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Talking about the risk factors of delayed healing of ulcer after gastric ESD

Talking about the risk factors of delayed healing of ulcer after gastric ESD

  • Categories:Stomach healthy
  • Author:
  • Origin:
  • Time of issue:2020-12-02
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(Summary description)

Talking about the risk factors of delayed healing of ulcer after gastric ESD

(Summary description)

  • Categories:Stomach healthy
  • Author:
  • Origin:
  • Time of issue:2020-12-02
  • Views:0
Information

  Preface

  Endoscopic submucosal dissection (ESD) is currently recognized as one of the treatment methods for gastric tumors, but this innovative surgical method will inevitably cause iatrogenic ulcers, leading to many adverse events such as pain, bleeding and perforation. Iatrogenic ulcers caused by endoscopic resection have special histological characteristics and heal faster than ordinary peptic ulcers. However, it is reported that persistent ulcers are observed in 5-20% of ESD patients for more than 8 weeks, which can cause delayed bleeding and persistent upper abdominal pain and other potential risk factors, which will seriously affect the quality of life of the patients, which is very frustrating. People worry. This article analyzed the risk factors of delayed ulcer healing after endoscopic submucosal dissection.

  1 Materials and methods

  1.1 Patients

  From January 2005 to February 2011, gastric tumor patients who received ESD treatment at Seoul National University Hospital, including early gastric cancer (EGC) and adenoma.

  1.2 Process

  Patients were injected with PPI intravenously on the day after ESD. From the second day on, the standard dose of PPI was taken orally once a day for 4 weeks. In the absence of signs of bleeding, the patient was discharged the next day. Two weeks later, the patient went to the clinic for a review and assessed the need for delayed bleeding and further surgical resection. When no further surgery is required, perform endoscopy at the 3rd, 6th, and 12th month.

  1.3 Effectiveness evaluation index

  The main efficacy indicator is delayed ulcer healing, which is defined as the active phase or healing phase of the ulcer during the 3-month follow-up. The secondary efficacy indicators are long-term upper abdominal pain and delayed bleeding. Long-term upper abdominal pain is defined as lasting more than 4 weeks. Delayed bleeding is vomiting blood, blood in the stool, or melena within 72 hours after ESD. Massive bleeding is defined as a drop in hemoglobin> 2 g/dL, requiring emergency endoscopic hemostasis or blood transfusion.

  Evaluate Helicobacter pylori (Hp) infection through rapid urease test and gastric antrum and histological examination. When both test results are positive, it is considered positive. Persistent Hp infection is defined as Hp still positive after ESD and 3 months follow-up.

  1.4 Risk factors

  To explore the potential risk factors for delayed ulcer healing, we analyzed the following factors: age (<65 years or ≥65 years), gender, comorbidities that may affect mucosal healing (diabetes, liver cirrhosis, chronic kidney disease or immune disorders), Abnormal blood clotting, history of peptic ulcer, taking antiplatelet or non-steroidal anti-inflammatory drugs, blood abnormalities before ESD (hypoproteinemia, azotemia, anemia or abnormal coagulation), lesions (adenoma or EGC), lesions Differentiation (differentiated or undifferentiated), diameter of excised specimen (<4 or ≥4 cm), Hp infection (continuously positive or not), electrocoagulation during ESD, tumor location (upper, middle, and lower third).

  1.5 Statistical analysis

  Univariate analysis uses chi-square test or Fisher's exact test to analyze categorical variables. The variables with p<0.200 in the univariate analysis were tested by the binary logistic regression model in the multivariate analysis. p<0.050 has a significant difference.

  2 Results and analysis

  2.1 Retrospective analysis

  From January 2005 to February 2011, there were 2039 cases of gastric tumor patients who received ESD treatment, including 983 cases of gastric cancer and 1,056 cases of adenoma. Among them, 346 cases were excluded due to lack of 3-month follow-up endoscopy, 11 cases were due to anticoagulation treatment, and 2 cases were excluded due to bleeding after ESD. The remaining 1680 tumor patients, including 866 adenomas and 814 EGCs, were retrospectively analyzed.

  2.2 Demographics and clinical characteristics

  The average age of the subjects was 62.5 years (29-88 years), and the proportion of men was 71.4% (Table 1). Co-morbidities affecting mucosal healing were found in 282 subjects (16.8%), including diabetes (224 cases), chronic kidney disease (34 cases), liver cirrhosis (33 cases) and immune disorders (19 cases). About 3% of the subjects had a history of peptic ulcer, including 10 cases of duodenal ulcer and 49 cases of gastric ulcer. Twenty-four patients had received Hp eradication treatment, and 5 of them showed Hp infection when the drug was stopped urgently. 321 patients (19.1%) took antiplatelet drugs and 42 patients (2.9%) took non-steroidal anti-inflammatory drugs. 3.8% of subjects had abnormal coagulation function.

  2.3 Tumor and ESD related features

  Among the lesions resected by ESD, 867 cases (51.6%) were EGCs and 814 cases (48.5%) were adenomas (Table 2). Among EGC patients, 6% showed undifferentiated disease. The average size of ESD excised specimens is 4.5cm (0.7-12.0cm). A total of 840 subjects had Hp infection during ESD, of which 462 subjects still had Hp infection during the 3-month follow-up, but eradication treatment was not considered.

  2.4 Incidence of delayed ulcer healing, delayed bleeding and long-term upper abdominal pain

  Among the 1680 subjects, 95 subjects had unhealed ulcers (5.7%) after 3 months. Four cases of active ulcers were followed up for 3 months, of which 1 case still had ulcer healing during 6 months of follow-up.

