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中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2020, Vol. 09 ›› Issue (04) : 377 -386. doi: 10.3877/cma.j.issn.2095-3224.2020.04.009

所属专题： 文献；

论著

结直肠肿物内镜下切除术后发生迟发性出血危险因素的Meta分析
许炎钦1, 林峥嵘1, 钟世顺1, 林晓露1, 梁玮1,†()   
  1. 1. 350108　福建医科大学省立临床医学院；350001　福州，福建省立医院消化内镜中心
  • 收稿日期:2019-12-27 出版日期:2020-08-25
  • 通信作者: 梁玮
  • 基金资助:
    福建省中青年骨干项目(No. 2018-ZQN-11)

Meta-analysis of the risk factors for delayed bleeding after endoscopic resection of colorectal tumors

Yanqin Xu1, Zhengrong Lin1, Shishun Zhong1, Xiaolu Lin1, Wei Liang1,†()   

  1. 1. Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350108, China; Department of Gastrointestinal Endoscopy, Fujian Provincial Hospital, Fuzhou 350001, China
  • Received:2019-12-27 Published:2020-08-25
  • Corresponding author: Wei Liang
  • About author:
    Corresponding author: Liang Wei, Email:
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引用本文：

许炎钦, 林峥嵘, 钟世顺, 林晓露, 梁玮. 结直肠肿物内镜下切除术后发生迟发性出血危险因素的Meta分析[J]. 中华结直肠疾病电子杂志, 2020, 09(04): 377-386.

Yanqin Xu, Zhengrong Lin, Shishun Zhong, Xiaolu Lin, Wei Liang. Meta-analysis of the risk factors for delayed bleeding after endoscopic resection of colorectal tumors[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2020, 09(04): 377-386.

目的

探讨结直肠肿物内镜下切除术后发生迟发性出血的危险因素。

方法

通过计算机检索2012年1月至2018年12月Pubmed、Cochrane、Embase、CNKI数据库、万方数据库中与结直肠肿物内镜下切除术后发生迟发性出血的危险因素相关文献，采用RevMan 5.3版软件进行统计处理，对纳入资料的异质性进行分析，计算OR值和95%可信区间。

结果

共纳入文献17篇，总例数6 689例，其中364例发生了内镜下切除术后迟发性出血（ESD193例，EMR119例，EPMR52例），总发生率为5.45%。Meta分析结果显示：肿物位于近端结肠（OR：1.83，95%CI：1.31~2.56；P=0.0004）、抗血栓药物使用史（OR：1.61，95%CI：1.19~2.18；P=0.002）、组织学为高级别上皮内瘤变或早癌（OR：0.63，95%CI：0.45~0.89；P=0.009）、分块切除（OR：2.71，95%CI：1.32~3.51；P=0.002）、术中出血（OR：2.52，95%CI：1.56~4.10；P=0.0002）、未置入止血夹（OR：2.19，95%CI：1.20~3.99；P=0.01）、黏膜下重度纤维化（OR：3.67，95%CI：2.02~6.65；P<0.0001）为内镜下切除术后发生迟发性出血的危险因素。而年龄、性别、病灶大小、病灶形态、是否有合并症不是迟发性出血的危险因素。

结论

结直肠肿物病灶位于近端结肠、抗血栓药物使用史、组织学为高级别上皮内瘤变或早癌、分块切除、术中出血、未置入止血夹、黏膜下重度纤维化为内镜下切除术后发生迟发性出血的主要危险因素。

关键词: 内镜下切除, 结直肠, 迟发性出血, 危险因素
Objective

To investigate the risk factors for delayed bleeding after endoscopic resection of colorectal tumors.

Methods

The literature on the risk factors of delayed bleeding after endoscopic resection of colorectal tumors was retrieved combined with manual retrieval from Pubmed, Cochrane, Embase, China National Knowledge Infrastructure (CNKI) and Wanfang Database published January 2012 to December 2018. Pooled odds ratio (OR) and 95% confidence intervals (95%CI) were calculated and the heterogeneity was also assessed.

