胃早癌患者内镜下黏膜剥离术后二次内镜检查的临床影响

Clinical effect of second-look endoscopy in patients with early gastric cancer after ESD

摘要:

目的??评价二次内镜是否能够预防内镜下黏膜剥离术（ESD）伴迟发性出血及确定何种病变需要二次内镜检查。方法?共纳入2014年10月-2016年9月经组织学诊断的胃早癌患者98例，ESD术后24 h出现黏膜破损相关性出血认为是迟发性出血。回顾性研究患者病变及手术相关因素，行二次内镜检查前后的出血率。结果?98例患者整块切除率为100.0%，所有病灶切缘为阴性，无消化道穿孔及死亡严重并发症发生。ESD术后迟发性出血发生率5.1%（5/98），均已在二次内镜下成功止血，无1例手术、迟发性出血阴性者，随访无再出血发生。40.0%迟发性出血者（2/5）给予输血。ESD术后二次内镜检查的时间中位数是术后第2天（1～3 d），5例ESD术后迟发性出血患者出血时间中位数是术后第1天（1～10 d），手术持续时间中位数是75 min（60～150 min），预测成功率94.9%。单因素分析结果表明；年龄[（69.6±7.9）vs（60.9±10.1）岁，P =0.003]，手术时间[（90.0±41.0）vs（66.0±42.0）min，P =0.000]是迟发性出血组和无出血组的2个危险因素。二元Logistic回归分析显示：手术时间（OR=1.07，95%CI：0.73～14.63，P =0.010）是ESD迟发性出血唯一预测因素。结论?二次内镜检查预防胃ESD术后迟发性出血可能有效，尤其在ESD术后48 h内，操作时间是胃ESD术后迟发性出血的独立危险因素。

Abstract:

Objective?To evaluate whether second-look endoscopy could prevent endoscopic submucosal dissection complicated with delayed bleeding and to clarify what kind of lesions that need second-look endoscopy.?Methods?98 patients with early gastric cancer by histological diagnosis from Oct. 2014 to Sep. 2016 were included in this study. Mucosal damage related bleeding within 24 h after ESD was considered delayed bleeding. Clinical data of patients, lesions, surgical factors, and the incidences of bleeding before and after the second endoscopy examination were retrospectively studied.?Results?The en bloc resection rate of 98 patients was 100.0%, and all incisal margins were negative. No gastrointestinal perforation, death or severe complications occurred. 5.1% of the patients (5/98) occurred delayed bleeding after ESD and had been successfully stopped in a second-look endoscopy, and none received operations. No delayed bleeding occurred in follow-ups of patients with negative delayed bleeding. 40.0 % of the patients (2/5) with delayed bleeding received blood transfusion. The median time of second-look endoscopy after ESD was the second day after operation (1 ~ 3 d). The median bleeding time of 5 patients with delayed bleeding after ESD was the first day after operation (1 ~ 10 d). The median duration of surgery was 75 min (60~150 min), and the prediction success rate was 94.9 %. The results of univariate analysis showed that age [(69.6 ± 7.9) vs (60.9 ± 10.1) years old, P = 0.003] and operation time [(90.0 ± 41.0) vs (66.0 ± 42.0) min, P = 0.000] were both the risk factors in delayed bleeding and non-bleeding group. Binary Logistic regression analysis showed that operation time (OR=1.07; 95%CI:0.73 ~ 14.63, P = 0.010) was the only predictor of delayed bleeding after ESD.?Conclusions?Second-look endoscopy might be effective in preventing delayed bleeding after gastric ESD, especially within 48 hours after ESD. The operation time was an independent risk factor for delayed bleeding after gastric ESD.