结肠巨大息肉内镜黏膜切除术术中出血1例

摘要

结直肠巨大息肉(直径>2.0 cm)癌变几率较高, 内镜下微创切除是首选治疗, 但有并发出血风险. 本文报告1例56岁男性患者, 降乙结肠交界处巨大带蒂息肉(3.0 cm×3.5 cm), 行内镜黏膜切除术(endoscopic mucosal resection, EMR)切除息肉后, 创面持续渗血, 氩离子凝固术(argon plasma coagulation, APC)处理后, 创面搏动性出血, 电凝止血钳钳夹亦难以止血. 以钛夹封闭创面, 创面下方迅速形成血肿, 后送外科急诊手术切除病变肠段. 对类似病例, 应尽可能利用尼龙圈套扎, 术中充分电凝, 较大创面尽早使用钛夹止血和封闭.

关键词: 结直肠巨大息肉; 内镜黏膜切除术; 出血

核心提示: 本文报告了1例降乙结肠交界处巨大带蒂息肉(3.0 cm×3.5 cm), 行内镜黏膜切除术(endoscopic mucosal resection)中并发出血的病例, 并分析其出血原因和后续处理方法, 最后讨论对类似结直肠短粗蒂巨大息肉内镜治疗病例的术中出血预防和处理方法.

A case of hemorrhage after endoscopic mucosal resection of a large colonic polyp

Hai-Dan Zhu, Li He, Qiu Zhao, De-An Tian, Pei-Yuan Li

Hai-Dan Zhu, Li He, Qiu Zhao, De-An Tian, Pei-Yuan Li, Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China

Supported by: National Natural Science Foundation of China, No.81372663.

Correspondence to: Pei-Yuan Li, Associate Professor, Associate Chief Physician, Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan 430030, Hubei Province, China. pyli@tjh.tjmu.edu.cn.

Received: June 6, 2015
Revised: August 27, 2015
Accepted: September 7, 2015
Published online: October 18, 2015

Abstract

Large colonic polyps (with a diameter larger than 2 cm) are associated with an increased risk of malignancy. Endoscopic resection is the first line treatment; however, there is a risk of bleeding. We reported a 56-year-old man with a large pedunculated polyp (3.0 cm × 3.5 cm) located between the rectum and the sigmoid. After endoscopic mucosal resection, the patient suffered from continuous hemorrhage at the wound site. He was then treated by argon plasma coagulation (APC), bipolar coagulation and hemoclip hemostasis. Unfortunately, all these attempts ended in failure. Finally, an operation was performed and a segment of the colon was removed to save his life. From this case we can learn that we should use endoscopic nylon loop as much as possible when treating large pedunculated polyps. In addition, we should do our best to stop the bleeding at the same time.

Key Words: Large colonic polyps; Endoscopic mucosal resection; Hemorrhage

0 引言

结直肠息肉是生长自结直肠黏膜并隆起于黏膜表面的病变, 是消化系统一种常见病、多发病, 与结直肠癌有密切关系. 通常将直径>2.0 cm的息肉称为巨大息肉[1], 而且, 巨大腺瘤性息肉癌变的危险性是小息肉(直径<2.0 cm)的4.6倍[2]. 因此, 积极发现并治疗结直肠巨大息肉对预防结直肠癌的发生甚为重要. 目前, 结直肠息肉首选治疗为内镜下黏膜切除术(endoscopic mucosal resection, EMR)或内镜黏膜下剥离术(endoscopic submucosal dissection, ESD), 效果好, 创伤小, 虽有出血、穿孔等并发症, 但发生率低. 本文报告1例结肠巨大息肉EMR术中出血, 并对其出血原因及处理方法进行分析.

