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中华胃肠内镜电子杂志 ›› 2021, Vol. 08 ›› Issue (02): 51 -56. doi: 10.3877/cma.j.issn.2095-7157.2021.02.002

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早期胃癌内镜黏膜下剥离术术中出血分级评估及相关因素分析
丁樑 1, 陈伟 2, 俞静华 2, 章粉明 2, 许国强 2 , ( )   
  1. 1. 310000 杭州,浙江大学医学院附属第一医院消化内科;312000 绍兴,绍兴市人民医院(浙江大学绍兴医院)消化内科
    2. 310000 杭州,浙江大学医学院附属第一医院消化内科
  • 收稿日期:2020-09-24 出版日期:2021-05-15
  • 通信作者: 许国强
  • 基金资助:
    浙江省医学重点学科(G3222)

Evaluation of intraoperative bleeding grading and related factors of ESD treatment for early gastric cancer

Liang Ding 1, Wei Chen 2, Jinghua Yu 2, Fenming Zhang 2, Guoqiang Xu 2 , ( )   

  1. 1. Department of Gastroenterology, First Affiliated Hospital of Zhejiang University, Hangzhou 310000, China; Department of Gastroenterology, Shaoxing People′s Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Hangzhou 312000, China
    2. Department of Gastroenterology, First Affiliated Hospital of Zhejiang University, Hangzhou 310000, China
  • Received:2020-09-24 Published:2021-05-15
  • Corresponding author: Guoqiang Xu
目的

评估早期胃癌内镜黏膜下剥离术(ESD)术中出血的分级及意义,并探究与术中出血分级相关的危险因素。

方法

回顾性分析2012年1月至2018年12月经浙江大学附属第一医院消化内镜中心行ESD治疗,并具有早期胃癌诊断依据的病例资料。根据术中止血方式对病例进行术中出血分级(J0-3),评估ESD术中出血特点,比较J0-2组与J3组组间ESD完成情况的差异,采用Logistic回归模型分析J3发生的相关因素。

结果

共纳入231例患者,J0-2病例占83.1%;J3组有3例患者未完成ESD操作,J0-2组无未完成ESD病例。相对J0-2组,J3组患者完整切除率低(52.8% vs 86.5%,P<0.01),追加手术率高(25% vs 10.9%, P=0.03)。单因素Logistic回归分析显示,胃角、胃体、贲门-胃底病灶,浸润达黏膜肌层及以下,病理类型为中-低分化癌是J3发生的高危因素。多因素Logistic回归显示,胃角、胃体、贲门-胃底病灶是J3发生的独立预测因素。

结论

ESD治疗早期胃癌术中出血方式分级通常为J0-2级;当术中出血分级达J3时会降低ESD完整切除率,增加追加手术率;非胃窦部位病灶是J3发生的独立预测因素。

Objective

To evaluate the intraoperative bleeding grading, significance and probe the risk factors of ESD treatment for early gastric cancer.

Methods

A retrospective analysis was performed on data of early gastric cancer cases that underwent ESD at the Digestive Endoscopy Center of the First Affiliated Hospital of Zhejiang University from January 2012 to December 2018. The intraoperative hemorrhage classification (J0-3) was used to evaluate the bleeding characteristics during ESD operation. The differences in ESD completion between J0-2 and J3 groups were compared and Logistic regression models were used to analyze the risk factors of J3.

Results

A total of 231 patients were included and J0-2 cases accounted for 83.1%. Three patients in the J3 group did not complete the ESD operation and the J0-2 group had no uncompleted cases. Compared with the J0-2 group, J3 group had lower complete resection rate (52.8% vs 86.5%, P<0.01), but higher additional surgery rate (25% vs 10.9%, P=0.03). Univariate Logistic regression analysis showed that the gastric horn, body, and cardia-fundus lesions, infiltrated into the mucosal muscle layer and below, moderate-low differentiated carcinoma was a risk factor for J3. Multivariate Logistic regression showed that gastric horn, body and cardia-fundus lesions were independent predictors of J3.

Conclusion

The intraoperative hemorrhage grade of ESD treatment for early gastric cancer is usually J0-2 grade. When the intraoperative hemorrhage grade reaches J3, the complete resection rate of ESD will be reduced and the additional operation rate will be increased. The non-antrum gastric lesion is an independent predictor of J3 occurrence.

表1 早期胃癌ESD术中出血分级(n)
表2 早期胃癌不同术中出血分级对ESD完成程度的影响
表3 早期胃癌不同术中出血分级的临床资料特点
表4 不同术中出血分级危险因素的Logistic回归分析
项目 单因素分析OR值(95%CI) P 多因素分析OR值(95%CI) P
部位        
  胃窦 1.00   1.00  
  胃角 4.04(1.52~10.72) <0.01 4.25(1.45~12.45) <0.01
  胃体 2.78(1.04~7.41) 0.04 3.53(1.21~10.30) 0.02
  贲门-胃底 3.89(1.47~10.29) <0.01 3.65(1.21~11.30) 0.02
切除大小        
  长径 1.02(0.83~1.27) 0.83 0.93(0.72~1.21) 0.61
  长径/短径 3.09(0.97~9.83) 0.06 3.48(0.84~14.44) 0.09
  萎缩性胃炎(是/否) 1.33(0.63~2.84) 0.46 1.70(0.72~4.02) 0.23
  术前EUS(是/否) 0.89(0.45~1.79) 0.75 0.67(0.30~1.49) 0.33
病灶状态        
  无糜烂或溃疡 1.00   1.00  
  糜烂 0.82(034~2.00) 0.67 0.76(0.28~2.06) 0.60
  溃疡 0.78(0.35~1.71) 0.53 0.51(0.19~1.39) 0.19
大体形态        
  Ⅰ类 1.44(0.57~3.64) 0.44 1.51(0.50~4.61) 0.47
  Ⅱ类 1.00   1.00  
  Ⅲ类 2.47(0.87~7.02) 0.09 2.64(0.73~9.58) 0.14
浸润深度        
  黏膜肌层以上 1.00   1.00  
  黏膜肌层及以下 2.16(1.06~4.40) 0.04 1.86(0.75~4.60) 0.18
病理类型        
  高分化 1.00   1.00  
  中-低分化 2.13(1.03~4.39) 0.04 2.20(0.88~5.54) 0.09
伴随疾病        
  高血压(是/否) 1.04(0.51~2.11) 0.91 0.94(0.40~2.18) 0.88
  糖尿病(是/否) 0.98(0.32~3.05) 0.98 1.02(0.27~3.85) 0.97
  其它慢性病(是/否) 1.28(0.52~3.19) 0.59 1.47(0.46~4.66) 0.52
1月内抗凝或抗血小板药物史(是/否) 1.24(0.25~6.09) 0.79 0.86(0.13~5.92) 0.88
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