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Risk factors of delayed post-polypectomy bleeding after treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection
Xiuyan Lu1, Ji Ma2
1 Department of Gastroenterology, Zhuji People's Hospital of Zhejiang Province, Zhuji, Zhejiang Province, China
2 Department of Gastroenterology, The First People's Hospital of Yongkang, Yongkang, Zhejiang Province, China
|Date of Submission||05-Jan-2022|
|Date of Acceptance||06-Jun-2022|
|Date of Web Publication||20-Jul-2022|
The First People&'s Hospital of Yongkang, Yongkang 321300, Zhejiang Province
Source of Support: None, Conflict of Interest: None
Context: Gastrointestinal polyps are common gastrointestinal diseases that involve localised hyperplastic masses derived from gastrointestinal mucosa.
Aims: To investigate the risk factors of delayed post-polypectomy bleeding (DPPB) after the treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection (ESD) and to construct a nomogram model to predict the risk of DPPB.
Settings and Design: A total of 226 patients who underwent snare-assisted ESD for gastrointestinal polyps from May 2018 to November 2020 were divided into DPPB group (n = 10) and non-DPPB group (n = 216).
Subjects and Methods: The correlations of clinical data and endoscopic data with DPPB were compared. Univariate analysis was performed to screen the influencing factors of DPPB. Multivariate logistic regression analysis was used to screen the risk factors of DPPB, which was employed to construct a nomogram prediction model.
Statistical Analysis Used: SPSS 16.0 software was utilised for statistical analysis. Numerical data were expressed as percentage (n [%]), and Chi-square test was performed for univariate analysis. The significant factors (P < 0.05) in univariate analysis were included in multivariate logistic regression analysis, and the variables with statistical significance (P < 0.05) were considered as independent risk factors. The factors were used to construct a nomogram model for predicting the risk of DPPB. Bootstrap method was employed to perform repeated sampling 1000 times for internal verification. The consistency index (C-index) was used to evaluate the discrimination of the model, and C-index ≥0.70 represented a good discrimination. Two-tailed P < 0.05 indicated that a difference was statistically significant.
Results: Univariate and multivariate logistic regression analyses revealed that hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding were the independent risk factors for DPPB (P < 0.05). The C-index of the nomogram model for predicting the risk of DPPB was 0.791, indicating a good discrimination. The calibration curve showed that the mean absolute error between predicted and actual DPPB occurrence risks was 0.014, indicating a high accuracy.
Conclusions: Hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding are the independent risk factors for DPPB, and the nomogram model established based on these factors for prediction has good discrimination and accuracy. Therefore, it is recommended to perform targeted intervention for high-risk groups to reduce the incidence of DPPB.
Keywords: Delayed post-polypectomy bleeding, gastrointestinal polyp, nomogram model, risk factor, snare-assisted endoscopic sub-mucosal dissection
|How to cite this URL:|
Lu X, Ma J. Risk factors of delayed post-polypectomy bleeding after treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection. J Min Access Surg [Epub ahead of print] [cited 2022 Aug 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=351255
| ¤ Introduction|| |
Gastrointestinal polyps are common gastrointestinal diseases that involve localised hyperplastic masses derived from gastrointestinal mucosa. Such disease is manifested by no obvious clinical symptoms in the early stage, but some patients may suffer abdominal pain, intestinal blockage and haematochezia when polyps grow larger, indicating high morbidity and cancer risk. Gastrointestinal polyps are usually treated by surgery in clinical practice, including endoscopic mucosal resection (EMR) and endoscopic sub-mucosal dissection (ESD), the latter of which has the advantages of less trauma, low cost, high safety and few complications and can effectively remove the diseased mucosa, but are also prone to bleeding and perforation due to insufficient exposure of the diseased mucosa during operation, thus increasing the difficulty of surgery. Especially for DPPB, failure to treat in time may lead to ischaemic shock.,, Hence, a clear visual field is essential. Snare traction has directional variability and can fully expose the sub-mucosal visual field through reverse traction of the lesion, which has advantages in the assisted ESD for gastro-oesophageal lesions and sub-mucosal tumours. At present, some scholars have reported the efficacy of snare-assisted ESD in the treatment of early gastrointestinal cancer and colon polyps, but DPPB after the treatment of gastrointestinal polyps has been rarely researched. In this study, the clinical data and endoscopic data of 226 patients who underwent snare-assisted ESD for gastrointestinal polyps in our hospital from May 2018 to November 2020 were analysed. Exploring the risk factors of DPPB and constructing the model for predicting the risk of DPPB are of great significance to reduce the occurrence of DPPB, which provide further reference for effective clinical prevention and control of DPPB.