1 病例报告

患者男性, 56岁, 因"排便不规律6 mo"于2014-03行肠镜检查发现结直肠多发息肉. 患者既往于2011-10因直肠癌行根治手术, 术后未化疗, 未复查肠镜; 有高血压病史4年, 最高170/110 mmHg, 口服硝苯地平缓释片血压控制满意. 入院后体格检查心率76次/min, 血压135/85 mmHg. 心肺听诊无特殊, 腹平软, 下腹见手术瘢痕, 无压痛, 未触及包块. 入院后完善辅助检查, 血常规、出凝血时间、肝肾功能电解质血糖、肿瘤标志物、心电图、腹部超声等均无异常. 入院次晨以聚乙二醇电解质散行肠道准备, 下午行肠镜检查和治疗. 肠镜于距肛缘8 cm见直肠吻合口, 黏膜光滑. 横结肠见一大小约0.6 cm×0.8 cm小息肉, 表面光滑; 病变基底黏膜下注射肾上腺素美兰生理盐水, 充分抬举后, 圈套器电凝切除(EMR治疗), 创面清洁. 距肛缘约40 cm降乙结肠交界见一大小约3.0 cm×3.5 cm菜花样息肉, 有短粗蒂. 其蒂上另生长一大小约1.0 cm×1.2 cm分叶状息肉(图1A). 息肉基底黏膜下多点注射肾上腺素美兰盐水, 抬举良好. 先以圈套器电凝切除较小息肉, 创面清洁. 较大息肉电凝切除术后创面渗血(图1B), 以氩离子凝固术(argon plasma coagulation, APC)处理, 创面见搏动性出血(图1C), 电凝止血钳钳夹止血亦不成功, 出血较多, 且创面水肿, 视野不佳(图1D). 试以钛夹封闭局部创面, 于创面下方迅速形成血肿(图1E). 外科会诊后行急诊开腹手术, 切除病变肠段约5 cm, 剖开见一大小约0.6 cm×0.8 cm溃疡, 黏膜下血肿, 直径约3.5 cm, 未见明显活动性出血(图2). 术后病理切片示: 降乙结肠交界符合息肉状腺瘤(图3A, B); 病变肠段镜下见肠壁黏膜下层内广泛出血, 余未见特殊(图3C, D). 术后行止血肠外营养治疗, 一般情况好, 遂出院. 1年后随访, 患者排便好, 结肠镜未发现息肉.

图1 降乙结肠交界处巨大息肉切除出血. A: 降乙结肠交界处巨大息肉; B: 巨大息肉电凝切除完毕创面渗血; C: 创面APC处理后发生搏动性出血; D: 创面电凝止血钳钳夹后未能止血, 创面水肿; E: 局部创面钛夹封闭后黏膜下形成血肿.

图2 外科手术切除病变肠段. 创面处黏膜下血肿, 未见活动性出血.

图3 降乙结肠交界处病理学变化. A, B: 息肉状腺瘤表现(×40); C, D: 肠段肠壁黏膜下层内广泛出血(×100).

2 讨论

自20世纪60年代末开展内镜下高频电凝切除消化道息肉以来, 至今已发展有多种内镜下息肉治疗方法, 包括APC、高频电息肉切除法、EMR、ESD以及尼龙绳套扎术等, 内镜下治疗结直肠息肉越来越安全, 巨大息肉也可在内镜下行微创电切除治疗[3]. 随之内镜下结直肠息肉切除术的并发症也逐渐增多, 主要为出血, 发生率为0.3%-10.2%[4,5], 包括切除后立即出血和迟发型出血. 立即出血是指在术中息肉切除后, 残端或创面持续性出血[6], 根据其出血程度分为三级[7]: 1级: 可自发停止的出血, 或者是持续渗血但逐渐减少; 2级: 持续性渗血需要内镜治疗; 3级: 活动性喷血. 迟发型出血是指内镜下息肉切除手术后到术后16 d内的出血[8]. 有学者认为[7,9], 出血相关因素大致可分为3类: (1)患者的基本情况, 如年龄是否>65岁、是否患有高血压或凝血功能障碍等基础疾病, 是否使用抗凝药物; (2)与息肉形态(无蒂或是有蒂、蒂的粗细)、尤其是大小相关. 有文献[10]报道, 息肉直径>1.0 cm切除术后出血概率为8%, 而直径是否>1.4 cm为息肉切除后是否出血的重要预测指标; (3)术前肠道准备是否充分, 是否正确选择内镜下息肉切除方法以及操作者的技术水平与出血也密切相关. 而内镜下结直肠息肉切除术后出血, 若不能自止, 根据创面情况不同, 有不同的处理方法: 如少量出血可喷洒1:10000去甲肾上腺素液[11]止血; 若出血量多, 冲洗明确出血点后, 可使用APC、电凝止血钳、金属夹或是尼龙套圈止血[12,13]. 在息肉直径>2 cm时, 有作者推荐尼龙圈套止血较有效[14].

