肩肘外科手术后并发上消化道出血的临床分析

Clinical analysis of postoperative upper gastrointestinal bleeding(UGIB)after shoulder and elbow surgery

目的分析肩肘外科手术后并发上消化道出血的临床特点,并分析其危险因素。方法回顾性分析2007年1月至2015年12月于北京大学人民医院行肩肘外科手术治疗后并发上消化道出血患者的临床资料,总结其临床特点,分析引起上消化道出血的危险因素。结果肩肘外科术后发生上消化道出血共33例,发生率为3.36%(33/983);单因素分析显示高龄、性别、手术时间长、吸烟史、饮酒史、消化性溃疡或出血史、应用抗凝药物或抗血小板药物等因素与肩肘外科手术患者术后发生上消化道出血明显相关(P<0.05);非条件多因素Logistic分析结果显示高龄、性别、手术时间长、消化性溃疡或出血史、应用抗凝药物或抗血小板药物是肩肘外科手术患者术后发生上消化道出血的独立危险因素(P<0.05)。结论肩肘外科手术患者术后发生上消化道出血较为少见,高龄、性别、手术时间长、消化性溃疡或出血史、应用抗凝药物或抗血小板药物是肩肘外科手术患者术后发生上消化道出血的独立危险因素。

Background Upper gastrointestinal bleeding(UGIB)is one of the seriouscomplications after major orthopedic operation,which is mainly caused by stress-related ulcer(SU).While showing no symptom in mild cases,UGIB can affect the rehabilitation and life of patients incritical cases.The symptoms of UGIB are usually hard to be detected during the early postoperativestage,which brings some difficulties to the diagnosis and treatment.Usually,more cases of UGIB arereported after major orthopedic surgery.Shoulder and elbow surgery is in rapid development recently,and most of them are small and medium surgeries including internal fixation of peripheral shoulderand elbow fractures,ligament injuries of peripheral shoulder and elbow,repair and reconstruction ofrotator cuff injury,shoulder and elbow arthroplasties,etc.Thus,the postoperative UGIB is seldomlyreported in these cases.Clinically,the application of prophylactic drug on every patient with shoulderand elbow surgery in avoiding digestive tract bleeding will cause unnecessary medical waste.Thisstudy retrospectively analyzed the clinical data of shoulder and elbow surgery in our hospital for nearly8years and collected the high-risk factors of postoperative UGIB to better grasp the clinical data ofUGIB after shoulder and elbow surgery,prevent postoperative UGIB,and optimize the guideline ofclinical individualized treatment.Methods(1)Research object.From January1,2007to December12,2015,the information of patients with shoulder and elbow surgery under the department of orthopedics andtraumatology was collected,and the patients with UGIB were included in this study.Inclusive and exclusivecriteria:within one week after operation,the patients had situations including hematemesis,melena and positiveoccult test.The bleeding of mouth,nasopharynx and biliary tract as well as preoperative active peptic ulcer andgastrointestinal bleeding should be excluded.(2)Research methods.The general and clinical data of patients were statistically analyzed.The general data includes demographic characteristics and lifestyle habits such asage,gender,smoking,drinking,etc.The clinical data includes causes of shoulder and elbow surgery,operationtime,operation method,anesthesia,gastrointestinal clinical manifestations,UGIB diagnosis,clinical outcomes,laboratory results,history of peptic ulcer and hemorrhage,anticoagulant or antiplatelet drug history,etc.The riskfactors for UGIB were analyzed by single-factor analysis and multiple-factor analysis.(3)Statistical analysis.SPSS19.0software was used for statistical analysis.The enumeration data was analyzed by Chi-square test,and the multiple-factor analysis was performed by Logistic regression analysis.A P value<0.05was regardedas statistically significant.Results(1)General information and clinical data.A total of33patientsdeveloped UGIB after shoulder and elbow surgery,including17males(51.56%)and16females(48.44%).The incidence rate was3.36%(33/983),and the average age was(67.609±13.948)years old.The operations that involved UGIB included shoulder and elbow arthroplasty,shoulder andelbow internal fixation,ligament repair and reconstruction,and open reduction and internal fixationof humeral shaft fracture.The average operation time was(131.00±93.36)mins.Gastrointestinalsymptoms include hematemesis or vomiting coffee ground vomitus,melena or dark red colored bloodystool,abdominal pain or discomfort,nausea,etc.All the patients included in this study had positivefecal occult blood.A total of27cases(81.82%)underwent gastroscopy:25cases of gastric mucosalerosion and ulcer were diagnosed as SU(8cases of which had active bleeding);1case had esophagealand gastric varices bleeding(the patient suffered from hepatitis B virus-related cirrhosis);1case hadanastomotic ulcer after subtotal gastrectomy.Among the patients who received gastroscopy,8out of23patients who underwent rapid urease test for detection of Helicobacter pylori were positive.Based onclinical manifestations and the endoscopic diagnosis of upper gastrointestinal bleeding,there were31cases of SU,1case of esophageal and gastric varices bleeding,and1case of anastomotic ulcer aftersubtotal gastrectomy.All patients with UGIB were treated with proton pump inhibitors(PPI),and11cases were treated with blood transfusion.31patients were discharged,and2patients died.Onecase died of UGIB,and the other died of respiratory failure caused by severe pulmonary infection.(2)Single-factor analysis of UGIB after shoulder and elbow surgery.Single-factor analysis was conductedon gender,age,international normalized ratio(INR),platelet count,operation time,operationmethod,anesthesia,drinking history,smoking history,peptic ulcer or gastrointestinal bleeding history,anticoagulant or antiplatelet drug application,etc.The results showed that the risk factors of UGIBafter shoulder and elbow surgery included male,advanced age,long time operation,smoking history,drinking history,peptic ulcer or gastrointestinal bleeding history,anticoagulant or antiplatelet drugusage,etc.(P<0.05).(3)Non-conditional multiple-factor Logistic analysis of UGIB after shoulderand elbow surgery.The factors were taken as independent variable for non-conditional multiple-factorLogistic analysis.The results showed that male,advanced age,long operation time,previous history ofpeptic ulcer or gastrointestinal bleeding and application of anticoagulant or antiplatelet drug were theindependent risk factors of UGIB after shoulder and elbow surge ry(P<0.05).Conclusions UGIB inpatients with shoulder and elbow surgery is relatively uncommon.Advanced age,male,long operationtime,history of peptic ulcer or gastrointestinal bleeding,usage of anticoagulant or antiplatelet drug arethe independent risk factors of UGIB after shoulder and elbow s urgery.