结直肠内镜黏膜下剥离术中出血的危险因素分析  

Risk factors for intraoperative hemorrhage during endoscopic submucosal dissection for colorectal lesions

作　　者：杨蓉蓉 张明远[1] 张健 王奕平[1] 何战鹏[1] 张鑫辰 贾冠华 王冬妮 王雅丽[1] Yang Rongrong;Zhang Mingyuan;Zhang Jian;Wang Yiping;He Zhanpeng;Zhang Xinchen;Jia Guanhua;Wang Dongni;Wang Yai(Department of Gastroenterology,The Third People's Hospital of Datong,Datong 037008,China.)

机构地区：[1]大同市第三人民医院消化内科,大同037008

出　　处：《中华消化内镜杂志》2023年第2期131-139,共9页Chinese Journal of Digestive Endoscopy

基　　金：山西省重点研发计划社发领域项目(201903D321142)。

摘　　要：目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)治疗结直肠病变并发术中出血情况, 并分析其危险因素。方法回顾分析2019年12月-2021年8月大同市第三人民医院及其合作单位南京鼓楼医院行结直肠ESD治疗的386例患者病例资料, 按术中出血情况分为出血组(n=85)和未出血组(n=301)。分析患者基本资料、病变相关因素与结直肠ESD术中出血的关系。采用单因素和多因素Logistic回归分析 ESD 术中出血的危险因素。根据筛选的危险因素构建ESD术中出血风险预测模型, 并采用ROC曲线对预测模型进行评价。结果单因素Logistic回归分析显示, 合并糖尿病(OR=2.340, P<0.05)、合并冠心病(OR=3.100, P<0.05)、病灶位于直肠(OR=3.272, P<0.05)、病灶长度越长(OR=1.093, P<0.05)、病灶宽度越宽(OR=1.057, P<0.05)、病灶面积越大(OR=1.126, P<0.05)、病灶形态为凹陷型(OR=6.128, P<0.05)、病灶形态为侧向发育型(OR=2.651, P<0.05)、浸润深度为SM-S癌(OR=0.088, P<0.05)、浸润深度为SM-D癌(OR=0.174, P<0.05)、出血血管直径为0.5~<1.0倍黏膜切开刀直径(OR=246.854, P<0.05)、术后病理类型为早期癌(OR=7.000, P<0.05)因素均与结直肠ESD术中出血相关。考虑到病灶长度、病灶宽度与病灶面积之间存在数量关系, 分别使用病灶长度和病灶面积构造多因素模型, 进行向前逐步回归筛选变量并确定最终模型形式, 结果表明采用合并冠心病、病灶形态为凹陷型、病灶长度越长、病灶面积越大、出血血管直径为0.5~<1.0倍黏膜切开刀直径为结直肠ESD术中出血独立危险因素, 且因两种建模得到的结果相似, 故临床上可选用更为易测的病灶长度以描述病变。结论合并冠心病、病灶形态为凹陷型、病灶长度越长、病灶面积越大、血管直径0.5~<1.0倍黏膜切开刀直径, 为结直肠ESD术中出血独立危险因素。Objective To investigate the risk factors for intraoperative hemorrhage during endoscopic submucosal dissection(ESD)for colorectal lesions.MethodsData of 386 patients with colorectal lesions,who underwent ESD at The Third People's Hospital of Datong and its cooperative hospital,Nanjing Drum Tower Hospital,from December 2019 to August 2021 were retrospectively analyzed.The patients were divided into the hemorrhage group(n=85)and the non-hemorrhage group(n=301)according to intraoperative hemorrhage.The correlationship of patientsbasic information,lesion-related factors and hemorrhage during colorectal ESD was analyzed.Univariate and multivariate logistic regression were used to identify the risk factors for intraoperative hemorrhage during ESD.The risk predictive model of intraoperative hemorrhage during ESD was established according to the screened risk factors,and receiver operator characteristic(ROC)curve was used to evaluate the predictive model.ResultsUnivariate logistic regression showed that a history of diabetes(OR=2.340,P<0.05),a history of coronary atherosclerotic heart diseases(OR=3.100,P<0.05),the lesion located in the rectum(OR=3.272,P<0.05),longer lesion(OR=1.093,P<0.05),wider lesion(OR=1.057,P<0.05),larger lesion(0R=1.126,P<0.05),depressed lesion(OR=6.128,P<0.05),the laterally spreading lesion(0R=2.651,P<0.05),the lesion infiltrated into the SM-S layer(OR=0.088,P<0.05),the lesion infiltrated into the SM-D layer(OR=0.174,P<0.05),the diameter of hemorrhage vessels 0.5-<1.0 times of the diameter of incision knife(OR=246.854,P<0.05),the postoperative pathology as early cancer(OR=7.000,P<0.05)were risk factors for intraoperative hemorrhage during ESD.Considering the quantitative relationship between the length,the width and the area of lesions,multi-factor models were constructed using the length and area of lesions respectively.Forward stepwise regression was used to screen variables and determine the final model,and the results showed that a history of coronary atherosclerotic heart diseases,the depress

关 键 词：手术中并发症 出血 结肠内窥镜 危险因素 内镜黏膜下剥离术 

分 类 号：R656[医药卫生—外科学]