消化道早癌患者内镜黏膜下剥离术后迟发性出血的危险因素分析

Risk factors for delayed bleeding after endoscopic submucosal dissection in patients with early cancer of the gastrointestinal tract

摘要:

目的 分析消化道早癌患者内镜黏膜下剥离术（ESD）后迟发性出血的危险因素。方法 回顾性分析2020年5月—2023年2月泰州市人民医院收治的625例消化道早癌患者，其中胃癌257例，食管癌368例。所有患者行ESD，记录消化道早期患者ESD术后迟发性出血情况。胃癌患者根据ESD术后是否发生迟发性出血分为胃癌未发生组与胃癌发生组，食管癌患者根据ESD术后是否发生迟发性出血分为食管癌未发生组与食管癌发生组。比较胃癌发生组与胃癌未发生组患者临床资料，食管癌发生组与食管癌未发生组患者临床资料，采用多因素逐步Logistic回归模型分析ESD术后发生迟发性出血的影响因素。结果 257例胃癌患者中，ESD术后迟发性出血27例，迟发性出血发生率为10.51%；368例食管癌患者中，ESD术后迟发性出血23例，迟发性出血发生率为6.25%。胃癌发生组病灶部位为胃体、病灶直径≥ 20 mm、黏膜下有粗大血管、黏膜下有纤维化、手术时间≥ 60 min、长期服用抗凝药物占比高于胃癌未发生组（P <0.05），胃癌发生组病灶深度为黏膜层占比低于胃癌未发生组（P <0.05）。多因素逐步Logistic回归分析结果显示：黏膜下有粗大血管［O^R=3.838（95% CI：1.687，8.731）］、黏膜下有纤维化［O^R=3.511（95% CI：1.544，7.988）］、手术时间≥60 min ［O^R=2.821（95% CI：1.240，6.417）］、长期使用抗凝药物［O^R=4.415（95% CI：1.941，10.043）］为胃癌患者ESD术后发生迟发性出血的影响因素（P <0.05）。食管癌发生组黏膜深度为黏膜下层、切片直径≥ 40 mm、切除管径大小为环周、黏膜下有粗大血管、黏膜下有纤维化、手术时间≥ 60 min、长期服用抗凝血药物占比高于食管癌未发生组（P <0.05）。多因素逐步Logistic回归分析结果显示：黏膜下有粗大血管［O^R=3.056（95% CI：1.343，6.951）］、手术时间≥ 60 min ［O^R=3.607（95% CI：1.586，8.206）］、长期使用抗凝药物［O^R=4.104（95% CI：1.804，9.336）］为食管癌患者ESD术后发生迟发性出血的影响因素（P <0.05）。结论 黏膜下有粗大血管、手术时间≥ 60 min、长期使用抗凝药物的消化道早癌患者ESD术后迟发性出血风险更高。

Abstract:

Objective To analyze the risk factors for delayed bleeding after endoscopic submucosal dissection (ESD) in patients with early cancer of the gastrointestinal tract.Methods A total of 625 patients with early cancer of the gastrointestinal tract admitted to our hospital from May 2020 to February 2023, including 257 cases of gastric cancer and 368 cases of esophageal cancer, were retrospectively analyzed. All patients received ESD, and occurrence of delayed bleeding after ESD in patients with early cancer of the gastrointestinal tract was recorded. Patients with gastric cancer were divided into non-occurrence group A and occurrence group A according to whether delayed bleeding occurred after ESD, and patients with esophageal cancer were divided into non-occurrence group B and occurrence group B according to whether delayed bleeding occurred after ESD. The clinical data of the occurrence group A and the non-occurrence group A, as well as the occurrence group B and the non-occurrence group B, were compared. Factors affecting the occurrence of delayed bleeding after ESD were determined by multivariable Logistic regression analysis.Results Among 257 patients with gastric cancer, 27 cases (10.51%) suffered from delayed hemorrhage after ESD. Of 368 patients with esophageal cancer, 23 cases had delayed bleeding after ESD, with an incidence of 6.25%. Compared with the non-occurrence group A, the proportions of gastric body involvement, the lesion size ≥ 20 mm, presence of large blood vessels within the submucosa, submucous fibrosis, operative duration ≥ 60 min, and long-term use of anticoagulant drugs were higher and the proportion of patients with the depth of tumor invasion limited to the mucosal layer was lower in the occurrence group A (P < 0.05). The multivariable Logistic regression analysis showed that presence of large blood vessels within the submucosa [O^R = 3.838 (95% CI: 1.687, 8.731) ], submucous fibrosis [O^R = 3.511 (95% CI: 1.544, 7.988) ], operative duration ≥ 60 min [O^R = 2.821 (95% CI: 1.240, 6.417) ] and long-term use of anticoagulant drugs [O^R = 4.415 (95% CI: 1.941, 10.043) ] were factors affecting the occurrence of delayed bleeding after ESD in patients with gastric cancer (P < 0.05). The proportions of patients with the depth of tumor invasion reaching the submucosal layer, the lesion size ≥ 40 mm, circumferential resection, presence of large blood vessels within the submucosa, submucous fibrosis, operative duration ≥ 60 min, and long-term use of anticoagulant drugs in the occurrence group B were higher than those in the non-occurrence group B (P < 0.05). Multivariable Logistic regression analysis revealed that presence of large blood vessels within the submucosa [O^R = 3.056 (95% CI: 1.343, 6.951) ], operative duration ≥ 60 min [O^R = 3.607 (95% CI: 1.586, 8.206) ], and long-term use of anticoagulant drugs [O^R = 4.104 (95% CI: 1.804, 9.336) ] were factors affecting the occurrence of delayed bleeding after ESD in patients with esophageal cancer (P < 0.05).Conclusions Among patients with early cancer of the gastrointestinal tract, those with large blood vessels within the submucosa, operative duration ≥ 60 min, and long-term use of anticoagulant drugs have a higher risk for delayed bleeding after ESD.