【摘要】：目的:探討內(nèi)鏡黏膜下剝離術(shù)(ESD)圍手術(shù)期不同抗栓治療方案的安全性,分別對停用抗栓藥和持續(xù)使用抗栓藥兩方面進(jìn)行系統(tǒng)評價(jià),以期日后為指導(dǎo)我國內(nèi)鏡黏膜下剝離術(shù)圍手術(shù)期抗栓策略的制定提供理論依據(jù)。方法:應(yīng)用計(jì)算機(jī)系統(tǒng)檢索Web of Science、PubMed、EMbase、Cochrane Central Trails等外文數(shù)據(jù)庫,以及其它國內(nèi)常用的數(shù)據(jù)庫,并輔以手動(dòng)檢索、文獻(xiàn)追溯等方法,收集有關(guān)接受ESD的患者在圍手術(shù)期間抗栓治療的臨床試驗(yàn),檢索時(shí)間截止至2017年1月,檢索語言為英文和中文。由2名研究員按照預(yù)先制定的納入與排除標(biāo)準(zhǔn),獨(dú)立對所檢索出的文獻(xiàn)完成文獻(xiàn)篩選、質(zhì)量評價(jià)和數(shù)據(jù)提取等步驟后,再采用RevMan 5.3軟件進(jìn)行Meta分析,并對各研究進(jìn)行數(shù)據(jù)合并、異質(zhì)性檢驗(yàn)以及評估發(fā)表偏倚。若2名研究員在上述過程中的任一環(huán)節(jié)存在分歧都需先進(jìn)行討論,必要時(shí)由第三人介入做出最終決定。結(jié)果:本文共納入16項(xiàng)符合要求的回顧性病例對照研究,共包括10535例受試者,其中服用抗栓藥物治療的患者有1762例,從未服用過抗栓藥物的患者有8773例。經(jīng)Meta分析結(jié)果顯示:(1)與從未服用過抗栓藥物的患者相比,服用抗栓藥物者即使在ESD術(shù)前停用抗栓藥仍會增加術(shù)后出血的風(fēng)險(xiǎn)(OR=1.66,95%CI:1.15~2.39,P=0.007),特別是遲發(fā)性出血的風(fēng)險(xiǎn)(OR=2.66,95%CI:1.42~4.98,P=0.002),而對早期出血無明顯影響(OR=1.38,95%CI:0.74~2.54,P=0.31);亞組分析結(jié)果顯示,術(shù)后7天內(nèi)恢復(fù)使用抗栓藥物會明顯增加ESD術(shù)后的出血風(fēng)險(xiǎn)(OR=2.46,95%CI:1.54~3.93,P=0.0002),而術(shù)后超過7天恢復(fù)抗栓藥則相對安全(OR=1.06,95%CI:0.71~1.57,P=0.78);此外,聯(lián)用多種抗栓藥者的術(shù)后出血風(fēng)險(xiǎn)會明顯增加(OR=5.17,95%CI:3.13~8.54,P0.00001),而單用抗血小板藥者則相對安全(OR=2.08,95%CI:0.93~4.63,P=0.07)。(2)在ESD圍手術(shù)期持續(xù)使用抗栓藥物會顯著增加術(shù)后的出血風(fēng)險(xiǎn),無論是與從未服用抗栓藥物者相比(OR=5.97,95%CI:4.36~8.18,P0.00001),還是與術(shù)前停用抗栓藥物者相比(OR=3.44,95%CI:1.82~6.50,P=0.0001);亞組分析結(jié)果顯示,使用肝素過渡治療者的術(shù)后出血風(fēng)險(xiǎn)明顯增加(OR=4.20,95%CI:1.94~9.09,P=0.0003),但發(fā)生血栓栓塞事件的風(fēng)險(xiǎn)并未下降(OR=4.67,95%CI:1.20~18.17,P=0.03);持續(xù)服用低劑量阿司匹林,與術(shù)前停用抗栓藥物者相比不會增加ESD術(shù)后的出血風(fēng)險(xiǎn)(OR=1.22,95%CI:0.17~8.61,P=0.84)。結(jié)論:服用抗栓藥物是ESD術(shù)后出血的危險(xiǎn)因素,術(shù)前停用抗栓藥而在術(shù)后7天內(nèi)恢復(fù)使用、和同時(shí)服用多種抗栓藥物都會顯著增加ESD術(shù)后的出血風(fēng)險(xiǎn),尤其是遲發(fā)性出血的風(fēng)險(xiǎn),而對早期出血無明顯影響;在ESD圍手術(shù)期使用肝素過渡治療會顯著增加其術(shù)后的出血風(fēng)險(xiǎn),且并不會降低發(fā)生血栓栓塞事件的發(fā)生;此外,在圍手術(shù)期繼續(xù)服用低劑量阿司匹林并不是ESD術(shù)后出血的危險(xiǎn)因素。但是,將來仍需要更多的大樣本、多中心、高質(zhì)量的臨床試驗(yàn)來進(jìn)一步證實(shí)。
[Abstract]:Objective: to investigate the safety of different antisuppressive regimens during the perioperative period of endoscopic submucous exudation of (ESD), and to evaluate the discontinuation of antisuppressive drugs and the continuous use of antisuppressive drugs, respectively. In order to provide theoretical basis for guiding the formulation of perioperative antithrombus strategy during endoscopic submucous peeling in China in the future. Methods: Web of Science,PubMed,EMbase,Cochrane Central Trails and other foreign language databases, as well as other databases commonly used in China, were searched by computer system, supplemented by manual retrieval and literature traceability. Clinical trials of patients receiving ESD during perioperative antithrombus therapy were collected and searched in English and Chinese until January 2017. According to the pre-established inclusion and exclusion criteria, two researchers independently completed the steps of literature screening, quality evaluation and data extraction, and then used RevMan 5.3 software for Meta analysis. Data consolidation, heterogeneity test and evaluation bias were carried out. If there are differences between the two researchers in either part of the process, they need to be discussed first, and if necessary, a third person will intervene to make the final decision. Results: a total of 16 retrospective case-control studies were included, including 10535 subjects, including 1762 patients treated with antisuppressive drugs and 8773 patients who had never taken antisuppressive drugs. The results of Meta analysis showed that: (1) compared with patients who had never taken antisuppressive drugs, patients who took antisuppressive drugs increased the risk of postoperative bleeding even if they stopped using antisuppressive drugs before ESD (OR=1.66,95%CI:1.15~2.39,P=0.007). In particular, the risk of delayed bleeding (OR=2.66,95%CI:1.42~4.98,P=0.002) had no significant effect on early bleeding (OR=1.38,95%CI:0.74~2.54,P=0.31). The results of subgroup analysis showed that the resumption of antisuppressive drugs within 7 days after operation significantly increased the risk of bleeding (OR=2.46,95%CI:1.54~3.93,P=0.0002) after ESD. However, it was relatively safe to recover antisuppressive drugs more than 7 days after operation (OR=1.06,95%CI:0.71~1.57,P=0.78). In addition, the risk of postoperative bleeding was significantly increased in patients with multiple antithrombotic drugs (OR=5.17,95%CI:3.13~8.54,P0.00001), while those treated with antiplatelet drugs alone were relatively safe (OR=2.08,95%CI:0.93~4.63,). P 鈮，

本文編號：2497062