| ¤ Subjects and Methods|| |
A total of 226 patients who underwent snare-assisted ESD for gastrointestinal polyps in our hospital from May 2018 to November 2020 were enrolled. The inclusion criteria were as follows: (a) patients who received snare-assisted ESD for gastrointestinal polyps, (b) those with complete clinical data and (c) those who aged ≥18 years. The exclusion criteria involved: (a) patients who were transferred to surgery due to intra-operative haemorrhage, (b) those with intra-operative or post-operative perforation, (c) those with other types of tumours or (d) those with incomplete medical records. Finally, a total of 226 patients were selected, including 152 males and 74 females, aged 31–78 years, with an average of 54.27 ± 11.26 years. Informed consent was obtained from all patients before surgery, and this study was approved by the medical ethics committee of our hospital.
| ¤ Methods|| |
The clinical data and pathological data including age, gender, smoking, drinking, comorbidities (cardiovascular disease, diabetes mellitus and hypertension), polyp location, polyp diameter, polyp number, polyp morphology, pathological type, intra-operative bleeding and administration of anti-thrombotic drugs were collected.
Patients meeting the following criteria were diagnosed with DPPB: (a) haematemesis, melena and haematochezia after snare-assisted ESD, (b) heart rate increased by 20 beats/min or blood pressure reduced by 20 mmHg, (c) haemoglobin decreased by 20 g/L and (d) endoscopic bleeding.
| ¤ Results|| |
Univariate analysis results of delayed post-polypectomy bleeding
Among the 226 patients included in the study, 10 cases (4.42%) had DPPB. The results of univariate analysis showed that hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding were influencing factors of DPPB (P < 0.05), but not age, gender, smoking, drinking, diabetes mellitus, cardiovascular disease, polyp number, pathological type and administration of anti-thrombotic drugs (P > 0.05) [Table 1].
|Table 1: Univariate analysis results of delayed post-polypectomy bleeding|
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Multivariate analysis results of delayed post-polypectomy bleeding
Factors with statistically significant differences in the univariate analysis were regarded as independent variables, while the presence or absence of DPPB was set as the dependent variable. They were incorporated into multivariate logistic regression analysis. Hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding were independent risk factors for DPPB (P < 0.05) [Table 2].
|Table 2: Multivariate analysis results of delayed post-polypectomy bleeding|
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Construction of a nomogram model for predicting risk of delayed post-polypectomy bleeding
The nomogram prediction model constructed based on the five related risk factors of DPPB showed 40 points for hypertension, 35 points for polyp in the intestine, 52.5 points for polyp diameter ≥3 cm, 32.5 points for polyp with pedicle and 37.5 points for intra-operative bleeding. The total score was 197.5 points, indicating that the risk of DPPB occurrence was 82.5% [Figure 1].
|Figure 1: Nomogram model for predicting risk of delayed post-polypectomy bleeding. DPPB: Delayed post-polypectomy bleeding|
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Evaluation of nomogram model for predicting risk of delayed post-polypectomy bleeding
The discrimination of the DPPB risk prediction model was determined, and the actual consistency index (C-index) of the model was 0.791, indicating a good discrimination [Figure 2]. Bootstrap method was employed to perform repeated sampling for internal verification, and the calibration curve showed that the mean absolute error between the predicted DPPB occurrence risk and the actual DPPB occurrence risk was 0.014, indicating a good accuracy [Figure 3].
|Figure 2: Receiver operating characteristic curve of nomogram model for predicting risk of delayed post-polypectomy bleeding|
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|Figure 3: Calibration curve after internal verification of nomogram model for predicting risk of delayed post-polypectomy bleeding|
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| ¤ Discussion|| |
Considering that gastrointestinal polyps have a high incidence rate in China and the literature reported that it is closely related to cancer, timely detection and intervention on the progression of gastrointestinal polyps can effectively prevent the occurrence of cancer. Clinically, gastrointestinal polyps are usually treated by ESD, but it is prone to DPPB, with an incidence rate of 0%–12%. In this study, snare-assisted ESD was utilised in patients with gastrointestinal polyps, and there were 10 cases with DPPB among the 226 patients enrolled, indicating an incidence rate of 4.42%, within the range of previous research results, and less than that of the above results. The reason may be that snare can fully expose the intra-operative mucosal visual field, thus reducing post-operative bleeding. In the present study, the clinical data and endoscopic data of patients with gastrointestinal polyps were explored by multivariate logistic regression analysis, and the results displayed that hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding were independent risk factors for DPPB.