  There were 20 cases of long-term upper abdominal pain. Among the patients with delayed ulcer healing, 8 patients (8.4%) needed an additional 4-8 weeks of anti-ulcer medication during follow-up due to upper abdominal pain, while 12 patients (0.8%) needed anti-ulcer medication (p=0.001).

  23 patients had delayed bleeding events, all of which occurred more than 72 hours after ESD. The delayed bleeding rate in the delayed healing group (6.7%) was significantly higher than that in the non-delayed healing group (1.1%) (p=0.001). The 6 cases of delayed bleeding in patients with delayed ulcer healing were all major bleeding, which required endoscopic hemostasis or blood transfusion. In particular, among patients with delayed ulcer healing, one patient experienced severe bleeding within 3 months after ESD. Another patient with delayed ulcer healing developed delayed bleeding 10 weeks after ESD, which was controlled after massive blood transfusion and APC hemostasis.

  2.5 Risk factors analysis of delayed healing of ulcer after ESD

  In the univariate analysis of delayed ulcer healing, the following factors showed p<0.200: male, diabetes, cirrhosis, coagulation abnormalities, EGC diagnosis, specimen size greater than 4cm, electrocoagulation during ESD, and tumor location (Table 3). In terms of location, the lower third was negatively correlated with delayed ulcer healing, and the middle third was positively correlated with delayed ulcer healing.

  Use multi-factor analysis to analyze related factors. The results showed that diabetes (OR 1.743; p=0.043), abnormal coagulation (OR 3.195; p=0.002), specimen size greater than 4 cm (OR 2.999; p=0.001) and electrocoagulation (OR 7.149; p=0.006) are delayed healing of ulcers However, EGC (OR 1.457; p=0.096) is not an independent risk factor for delayed ulcer healing (Table 4).

  2.6 Hp infection and delayed healing of ulcers

  In ESD, Hp infected 840 subjects. Of these, 345 cases were untreated. Whether the 39 patients received treatment is unclear. Among the patients initially infected with Hp, 437 had persistent Hp infection at the 3-month follow-up, and 394 had no Hp infection at the follow-up. The Hp status of the remaining 9 cases is unknown. Among patients initially infected with Hp, 54 patients (6.4%) experienced delayed healing, and among patients without Hp infection, 33 patients (4.7%) experienced delayed healing. However, the difference was not statistically significant (p=0.147). In patients with Hp infection for the first time, the delayed ulcer healing rate was 6.9% in the persistent group and 5.8% in the negative transformation group, which was not statistically significant (p=0.545).

  2.7 Delayed electrocoagulation and ulcer healing

  "Electrocoagulation" is the most commonly used hemostasis technique during ESD (n=1440), followed by blood clamping (n=15) and APC (n=4). There was no significant correlation between hemostasis and APC in ESD and delayed healing of ulcer, the p values ​​were 0.207 and 1.000, respectively. Electrocoagulation is also the most common method to stop bleeding after ESD (n=48), followed by hemostatic clipping (n=7) and APC (n=5). Bleeding after electrocoagulation treatment of ESD is related to delayed ulcer healing, which is close to significance (OR, 2.477; 95%CI 1.026-5.981; p=0.050). During ESD, one-third of the lesions in the stomach undergo electrocoagulation more frequently than other parts (p<0.001).

  2.8 Subgroup analysis without delayed bleeding

  Since many delayed bleeding events are treated by electrocoagulation, a subgroup analysis of subjects without delayed ESD postoperative bleeding was carried out to exclude possible confounding effects of postoperative bleeding after ESD. In univariate analysis, male, diabetes, cirrhosis, coagulation abnormalities, EGC, specimen size, persistent Hp infection, electrocoagulation during ESD and the middle third position showed p<0.200.

  In a multivariate analysis, coagulation abnormalities, specimen size, and electrocoagulation during ESD are independent risk factors for delayed ulcer healing.

  Discuss

  Endoscopic resection was introduced in the early stage, and what attracted much attention was the surgical resection rate and technical feasibility. However, with the accumulation of a lot of experience, ESD technique is widely used in various indications. Safety and quality of life, which have been neglected so far, are attracting increasing attention.

  The results showed that the independent risk factors for delayed ulcer healing after ESD were diabetes, coagulation abnormalities, specimen size, and massive hemostasis during the operation, while the status of Helicobacter pylori had no effect on ulcer healing. For ESD patients with these risk factors, it is recommended to strengthen anti-ulcer drug treatment, such as increasing the dose of PPI or adding other mucosal protective agents as appropriate.

  Boda Weiye Ruilaisheng (Polyprezinc Granules) is a chelate of L-carnosine and zinc. It is a new generation of anti-gastric ulcer drug. Polyprezinc can stimulate mucus secretion, antioxidant, stabilize cell membrane, and induce heat shock protein. (HSP) and heme oxygenase (HO-1) are produced to promote the healing of ulcers caused by various reasons. Both zinc and L-carnosine can accelerate the healing of gastric mucosal injury. Zinc mainly accelerates the wound healing process of various types of tissues by promoting cell proliferation and protein synthesis. Polyprezinc is an insoluble chelate composed of zinc and L-carnosine. Compared with zinc or L-carnosine alone, polyprezinc dissociates slowly in the gastric juice, and stays longer in the diseased part of the stomach, and continues to exert a local protective effect to promote the healing of the ulcer mucosa. In addition, polyprezinc can stimulate the synthesis of insulin-like growth factor I, promote mucosal repair through endothelial cells, and significantly inhibit the basal protrusion of ulcers caused by PPI after ESD, which can significantly improve the quality of ulcer healing, shorten the healing time, and Reduce risk factors such as delayed postoperative bleeding.

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