结直肠镜下结直肠腺瘤切除术后复发的影响因素

Influencing factors of recurrence after colonoscopic resection of colorectal adenoma

目的研究结直肠镜下结直肠腺瘤切除术后复发的影响因素。方法选择青岛市市立医院2014年1月至2016年8月行结肠镜下结直肠腺瘤切除术且在切除术后3年内有结肠镜随访结果的患者501例。分析性别、年龄、BMI、是否吸烟、是否合并非酒精性脂肪性肝病(NAFLD)、是否合并糖尿病,腺瘤最大径、数量、病理类型,以及手术方式对患者术后腺瘤复发率的影响,将差异有统计学意义的结果纳入多因素logistic回归模型,分析腺瘤复发的独立危险因素。统计学方法采用卡方检验和多因素logistic回归分析。结果 501例结肠镜下结直肠腺瘤切除术患者术后3年的腺瘤复发率为25.5%(128/501)。腺瘤复发率在不同性别和年龄的患者间的差异均无统计学意义(P均>0.05)。BMI为<25、25~29和>29 kg/m^(2)的患者的腺瘤复发率分别为19.2%(32/167)、27.5%(44/160)和29.9%(52/174),其中BMI>29 kg/m^(2)者的腺瘤复发率高于BMI<25 kg/m^(2)者,差异有统计学意义(χ^(2)=6.978,P<0.05),腺瘤复发率在BMI<25 kg/m^(2)与25~29 kg/m^(2)、BMI为25~29 kg/m^(2)与>29 kg/m^(2)的患者间的差异均无统计学意义(P均>0.05)。吸烟、合并NAFLD、合并糖尿病的患者的腺瘤复发率分别高于不吸烟、不合并NAFLD、不合并糖尿病的患者[32.9%(51/155)比22.3%(77/346)、27.6%(61/221)比23.9%(67/280)、31.3%(25/80)比24.5%(103/421)],差异均有统计学意义(χ^(2)=8.132、7.232、6.874,P均<0.05)。腺瘤最大径为≤5、>5~<10、10~<20和≥20 mm的患者腺瘤复发率分别为11.6%(23/198)、18.5%(23/124)、41.7%(43/103)、51.3%(39/76),其中最大径为10~<20 mm和≥20 mm的患者腺瘤复发率均高于最大径为≤5 mm和>5~<10 mm的患者,差异均有统计学意义(χ^(2)=35.990、14.690、49.440、23.650,P均<0.05),腺瘤复发率在最大径≤5 mm与>5~<10 mm、最大径为10~<20 mm与≥20 mm的患者间的差异均无统计学意义(P均>0.05)。有1、2和≥3个腺瘤的患者的腺瘤复发率分别为19.6%(20/102)、23.2%(46/198)和30.8%(62/201),其中有3个腺瘤的患者的腺瘤复发率高于有1个腺瘤的患者,差异有统计学意义(χ^(2)=7.956,P<0.05),有1个与2个、有2个与3个腺瘤的患者间的差异均无统计学意义(P均>0.05)。进展性腺瘤患者的腺瘤复发率高于非进展性腺瘤患者[28.8%(98/340)比18.6%(30/161)],差异有统计学意义(χ^(2)=8.539,P<0.05)。在腺瘤最大径为10~<20 mm和≥20 mm的患者中,分块切除(内镜下分块黏膜切除术与内镜下分块黏膜剥离术合并)组的局部复发率均高于整块切除(内镜下黏膜切除术与内镜黏膜下剥离术合并)组[5/19比4.8%(4/84)、45.7%(16/35)比14.6%(6/41)],差异均有统计学意义(χ^(2)=9.027、8.868,P均<0.05)。多因素logistic回归分析显示,腺瘤最大径、腺瘤数量、腺瘤病理类型均为影响腺瘤复发的独立危险因素(OR值=3.673、1.523、1.989,95%CI 1.759~6.528、1.096~2.897、1.564~4.089,P均<0.05)。结论高BMI、吸烟、合并NAFLD和合并糖尿病的患者结直肠腺瘤切除术后复发率高。腺瘤的最大径越大,数量越多,病理类型为进展性腺瘤,患者结直肠腺瘤术后复发率越高。在较大腺瘤的患者中,接受分块切除术的患者局部复发率比整块切除术高。