本病例患者56岁, 有高血压病史, 血压控制尚满意, 未服用抗凝血药物且凝血功能正常, 肠道准备满意. 但息肉巨大(3.0 cm×3.5 cm)、短粗蒂, 估计滋养血管较粗大丰富, 属于切除后出血风险较高者. 患者EMR术后立即出血, 考虑术中圈套器收缩过快, 和/或电凝不充分, 导致创面出血. 初步APC处理后, 息肉滋养动脉断面血痂脱落并收缩至黏膜下层或肌层, 形成搏动性出血. 以电凝止血钳钳夹, 难以发现血痂下准确出血点, 反复操作后创面水肿, 视野不清晰. 后钛夹难以对出血点进行准确夹闭, 局部封闭后, 创面形成黏膜下血肿. 考虑到黏膜下血肿可能继续发展, 或后期形成肠壁压迫性坏死穿孔, 予以手术切除. 术中未发现活动性出血, 或已产生压迫性止血效果.

对于类似结直肠短粗蒂巨大息肉内镜治疗病例, 防止术中术后创面出血是关键. 综合前面分析, 以下几方面措施或可减少出血和利于术中止血: (1)术前患者准备, 调整血压, 注意血小板和出凝血时间, 充分清洁肠道; (2)有蒂者, 尽可能利用尼龙圈套扎息肉蒂部, 阻断血流; (3)和助手密切配合, 圈套器收紧不宜过快, 充分电凝; (4)较大创面尽早使用钛夹止血和封闭, 避免过多使用APC和电凝, 以免后期导致创面水肿后难以再行钛夹止血; (5)蒂部很宽大的情况下, 也可考虑ESD术.

评论

背景资料

结直肠巨大息肉(直径>2.0 cm)癌变几率较高, 目前, 其首选治疗为内镜下黏膜切除术(endoscopic mucosal resection, EMR)或内镜黏膜下剥离术(endoscopic submucosal dissection, ESD), 效果较好, 较安全. 但是, 随着息肉直径的增大, 手术难度增大, 手术并发症亦增加, 特别是术中出血风险大大增高. 所以, 探讨巨大息肉手术出血发生原因及处理方式对结肠巨大息肉的治疗以及结直肠癌的预防有重要意义.

同行评议者

蔡全才, 副教授, 中国人民解放军第二军医大学附属长海医院临床流行病学与循证医学中心

相关报道

有关结直肠巨大息肉内镜下微创切除的报道以较多, 通常收集大样本该种病例, 对其不同息肉情况进行不同的内镜切除处理, 进而分析总结其切除效果, 归纳出结论.

创新盘点

本文报道1例结直肠巨大息肉内镜下微创切除术中出血病例, 详细介绍其基本情况, 息肉状态, 对其处理方法和过程, 以及出血后的治疗措施; 相比之多样本病例复习更加详细清晰, 可讨论性更强.

同行评价

该文分析了1例结肠巨大息肉EMR术中出血的原因及处理方法, 对于类似结直肠短粗蒂巨大息肉内镜治疗病例的术中出血预防和处理具有一定借鉴价值.

备注

编辑:郭鹏 电编:都珍珍

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