The nomogram prediction model can graphically visualise the logistic regression results and visually show the individual risk of disease, which is worthy of clinical promotion and application. Compared with traditional scoring system, the nomogram model can integrate more predictive factors, deserving extensive application. Based on the above-mentioned risk factors of DPPB, a nomogram model was constructed to predict the risk of DPPB in this study, and the results displayed that for hypertension, the nomogram score increased by 40 points. The vascular endothelial cell function in hypertensive patients is damaged, which affects the contraction and vasodilation of blood vessels. Such patients have relatively fragile vascular wall and weakened elasticity of blood vessels than normal people, and long-term hypertension can cause atherosclerosis. Moreover, high blood pressure fluctuations are prone to unstable blood flow rate. Based on the above situations, post-operative bleeding easily occurs. Besides, in this study, for polyp in the intestine, the nomogram score increased by 35 points. Previous studies have revealed that DPPB easily occurs in the caecum due to its high elasticity, bile and digestive enzymes in the ileal intestinal fluid may destroy post-operative ulcer surface, rectal mucosa is rich in a large number of nutrient vessels and blood supply, rectum contains gas and faeces, leading to the frequent dilation and contraction of the rectal wall and causing the titanium clip to fall off, thus inducing bleeding, and defecation also affects the healing of post-operative ulcers, which all increase the risk of DPPB., In addition, the operation of ESD for the lower gastrointestinal tract is more difficult due to the thin intestinal wall, so post-operative bleeding easily occurs, consistent with the results of Jin et al. For polyp diameter ≥3 cm in this study, the nomogram score increased by 52.5 points. The larger the polyp diameter, the larger the corresponding lesion size and the more abundant nutritional blood vessels. The larger the wound surface during endoscopic surgery, the more blood vessels are damaged, and the more ulcers on the wound surface after surgery, leading to a notable increase in the exposure risk of the basal blood vessels, so the failure of intra-operative haemostasis in time may easily induce DPPB, consistent with the results of Choung et al. Moon et al. also reported that polyp size was the only risk factor for DPPB. In this study, the nomogram score for polyp morphology with pedicle increased by 32.5 points. Previous studies have showed that a large number of blood vessels are nourished by polyps with pedicle, so the blood supply is abundant, and vascular size is positively related to the thickness of the polyp pedicle, which is prone to DPPB due to improper operation during surgery. In this study, for the occurrence of intra-operative bleeding, the nomogram score increased by 37.5 points. Higashiyama et al. reported that poor control of bleeding during gastric surgery would increase the risk of DPPB and considered that the blood vessels exposed at the bottom of the ulcer were not seen during the operation, leading to the failure to use haemostats for early coagulation. The greater the amount of intra-operative bleeding indicated a greater possibility of DPPB. The amount of intra-operative bleeding was related to vascular damage to some extent. The effect of endoscopic haemostasis would be worse in the cause of large amount of intra-operative bleeding, implying the insufficient surgical experience of doctor.
In the present study, the C-index of the nomogram model to predict the risk of DPPB was 0.791, bootstrap method was employed to perform repeated sampling for internal verification and the calibration curve showed that the mean absolute error between the predicted DPPB occurrence risk and the actual DPPB occurrence risk was 0.014, indicating good discrimination and accuracy.
| ¤ Conclusion|| |
Hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding are the independent risk factors for DPPB. The constructed nomogram model for predicting the risk of DPPB has good discrimination and accuracy, which helps physicians intuitively analyse the risk ratio of each factor level to DPPB in patients with gastrointestinal polyps and formulate effective intervention strategies for high-risk groups. However, considering that this is a retrospective single-centre study with small sample size, the prediction model will be further verified by multi-centre studies with large sample sizes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]