding within 24 hours, 10 cases (62.5%, 10/16) had postoperative bleeding within 48 hours, 1 patient had two consecutive bleeding within 48 hours, and 1 patient developed hemorrhagic shock, those patients successed in hemostasis under endoscope.The independent risk factor for postoperative hemorrhage of ESD in EGC patients was preoperative antiplatelet therapy (OR=0.051, 95% CI 0.011-0.230, P<0.01), operation time ≥2 hours (OR=0.048, 95% CI 0.009-0.263, P<0.01) and complication by ulcer (OR=0.038, 95% CI 0.007-0.193, P<0.01). Conclusion Independent risk factor for postoperative hemorrhage of ESD in EGC patients was operation time more than 2 hours, preoperative antiplatelet therapy, complication by ulcer.

Key words: stomach neoplasms, endoscopic submucosal dissection, postoperative bleeding

中图分类号:

R735.2

芦迅达, 冯志杰, 纪晨光, 尹凯歌, 刘丽. 早期胃癌内镜黏膜下剥离术后出血的危险因素分析[J]. 临床荟萃, 2021, 36(12): 1087-1091.

Lu Xunda, Feng Zhijie, Ji Chenguang, Yin Kaige, Liu Li. Analysis on risk factors of postoperative hemorrhage of endoscopic submucosal dissection in early gastric cancer[J]. Clinical Focus, 2021, 36(12): 1087-1091.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2021.12.006

https://huicui.hebmu.edu.cn/CN/Y2021/V36/I12/1087

图/表 3

参考文献 19

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项目	未出血组 (n=265)	出血组 (n=16)	χ²值	P值
性别
女男	45(17.0) 220(83.0)	2(12.5) 14(87.5)	0.218	0.64
年龄
<60岁 ≥60岁	90(34.0) 175(66.0)	9(35.2) 7(64.8)	3.285	0.07
应用抗血小板药
否是	256(96.6) 9(3.4)	12(75.0) 4(25.0)	15.961	<0.01
合并高血压
否是	204(77.0) 61(23.0)	11(68.8) 5(31.3)	0.569	0.45
合并糖尿病
否是	228(86.0) 37(14.0)	14(87.5) 2(12.5)	0.027	0.87
合并缺血性血管病
否是	228(86.0) 37(14.0)	13(81.3) 3(18.8)	0.283	0.60

项目	未出血组 (n=265)	出血组 (n=16)	χ²值	P值
性别
女男	45(17.0) 220(83.0)	2(12.5) 14(87.5)	0.218	0.64
年龄
<60岁 ≥60岁	90(34.0) 175(66.0)	9(35.2) 7(64.8)	3.285	0.07
应用抗血小板药
否是	256(96.6) 9(3.4)	12(75.0) 4(25.0)	15.961	<0.01
合并高血压
否是	204(77.0) 61(23.0)	11(68.8) 5(31.3)	0.569	0.45
合并糖尿病
否是	228(86.0) 37(14.0)	14(87.5) 2(12.5)	0.027	0.87
合并缺血性血管病
否是	228(86.0) 37(14.0)	13(81.3) 3(18.8)	0.283	0.60

变量	未出血组 (n=265)	出血组 (n=16)	χ²值	P值
手术时间
<2 h ≥2 h	195(73.6) 70(26.4)	3(18.8) 13(81.3)	21.799	<0.01
大体分型
Ⅰ	14(5.3)	0
Ⅱa	23(8.7)	1(6.3)
Ⅱb	79(29.8)	5(31.3)
Ⅱc	77(29.1)	3(18.8)	5.282	0.63
Ⅱa+Ⅱb	9(3.4)	1(6.3)
Ⅱa+Ⅱc	50(18.9)	6(37.5)
Ⅱb+Ⅱc	3(1.1)	0
Ⅲ	10(3.8)	0
病变部位
上1/3	186(70.2)	9(56.3)
中1/3	31(11.7)	3(18.8)	1.429	0.489
下1/3	48(18.1)	4(25.0)
肿瘤直径
<30 mm ≥30 mm	178(67.2) 87(32.8)	9(56.3) 7(43.8)	0.808	0.37
浸润深度
M	178(67.2)	13(81.3)
SM1	53(20.0)	1(6.3)	1.926	0.38
SM2	34(12.8)	2(12.5)
溃疡
无有	252(95.1) 13(4.9)	11(68.8) 5(31.3)	17.467	<0.01
完全切除
否是	45(17.0) 220(83.0)	2(12.5) 14(87.5)	0.218	0.64
整块切除
否是	2(0.8) 263(99.2)	0 16(100.0)	0.122	0.73
脉管侵犯
否是	261(98.5) 4(1.5)	16(100.0) 0	0.245	0.62

变量	未出血组 (n=265)	出血组 (n=16)	χ²值	P值
手术时间
<2 h ≥2 h	195(73.6) 70(26.4)	3(18.8) 13(81.3)	21.799	<0.01
大体分型
Ⅰ	14(5.3)	0
Ⅱa	23(8.7)	1(6.3)
Ⅱb	79(29.8)	5(31.3)
Ⅱc	77(29.1)	3(18.8)	5.282	0.63
Ⅱa+Ⅱb	9(3.4)	1(6.3)
Ⅱa+Ⅱc	50(18.9)	6(37.5)
Ⅱb+Ⅱc	3(1.1)	0
Ⅲ	10(3.8)	0
病变部位
上1/3	186(70.2)	9(56.3)
中1/3	31(11.7)	3(18.8)	1.429	0.489
下1/3	48(18.1)	4(25.0)
肿瘤直径
<30 mm ≥30 mm	178(67.2) 87(32.8)	9(56.3) 7(43.8)	0.808	0.37
浸润深度
M	178(67.2)	13(81.3)
SM1	53(20.0)	1(6.3)	1.926	0.38
SM2	34(12.8)	2(12.5)
溃疡
无有	252(95.1) 13(4.9)	11(68.8) 5(31.3)	17.467	<0.01
完全切除
否是	45(17.0) 220(83.0)	2(12.5) 14(87.5)	0.218	0.64
整块切除
否是	2(0.8) 263(99.2)	0 16(100.0)	0.122	0.73
脉管侵犯
否是	261(98.5) 4(1.5)	16(100.0) 0	0.245	0.62

自变量	回归系数	标准误	Wald χ²值	P值	OR值	95%CI
自变量	回归系数	标准误	Wald χ²值	P值	OR值	下限	上限
应用抗血小板药	-3.033	0.866	12.264	<0.01	0.051	0.011	0.230
手术时间	-2.970	0.765	15.072	<0.01	0.048	0.009	0.263
溃疡	-3.278	0.832	15.511	<0.01	0.038	0.007	0.193