结直肠肿瘤ESD术后迟发性出血的危险因素分析

Risk factors for delayed bleeding following endoscopic submucosal dissection of colorectal tumor

目的：探讨内镜黏膜下剥离术（ ESD）治疗结直肠肿瘤后发生迟发性出血的危险因素。方法对2010年1月—2013年12月间在南京医科大学第二附属医院进行ESD治疗的124例结直肠肿瘤患者进行回顾性调查研究，分析患者年龄、性别、合并症、肿瘤大小、位置、浸润深度等相关危险因素与ESD术后迟发性出血的关系。结果有7例（5．6％）患者发生了ESD术后迟发性出血，时间在术后1～4 d，均在内镜下运用止血夹成功止血，无一例需要紧急手术与输血。发生迟发性出血的患者中位血红蛋白浓度下降了21．3 g／L。 ESD术后迟发性出血与肿瘤位置位于盲肠、黏膜下层浸润腺癌深度≥1000μm（术前经超声内镜诊断明确）、ESD术中出血等因素有关（ P＜0．05）。结论肿瘤位置位于盲肠、侵袭深度≥1000μm黏膜下浸润癌、ESD术中出血的患者易发生术后迟发性出血，需密切观察病情，早期发现并进行内镜下止血。

Objective To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection （ ESD） of colorectal tumor.Methods We retrospectively reviewed the medical records of 124 patients （128 lesions） , who underwent ESD for superficial colorectal neoplasms at the 2nd affiliated hospital of Nanjing Medical University from January 2010 to December 2013.The risk factors for delayed bleeding following ESD such as age, gender, lesion size, lesion loca-tion and the presence of significant bleeding during ESD, were analyzed by univariate analyses.Results Delayed post-ESD bleeding was found in 7 lesions from 7 patients （5.5%of all specimens, 5.6% of patients）.The onset of bleeding occurred between postoperative day 1 and 4.Patients with delayed post-ESD bleeding had a mean hemoglobin decrease of 21.3 g/L.All patients were treated successfully using endoscopic hemostatic clips.Emergency surgery and blood transfu-sion were not required in any of the cases.Univariate analysis revealed that lesions located in the cecum, submucosal deep-ly invasive adenocarcinoma （≥1 000μm, diagnosed by endoscopic ultrasonography before ESD） and the presence of sig-nificant bleeding during ESD were significantly associated with delayed post-ESD bleeding （P＆lt;0.05）.Conclusion Lo-cation in the cecum, submucosal deeply invasive adenocarcinoma and significant bleeding during ESD predispose patients to delayed post-procedural bleeding.Therefore, careful and additional management is recommended for these patients.