Results

A total of 17 published studies were included, with total of 6 689 cases, of which 364 cases developed delayed bleeding after endoscopic resection (ESD 193 cases, EMR 119 cases, EPMR 52 cases), Meta analysis showed that the tumor located in the proximal colon (OR: 1.83, 95% CI: 1.31~2.56; P=0.0004), history of antithrombotic drugs (OR: 1.61, 95%CI: 1.19~2.18; P=0.002), high grade intraepithelial neoplasia or early cancer (OR: 0.63, 95%CI: 0.45~0.89; P=0.009), resection method (OR: 2.71, 95% CI: 1.32~3.51; P=0.002), bleeding during operation (OR: 2.52, 95% CI: 1.56~4.10; P=0.0002), no clip placement (OR: 2.19, 95% CI: 1.20~3.99; P=0.01), and severe submucosal fibrosis (OR: 3.67, 95% CI: 2.02~6.65; P<0.0001) were the risk factors for delayed bleeding after endoscopic resection. Moreover, age, sex, lesion size, morphology, comorbidity were not associated with delayed bleeding.

Conclusion

Colorectal tumor located in the proximal colon, history of anti-thrombotic drug, high grade intraepithelial neoplasia or early cancer, piecemeal resection, intraoperative hemorrhage, no clip placement, severe submucosal fibrosis were the risk factors for delayed bleeding after endoscopic resection.