Objective To study the influencing factors of recurrence after colonoscopic resection of colorectal adenoma.Methods From January 2014 to August 2016,in Qingdao Municipal Hospital,501 patients who underwent colonoscopic resection of colorectal adenoma and were followed up by colonoscopy within three years after resection were selected.The effects of gender,age,body mass index(BMI),smoking,non-alcoholic fatty liver disease(NAFLD),diabetes,and the maximum diameter,number,pathologic type of adenoma,and operation method on the recurrence rates of adenoma after resection.Multivariate logistic regression model was used to analyze the independent risk factors of adenoma recurrence in the results with statistically significant difference.Chi-square test and multivariate logistic regression analysis were used for statistical analysis.Results The recurrence rate of adenoma was 25.5%(128/501)in three years after operation among 501 patients who underwent colonoscopic resection of colorectal adenoma.There were no statistically significant differences in the recurrence rates among patients with different gender and age(both P>0.05).The recurrence rates of patients with BMI<25,25 to 29 and>29 kg/m^(2) were 19.2%(32/167),27.5%(44/160)and 29.9%(52/174),respectively.And the recurrence rate of patients with BMI>29 kg/m^(2) was higher than that of patients with BMI<25 kg/m^(2),and the difference was statistically significant(χ^(2)=6.978,P<0.05).There were no statistically significant differences in the recurrence rates between patients with BMI<25 kg/m^(2) and 25 to 29 kg/m^(2),between BMI 25 to 29 kg/m^(2) and>29 kg/m^(2)(both P>0.05).The recurrence rate of adenomas in patients who smoked,complicated with NAFLD or diabetes were higher than those of non-smokers,patients without NAFLD or diabetes(32.9%,51/155 vs.22.3%,77/346;27.6%,61/221 vs.23.9%,67/280;31.3%,25/80 vs.24.5%,103/421),and the differences were statistically significant(χ^(2)=8.132,7.232 and 6.874,all P<0.05).The recurrence rates of patients with of adenomas≤5,>5 to<10,10 to<20 and≥20 mm were 11.6%(23/198),18.5%(23/124),41.7%(43/103)and 51.3%(39/76),respectively.The recurrence rates of adenomas in patients with a maximum diameter of 10 to<20 mm and≥20 mm were higher than those of adenomas with a maximum diameter of adenomas≤5 mm and>5 to<10 mm,and the differences were statistically significant(χ^(2)=35.990,14.690,49.440 and 23.650,all P<0.05).There were no statistically significant differences in the recurrence rates between patients with adenomas of≤5 mm and>5 to<10 mm in maximam diameter,and between patients with adenomas of 10 to<20 mm and≥20 mm(both P>0.05).The recurrence rates of adenomas in the patients with 1,2 and≥3 adenomas were 19.6%(20/102),23.2%(46/198)and 30.8%(62/201),respectively.The recurrence rate of adenoma in patients with≥3 adenomas was higher than that in patients with 1 adenoma,and the difference was statistically significant(χ^(2)=7.956,P<0.05).There were no statistically significant differences in the recurrence rates of adenoma between patients with 1 and 2 adenomas,between patients with 2 and 3 adenomas(both P>0.05).The recurrence rates of adenomas in the patients with progressive adenoma was higher than that of patients with non-progressive adenoma(28.8%,98/340 vs.18.6%,30/161),and the difference was statistically significant(χ^(2)=8.539,P<0.05).Among patients with adenoma diameter of 10 to<20 mm or≥20 mm,the local recurrence rates of block resection(endoscopic piecemeal mucosal resection and endoscopic piecemeal submucosal dissection)group were higher than those of whole resection(endoscopic mucosal resection and endoscopic submucosal dissection)group(5/19 vs.4.8%,4/84;45.7%,16/35 vs.14.6%,6/41),and the differences were statistically significant(χ^(2)=9.027 and 8.868,both P<0.05).The results of multivariate logistic regression analysis showed that maximum diameter of adenoma,number of adenoma,and pathological type of adenoma were all independent risk factors influencing adenoma recurrence(odds ratio=3.673,1.532 and 1.989;95%confidence interval 1.759 to 6.528,1.096 to 2.897 and 1.564 to 4.089;all P<0.05).Conclusions The recurrence rates after colorectal adenoma resection are higher in patients with high BMI,smoking,NAFLD and diabetes.The larger the maximum diameter,number and progression of the adenoma,the higher the recurrence rate of colorectal adenoma after resection.For the larger adenoma,the local recurrence rate of the patients receiving block resection is significantly higher than that of whole resection.