早期胃癌内镜黏膜下剥离术后迟发性出血风险预测评分系统的研究

A risk-scoring system for the prediction of delayed bleeding after endoscopic submucosal dissection of early gastric cancer

目的:探讨早期胃癌(early gastric cancer,EGC)内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)后发生迟发性出血风险的预测评分系统。方法:回顾性分析2016年2月—2020年11月在苏州大学附属第一医院消化科行ESD术治疗的296例EGC(包括高级别上皮内瘤变)患者的资料,经多因素分析找出影响EGC ESD术后迟发性出血的独立危险因素,并根据其回归系数对独立危险因素进行赋分,建立术后迟发性出血风险预测评分系统,且根据评分及迟发性出血发生率,绘制受试者工作特征曲线(receiver operating characteristic curve,ROC曲线),计算曲线下面积(area under the curve,AUC),根据评分进行危险分层。结果:病灶黏膜下层纤维化(OR=12.163,95%CI:2.735~54.102)、切除标本直径>4 cm(OR=19.091,95%CI:3.726~97.819)、使用抗凝药和/或抗血小板药(OR=5.334,95%CI:1.013~28.088)是EGC ESD术后发生迟发性出血的独立危险因素(P均<0.05);评分系统:使用抗凝药和/或抗血小板药为1分,病灶黏膜下层纤维化为2分,切除标本直径>4 cm为2分。根据评分和迟发性出血发生率绘制ROC曲线,其AUC值为0.85(95%CI:0.753~0.947,P<0.001),最佳截断值为1.5分,以评分0~1分定义为低危组,评分2~5分定义为高危组,评分为低危组者ESD术后迟发性出血发生率为1.03%(2/194),评分为高危组者ESD术后迟发性出血发生率为16.67%(17/102),两组差异有统计学意义(χ2=27.208,P<0.001)。结论:病灶黏膜下层纤维化、切除标本直径大于4 cm、使用抗凝药和/或抗血小板药,这3个独立危险因素构建的风险预测评分系统,能够有效识别EGC ESD术后发生迟发性出血的高风险患者。

Objective:This study aims to explore a scoring system for predicting the risk of delayed bleeding after endoscopic submucosal dissection(ESD)for early gastric cancer(EGC).Methods:A retrospective analysis was performed on the data of 296 patients with early gastric cancer(including high-grade intraepithelial neoplasia)who underwent ESD treatment in the Gastroenterology Department of the First Affiliated Hospital of Soochow University from February 2016 to November 2020.Multivariate logistic regression analysis was performed to investigate independent risk factors of delayed bleeding after ESD in EGC.Weighted points was proportionally assigned based onβregression coefficients value to construct the scoring system.According to the scores and the incidence of delayed bleeding,the receiver operating characteristic curve(ROC curve)was plotted,the area under the curve(AUC)was calculated,and risk stratification based on the scores was performed.Results:Multivariate analysis revealed that submucosal fibrosis(OR=12.163,95%CI:2.735-54.102),resected specimen diameter>4 cm(OR=19.091,95%CI:3.726~97.819),use of anticoagulants and/or antiplatelet drugs were independent risk factors for delayed bleeding after ESD in EGC(all P<0.05).Scoring system:1 point for the use of anticoagulants and/or antiplatelet drugs,2 points for submucosal fibrosis of the lesion,and 2 points for resected specimen diameter>4 cm.The AUC value of the scoring system was 0.85(95%CI:0.753-0.947,P<0.001),of which the cutoff value was 1.5.According to the cut-off value,a score of 0-1 was defined as the low-risk group,and a score of 2-5 was defined as the high-risk group for EGC after ESD.The incidence of delayed bleeding after ESD in the low-risk group was 1.03%(2/194),and in the high-risk group was 16.67%(17/102).The differences between the two groups were statistically significant(χ2=27.208,P<0.001).Conclusion:The predictive scoring system constructed by the three independent risk factors,which were submucosal fibrosis of the lesion,the use of anticoagulants and/or antiplatelet drugs,and resected specimen diameter>4 cm,can effectively identify high-risk patients with delayed bleeding after ESD for EGC.