Key words: Endoscopic resection, Colorectal, Delayed bleeding, Risk factors
图1 流程图
表1 纳入文献的一般情况及文献特征
第一作者 年份 国家 题目 出血情况（出血例数/总例数） ESD EPMR EMR NOS评分
Okamoto[3] 2017 日本 Risk Factors for Postoperative Bleeding in Endoscopic Submucosal Dissection of Colorectal Tumors 14/451 14/451 ? ? 6
Arimoto[14] 2017 日本 Continued Use of a Single Antiplatelet Agent Does Not Increase the Risk of Delayed Bleeding After Colorectal Endoscopic Submucosal Dissection 31/919 31/919 ? ? 7
Matsumoto1[2] 2012 日本 Risk Factors for Delayed Bleeding After Endoscopic Resection for Large Colorectal Tumors 17/403 ? 11/214 6/189 7
Ji-Yun Hong[18] 2018 韩国 Risk factors for procedure-related complications after endoscopic resection of colorectal laterally spreading tumors 44/594 11/209 ? 33/385 7
Ogasawara[4] 2016 日本 Clinical risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal tumors in Japanese patients 10/124 10/124 ? ? 7
Ninomiya[26] 2015 日本 Risk of bleeding after endoscopic submucosal dissection for colorectal tumors in patients with continued use of low-dose aspirin 35/607 35/607 ? ? 7
Terasaki[24] 2014 日本 Risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal neoplasms 25/377 25/377 ? ? 8
Burgess[6] 2014 澳大利亚 Risk Factors for Intraprocedural and Clinically Significant Delayed Bleeding After Wide-field Endoscopic Mucosal Resection of Large Colonic Lesions 73/1171 ? ? 73/1171 7
Yamamoto[25] 2018 日本 Perforation and Postoperative Bleeding Associated with Endoscopic Submucosal Dissection in Colorectal Tumors:An Analysis of 398 Lesions Treated in Saga, Japan 19/398 19/398 ? ? 7
Dokoshi[27] 2015 日本 A Randomized Study on the Effectiveness of Prophylactic Clipping during Endoscopic Resection of Colon Polyps for the Prevention of Delayed Bleeding 7/288 ? ? 5/234 7
Metz[7] 2011 澳大利亚 Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions 21/302 ? 19/196 2/87 6
Elliott[28] 2018 英国 Factors associated with delayed bleeding after resection of large nonpedunculated colorectal polyps 22/330 ? 22/330 ? 7
Sho Suzuki[5] 2014 日本 Risk factors for bleeding after endoscopic submucosaldissection of colorectal neoplasms 14/311 14/311 ? ? 8
Cheng-fu Wu[29] 2018 中国 Analysis of risk factors of delayed bleeding after endoscopic submucosal dissection for early colorectal cancer and precancerous lesion 9/102 9/102 ? ? 6
Hong-Bo Wang[30] 2018 中国 Analysis of risk factors of delayed bleeding after endoscopic submucosal dissection for early colorectal cancer and precancerous lesion 10/138 10/138 ? ? 6
Da-Peng Wu[31] 2018 中国 Risk Analysis of Bleeding of Endoscopic Submucosal dissection for Colorectal Tumors 8/119 8/119 ? ? 6
Jie Lin[32] 2014 中国 Analysis of Risk Factors for Delayed Bleeding after ESD in Patients with Colorectal Cancer 7/128 7/128 ? ? 6
? ? ? 共计 364/6 689 193 52 119 ?
图2 结直肠肿物ESD术后迟发性出血率的Meta分析
图3 抗栓药物对结直肠肿物内镜术后迟发性出血的影响
图4 病灶位置对结直肠肿物内镜术后迟发性出血的影响
图5 组织病理学在结直肠肿物内镜术后迟发性出血的影响
图6 黏膜下纤维化在结直肠肿物内镜术后迟发性出血的影响
图7 切除方式在结直肠肿物内镜术后迟发性出血的影响
图8 术中出血在结直肠肿物内镜术后迟发性出血的影响
图9 止血夹置入在结直肠肿物内镜术后迟发性出血的影响
图10 组织病理学
表2 结直肠肿物内镜切除术后迟发性出血危险因素Meta分析结果
危险因素 文献数 OR（FE）值 95%CI 异质性检验 总体效应检验 Egger（P） 敏感性分析
P值 I2（%） Z值 P值 OR（RE）值 95%CI
年龄 11 0.20 （-1.0~1.4） 0.70 0% 0.33 0.74 0.04 0.20 （-1.0~1.4）
性别 13 1.09 （0.81~1.45） 0.80 0% 0.55 0.58 0.096 1.04 （0.77~1.41）
合并症 9 0.85 （0.52~1.40） 0.38 6% 0.64 0.52 0.081 0.84 （0.50~1.42）
抗血栓药物使用史 14 1.61 （1.19~2.18） 0.19 24% 3.05 0.002 0.313 1.67 （1.14~2.45）
病灶大小 9 0.49 （-1.41~2.38） 0.10 40% 0.50 0.61 0.127 1.19 （-1.7~4.08）
病灶位置 7 1.83 （1.31~2.56） 0.48 0% 3.52 0.0004 0.896 1.85 （1.31~2.61）
病灶形态（隆起型与LST） 6 0.62 （0.27~1.42） 0.96 0% 1.13 0.26 ? 0.66 （0.29~1.51）
病灶形态（LST-NG与LST-G） 9 1.35 （0.94~1.94） 0.66 0% 1.62 0.11 0.067 1.28 （0.88~1.85）
组织病理学 10 0.63 （0.45~0.89） 0.18 29% 2.60 0.009 0.746 0.64 （0.43~0.97）
粘膜下纤维化 4 0.27 （0.15~0.49） 0.25 28% 4.28 <0.0001 ? 0.23 （0.11~0.48）
切除方式 5 2.17 （1.32~3.57） 0.65 0% 3.07 0.002 ? 2.17 （1.32~3.57）
术中出血 5 2.52 （1.56~4.10） 0.20 33% 3.75 0.0002 ? 3.40 （1.66~6.98）
止血夹置入 4 0.46 （0.25~0.83） 0.13 48% 2.56 0.01 ? 0.46 （0.25~0.83）
表3 结直肠肿物内镜切除术后迟发性出血危险因素Meta回归结果
危险因素 自变量
发表年份 研究类型 平均年龄 国家
年龄 P=0.949 P=0.836 / P=0.998
性别 P=0.331 P=0.331 P=0.520 P=0.635
合并症 P=0.846 P=0.695 P=0.853 P=0.767
抗血栓药物 P=0.997 P=0.376 P=0.326 P=0.501
病灶形态（LST-NG与LST-G） P=0.119 P=0.336 P=0.252 P=0.206
病灶大小 P=0.997 P=0.948 P=0.869 P=0.961
组织病理学 P=0.118 P=0.067 P=0.427 P=0.771
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