陈佳园 陈怡 陈成帷 张益光

[摘要] 目的 探讨抗栓药物对内镜黏膜下剥离术（ESD）术后出血的影响。 方法 选取2016年1月至2020年12月期间接受ESD治疗的患者纳入本研究，分析抗栓药物对ESD术后出血的影响。 结果 肝素替代治疗（HR）、多重抗栓药物、切除标本直径超过38 mm、病灶位于胃上1/3均为术后出血的危险因素，连续使用阿司匹林不是术后出血的危险因素。在单抗血栓药物组，持续组与停药组的出血率比较，差异无统计学意义（4.5% vs. 4.4%，P=1.000）;在多种抗血栓药物组，持续组出血率高于停药组（66.7% vs. 14.8%，P=0.020）。 结论 ESD术后出血风险与抗栓药物种类、组合、使用方法相关。在抗血栓药物ASA停用或连续使用的情况下，可行胃ESD术。使用多种抗栓药物或HR会增加ESD术后出血的风险。

[关键词] 抗栓药物;内镜黏膜下剥离术;术后出血;危险因素;药物管理

[中图分类号] R735.2          [文獻标识码] B          [文章编号] 1673-9701（2021）34-0105-04

[Abstract] Objective To investigate the effect of antithrombotic drugs on postoperative bleeding after endoscopic submucosal dissection （ESD）. Methods Patients who received ESD from January 2016 to December 2020 were included in this study. The effect of antithrombotic drugs on bleeding after ESD was analyzed. Results Heparin replacement therapy （HR），multiple antithrombotic drugs， the diameter of excised specimen exceeding 38 mm，and the focus located in the upper third of the stomach were all risk factors for postoperative bleeding. Continuous administration of aspirin was not a risk factor for postoperative bleeding.In the monotherapy antithrombotic drug group， there was no significant difference in bleeding rate between the continuous group and the drug withdrawal group （4.5% vs. 4.4%，P=1.000）. In the multi-antithrombotic drug group，the bleeding rate in the continuous group was higher than that in the drug withdrawal group （66.7% vs. 14.8%，P=0.020）. Conclusion The risk of bleeding after ESD is related to the type，combination and use of antithrombotic drugs. Gastric ESD is feasible when ASA， an antithrombotic drug， is discontinued or used continuously. The use of multiple antithrombotic drugs or HR will increase the risk of bleeding after ESD.

[Key words] Antithrombotic drugs; Endoscopic submucosal dissection; Postoperative bleeding; Risk factor; Drug management

内镜黏膜下剥离术（ESD）广泛应用于早期胃癌的治疗[1]。荟萃分析显示，术后出血是ESD最常见的并发症，发生率约4.5%，应用抗栓药的患者风险更高[2]。血栓栓塞高危患者停用抗栓药物可能引起严重的血栓事件，因此内镜围术期抗栓药物管理需引起高度关注。日本学者建议针对血栓栓塞高危患者，在持续使用阿司匹林（Acetylsalicylic acid，ASA）单药的情况下进行ESD[3]。美国、英国和欧洲指南也建议血栓栓塞高危患者在继续服用ASA情况下进行ESD[4-5]。少数研究指出单一持续使用抗血小板药物不会增加胃ESD术后出血的风险[6-7]。然而这些研究结果仍存在争议，本研究旨在根据对抗栓药物的管理评估ESD术后出血风险，现报道如下。……