消化道黏膜肿瘤患者EMR术后迟发性出血危险因素分析

doi:10.11958/20252631

摘要/Abstract

摘要：

目的探讨消化道黏膜肿瘤患者内镜黏膜切除术（EMR）术后迟发性出血的危险因素，并构建列线图预测模型。方法回顾性分析2020年5月—2023年9月在哈尔滨市第二医院行EMR的消化道黏膜肿瘤患者临床资料，以术后30 d发生迟发性出血的160例患者作为出血组，采用1∶2简单随机抽样法，从同期术后未出血的患者中抽取320例作为未出血组。比较2组患者的临床资料，多因素Logistic回归分析EMR术后迟发性出血的危险因素，建立术后迟发性出血列线图模型，受试者工作特征（ROC）曲线分析预测效能，校准曲线评估模型校准度，临床决策曲线分析（DCA）评估模型净获益。结果与未出血组比，出血组的年龄、合并高血压比例、肿瘤直径、切除面积、术中出血和术后抗凝药使用率更大，术前凝血酶原时间（PT）、抗凝药物停药时间、术后抗凝药物持续时间更长，术前活检次数更多（P<0.05）。Logistic回归分析结果显示，患者年龄增大、术前活检次数增多和术中出血是消化道黏膜肿瘤患者术后30 d迟发性出血的危险因素（P<0.05）。基于上述因素构建列线图模型，其预测术后迟发性出血的ROC曲线下面积（AUC）为0.906（95%CI：0.804~0.951），提示预测判别效能较高；校准曲线显示模型预测概率与实际出血率一致性良好，Hosmer-Lemeshow检验P=0.352，证实模型校准度稳定；DCA显示模型在广泛阈值概率内具有临床净获益。结论基于独立危险因素构建的列线图预测模型具有较高的预测效能与判别能力，可为临床术前风险分层、围术期个体化管理提供参考。

关键词: 消化系统肿瘤, 黏膜, 内窥镜黏膜切除术, 列线图, 迟发性出血

Abstract:

Objective To explore the risk factors of delayed bleeding in patients with gastrointestinal mucosal tumors after endoscopic mucosal resection (EMR), and to construct the nomogram prediction model. Methods A retrospective analysis was performed on clinical data of patients with gastrointestinal mucosal tumors who underwent EMR in Harbin Second Hospital between May 2020 and September 2023. Among all patients, 160 cases with delayed bleeding within 30 d after surgery were enrolled as the bleeding group, while 320 cases from patients without bleeding during the same period were enrolled as the non-bleeding group according to 1∶2 simple and random sampling method. The clinical data were compared between the two groups. The risk factors of delayed bleeding after EMR were analyzed by multivariate Logistic regression analysis. The nomogram model for postoperative delayed bleeding was constructed. Its predictive efficiency was analyzed by receiver operating characteristic (ROC) curves, calibration degree of the model was evaluated by calibration curves, and the net benefit of the model was evaluated by clinical decision curve analysis (DCA). Results Compared with the non-bleeding group, patient age, proportion of hypertension, tumor diameter, resection area, intraoperative blood loss and postoperative usage rate of anticoagulant agents were higher, and preoperative prothrombin time (PT), withdrawal time of anticoagulant drugs and postoperative duration of anticoagulant drugs were longer, and frequency of preoperative biopsy was higher in the bleeding group (P<0.05). Results of Logistic regression analysis showed that increased age and frequency of preoperative biopsy and intraoperative bleeding were risk factors of delayed bleeding within 30 d after surgery (P<0.05). The area under ROC curve (AUC) of the nomogram model constructed based on the above factors was 0.906 (95%CI: 0.804-0.951), showing high predictive and discriminative efficiency. The calibration curve showed that the consistency between the model and actual condition for predicting bleeding rate was good. Hosmer-Lemeshow test with P=0.352 confirmed the stability of model calibration. DCA revealed that the model achieved clinical net benefit across a wide range of threshold probabilities. Conclusion The nomogram prediction model constructed based on independent risk factors has high predictive efficiency and discriminative ability, which can provide reference for preoperative risk stratification and perioperative individualized management in clinical practice.

Key words: gastrointestinal tumor, mucosa, endoscopic mucosal resection, nomogram, delayed bleeding

中图分类号:

