内镜下胃粘膜剥离术后出血的相关危险因素分析

Risk factors of post-ESD bleeding

目的探讨胃粘膜病变经内镜下粘膜剥离术(endoscopic submucosal dissection,ESD)后出血情况及其相关危险因素。方法回顾性分析我院自2009年1月至2011年10月以来,因胃粘膜病变行ESD患者的相关临床、内镜及病理资料,统计分析以下相关因素:①患者相关因素:性别,年龄,伴发高血压、糖尿病、及其他慢性病等情况,既往服用抗凝药物情况;②病变相关因素:病变大小,病变部位,表面溃疡或瘢痕情况,大体形态,病理类型;③操作相关因素:整块切除情况,创面喷洒猪源纤维蛋白粘合剂,操作时间等因素。结果纳入研究病例共有215例,对应病变有223处,有13例患者(13处病变)发生ESD术后出血,其中7例(53.8%)于术后24小时内发生出血,5例(38.5%)于术后1周内发生出血,1例(7.7%)发生于术后第16天。通过单因素与多因素分析,病变长度≥5.0cm(OR值8.663,95%CI为2.081～36.075)为ESD术后出血的独立危险因素。结论病变大小为ESD术后出血的独立危险因素,对于较大病变,ESD术中与术后应给以重视,同时应该优化ESD术前评估使病变最小化以预防术后出血。

Objective To determine the incidence rate and clinical factors associated with bleeding after endoscopic submucosal dissection(ESD) for gastric mucosal lesions.Methods Between January 2009 and October 2011,clinical,endoscopic and pathological data of ESD were retrospectively collected.Then the following factors associated with bleeding were analyzed:①Patient-related factors:sex,age,comorbidities like hypertension,diabetes mellitus and other chronic diseases,history of anticoagulants or anti-platelet agents;②lesion-related factors:specimen size,location,ulcer or scar findings,macroscopic types and pathological type;③procedure-related factors:en-bloc resection,spraying porcine fibrin sealant and operation time.Results A total of 223 lesions in 215 patients were reviewed.There was 13 patients with 13 lesions presenting with bleeding after ESD,among which 7 ones(53.8%) bled within 24 hours,5 ones(38.5%)within 1 week and one(7.7%)on the sixteenth day after ESD.Univariate and multivariate analysis revealed that the only factor found to be significantly associated with bleeding was the size of the lesion(≥5cm;odds ratio 8.663;95%confidence interval 2.081-36.075).Conclusion Considering the size is the dependent risk factor for bleeding after ESD,careful preparation and close monitoring are required during and after ESD.Meantime efforts should be made to identify and exactly demarcate lesions to minimize the size of resected specimens and reduce the risk of bleeding after ESD.