结肠息肉切除术后迟发性出血因素的临床研究

Clinical study of risk factors and treatment strategies for bleeding after colonic polypectomy

目的探讨结肠息肉切除术后迟发性出血的危险因素。方法选取2019年1月至2020年12月在浙江省慈溪市第三人民医院行结肠息肉(≥0.5cm)内镜下切除的1752例患者进行回顾性研究,统计和分析者的息肉特征、术中是否出血及切除方式、患者是否合并相关因素等,及出血发生时间、止血方法;并采用多因素Logistic回归分析分析术后迟发性出血的危险因素。结果1752例患者共切除4277枚息肉,20例患者发生迟发性出血,出血率为1.14%。单因素分析发现,出血组较未出血组患者中合并高血压、糖尿病、动脉粥样硬化、服用阿司匹林、使用低分子肝素、息肉直径≥1.0cm、位于乙状结肠、结肠肝曲、带蒂息肉、术中预防应用金属铗、术中有出血以及内镜下黏膜切除术(endoscopic mucosal resection,EMR)或内镜下黏膜剥离术(endoscopic submucosal dissection,ESD)的出血率明显升高,差异有统计学意义(P<0.05)。多因素分析显示:高血压(95%CI:3.830~35.944)、糖尿病(95%CI:3.455~46.903)、动脉粥样硬化(95%CI:3.963~33.611)、服用阿司匹林(95%CI:1.542~15.340)、使用低分子肝素(95%CI:0.748~15.485)、息肉直径≥1.0cm(95%CI:0.748~15.485)、位于乙状结肠(95%CI:2.813~64.197)、结肠肝曲(95%CI:0.260~258.664)、带蒂息肉(95%CI:4.495~34.657)、术中预防应用金属铗(95%CI:1.571~11.472)、术中有出血(95%CI:1.571~11.472)及EMR(95%CI:1.976~39.089)或内镜下黏膜剥离术(95%CI:3.749~202.500)是术后出血的独立危险因素(P<0.05);20例出血患者术后24~48h内出血率65%;单纯金属铗止血的成功率达81.8%(9/11),金属铗联合电凝止血均成功100.0%(4/4)。结论合并高血压、糖尿病、动脉粥样硬化、应用抗凝药物,息肉位于肝曲或乙状结肠、直径≥1.0cm、有蒂息肉、EMR或ESD切除、术中出血是息肉切除术后迟发性出血的独立危险因素;迟发性出血多发生于术后24~48h;金属铗创面闭合联合电凝治疗是息肉切除术后出血行内镜下止血的首选方法。

Objective To investigate the risk factors of delayed bleeding after colonic polyp surgery.Methods A total of 1752 patients who underwent endoscopic polypectomy(≥0.5cm)in the Third People's Hospital of Cixi City of Zhejiang Province from January 2019 to December 2020 were selected for a retrospective study,and the correlation between the polyp's characteristics,whether bleeding occurred during the operation and the way of resection,whether patients were associated with high-risk factors of bleeding,and the postoperative bleeding,as well as the differences in the time of bleeding,the method of hemostasis and the success rate were statistically analyzed.Multivariate logistic regression analysis was used to determine the related-risk factors of late postoperative bleeding,and evaluate the hemostatic effect of metal titanium clips for postoperative bleeding.Results A total of 4277 polyps were resected in 1752 patients,and 20 patients had delayed bleeding,the bleeding rate was 1.14%.Univariate analysis showed that patients in the bleeding group were more complicated with hypertension,diabetes,arteriosclerosis,aspirin,low-molecular-weight heparin,polyps≥1.0cm in diameter,located in the sigmoid colon,hepatic flexure of colon,pedicled polyps,and metal clips for prevention during operation.The rate of bleeding during operation and the rate of bleeding after endoscopic mucosal resection(EMR)or endoscopic submucosal dissection(ESD)were significantly higher(P<0.05).Multivariate logistic regression analysis showed that the OR(95%CI)values of the above factors were 3.830-35.944,3.455-46.903,3.963-33.611,1.542-15.340,2.813-64.197,0.260-258.664,1.288-15.768,4.495-34.657,0.534-13.419,1.571-11.472,0.909-43.732,1.976-39.089 respectively,which were independent high risk factors for postoperative bleeding(P<0.05);The bleeding rate of 20 patients with postoperative bleeding was the highest(65%)within 24-48 hours(P<0.05);The success rate of hemostasis with metal clips alone was 81.8%(9/11),and that with metal clips combined with electrocoagulation was 100.0%(4/4).Conclusion Patients with hypertension,diabetes mellitus,arteriosclerosis,anticoagulants,polyps located in hepatic flexure or sigmoid colon,with a diameter≥1.0cm,pedicled polyps,EMR or ESD resection,and intraoperative bleeding are independent risk factors for late bleeding after polypectomy;Late bleeding occurred more frequently than 2448 hours after operation;Metal clip wound closure combined with electrocoagulation is the first choice for endoscopic hemostasis after polypectomy.