R619.3

图/表 6

参考文献 25

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组别	n	年龄/岁			男性			合并基础病						肿瘤直径/cm			肿瘤部位
组别	n	年龄/岁			男性			高血压		糖尿病			冠心病	肿瘤直径/cm			胃窦			胃体			贲门胃底		结肠			直肠
未出血组	320	61.78±8.18			161（50.3）			37（11.6）		21（6.6）			25（7.8）	4.26±1.24			36（11.2）			122（38.1）			51（38.1）		69（21.6）			42（13.1）
出血组	160	66.78±8.43			81（50.6）			34（21.2）		11（6.9）			13（8.1）	4.82±1.23			18（11.3）			61（38.1）			26（16.3）		35（21.9）			20（12.5）
t或χ²		6.248^＊＊			0.004			7.942^＊＊		0.017			0.014	4.646^＊＊			0.044
组别			肿瘤良恶性						术前 PT/s		术前 APTT/s				术前PLT/ （×10⁹/L）			抗凝药物停药时间/d			术前活检次数/次			切除面积/cm²			术中出血
组别			良性			恶性			术前 PT/s		术前 APTT/s				术前PLT/ （×10⁹/L）			抗凝药物停药时间/d			术前活检次数/次			切除面积/cm²			术中出血
未出血组			256（80.0）			64（20.0）			12.11±1.02		29.98±2.39				215.36±44.53			4.74±1.30			2.00（1.00，3.00）			4.26±1.43			50（15.6）
出血组			128（80.0）			32（20.0）			12.37±1.15		30.20±2.47				216.32±49.53			5.30±1.72			3.00（2.00，4.00）			4.91±1.65			72（45.0）
t、χ²或Z			0.000						2.547^＊		0.948				0.213			3.968^＊＊			5.779^＊＊			4.474^＊＊			48.554^＊＊
组别				术中使用钛夹			钛夹使用数量/枚					钛夹类型							术中使用肾上腺素			术后应用抗凝药				术后抗凝药物持续时间/d
组别				术中使用钛夹			钛夹使用数量/枚					金属				可吸收			术中使用肾上腺素			术后应用抗凝药				术后抗凝药物持续时间/d
未出血组				84（26.2）			2.12±0.73					50（15.6）				270（84.4）			97（30.3）			199（62.2）				5.03±1.29
出血组				42（26.3）			2.18±0.79					28（17.5）				132（82.5）			49（30.6）			28（93.7）				5.34±1.99
t或χ²				0.000			0.775					0.276							0.005			85.455^＊＊				2.052^＊＊

组别	n	年龄/岁			男性			合并基础病						肿瘤直径/cm			肿瘤部位
组别	n	年龄/岁			男性			高血压		糖尿病			冠心病	肿瘤直径/cm			胃窦			胃体			贲门胃底		结肠			直肠
未出血组	320	61.78±8.18			161（50.3）			37（11.6）		21（6.6）			25（7.8）	4.26±1.24			36（11.2）			122（38.1）			51（38.1）		69（21.6）			42（13.1）
出血组	160	66.78±8.43			81（50.6）			34（21.2）		11（6.9）			13（8.1）	4.82±1.23			18（11.3）			61（38.1）			26（16.3）		35（21.9）			20（12.5）
t或χ²		6.248^＊＊			0.004			7.942^＊＊		0.017			0.014	4.646^＊＊			0.044
组别			肿瘤良恶性						术前 PT/s		术前 APTT/s				术前PLT/ （×10⁹/L）			抗凝药物停药时间/d			术前活检次数/次			切除面积/cm²			术中出血
组别			良性			恶性			术前 PT/s		术前 APTT/s				术前PLT/ （×10⁹/L）			抗凝药物停药时间/d			术前活检次数/次			切除面积/cm²			术中出血
未出血组			256（80.0）			64（20.0）			12.11±1.02		29.98±2.39				215.36±44.53			4.74±1.30			2.00（1.00，3.00）			4.26±1.43			50（15.6）
出血组			128（80.0）			32（20.0）			12.37±1.15		30.20±2.47				216.32±49.53			5.30±1.72			3.00（2.00，4.00）			4.91±1.65			72（45.0）
t、χ²或Z			0.000						2.547^＊		0.948				0.213			3.968^＊＊			5.779^＊＊			4.474^＊＊			48.554^＊＊
组别				术中使用钛夹			钛夹使用数量/枚					钛夹类型							术中使用肾上腺素			术后应用抗凝药				术后抗凝药物持续时间/d
组别				术中使用钛夹			钛夹使用数量/枚					金属				可吸收			术中使用肾上腺素			术后应用抗凝药				术后抗凝药物持续时间/d
未出血组				84（26.2）			2.12±0.73					50（15.6）				270（84.4）			97（30.3）			199（62.2）				5.03±1.29
出血组				42（26.3）			2.18±0.79					28（17.5）				132（82.5）			49（30.6）			28（93.7）				5.34±1.99
t或χ²				0.000			0.775					0.276							0.005			85.455^＊＊				2.052^＊＊

变量	β	SE	Wald χ²	P	OR	OR95%CI
年龄	0.080	0.014	31.645	<0.001	1.084	1.057~1.114
术前活检次数	0.464	0.107	25.253	<0.001	1.709	1.387~2.107
术中出血	1.645	0.246	44.802	<0.001	5.179	3.199~8.382
常数项	-7.677	0.994	59.696	<0.001	0.000	-

变量	β	SE	Wald χ²	P	OR	OR95%CI
年龄	0.080	0.014	31.645	<0.001	1.084	1.057~1.114
术前活检次数	0.464	0.107	25.253	<0.001	1.709	1.387~2.107
术中出血	1.645	0.246	44.802	<0.001	5.179	3.199~8.382
常数项	-7.677	0.994	59.696	<0.001	0.000	-