心脏换瓣术后患者行内镜下结肠息肉切除的治疗策略初探

Treatment strategy of endoscopic colonic polypectomy in patients with cardiac valve replacement surgery

目的探讨心脏换瓣术后行内镜下结肠息肉切除的治疗策略。方法回顾性分析2014年1月至2018年6月本院消化内科收治的心脏换瓣术后行内镜下结肠息肉切除术的16例患者的临床资料,根据2016年英国胃肠病学和欧洲胃肠内镜指南,将患者按照中断抗凝治疗发生栓塞的风险分为低风险组(7例)和高风险组(9例),低风险组停用华法林后未给予低分子肝素桥接治疗,高风险组停用华法林后给予低分子肝素桥接治疗。结果停华法林前、内镜治疗前和恢复华法林治疗3天后低风险组和高风险组国际标准化比值中位数分别为2.25和2.12、1.06和1.10、1.14和1.28。低风险组和高风险组患者住院时间中位数分别为10.0天和14.0天,结肠息肉最大直径中位数分别为12.0mm和20.0mm。低风险组和高风险组结肠息肉切除术后出血比例分别为28.6%(2/7)和44.4%(4/9),6例患者均再次行肠镜检查,予钛夹夹闭出血创面后出血停止。两组患者均未出现卡瓣及血栓栓塞等严重并发症。结论心脏换瓣术后患者行内镜下结肠息肉切除术需根据病情制定个体化治疗方案,停抗凝药物高栓塞风险者可采取桥接治疗,同时要考虑息肉大小、是否合并高血压病、停药时间及重新恢复抗凝治疗时间等,以减少不良事件的发生。

Objective To explore the clinical treatment strategy of endoscopic colonic polypectomy in patient with cardiac valve replacement surgery. Method In this study, the clinical data of patients＇ with cardiac valve replacement surgery were retrospectively analyzed from the digestive department, Beijing Anzhen Hospital, Capital Medical University, after undertaking endoscopic colonic polypectomy between January, 2014 and June, 2018. Patients were divided into low-risk group and high-risk group according to British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guidelines in 2016. Low-risk group did not need heparin bridging after stopping warfarin, but high-risk group was given heparin bridging. Result 16 patients were enrolled and divided into lowrisk group and high-risk group, 7 and 9 cases, respectively. The median values of low-risk group and high-risk group were as follows： the values of international normalized ratio（INR） with warfarin 2.25 and 2.12, INR before endoscopy 1.06 and 1.10, INR recovery warfarin for 3 days 1.14 and 1.28, hospital length of stay were 10.0 and 14.0 day, the maxium diameter of polyps were 12.0 and 20.0 mm, proportion of patients with post-polypectomy bleeding were 28.6%（2/7） and 44.4%（4/9）, respectively. Patients with postoperative bleeding underwent emergency colonoscopy, and the bleeding was stopped after titanium clips were used. There were no serious complications such as stuck leaflet and thromboembolism in both groups. Conclusion The patients after cardiac valve replacement surgery could undertake the treatment of endoscopic colonic polypectomy, and patients with high risk of discontinuing warfarin could be treated with heparin. And attention should also be paid to the the maxium diameter of polyp, whether complicated with hypertension, and the withdrawal time of warfarin and recovery of anticoagulation. Individualized treating plan should be developed for patients to reduce the incidence of adverse events.