背景:具有粘附凝块的消化性溃疡与再出血和死亡的高风险相关。然而,有粘连性凝块的出血性溃疡的最佳治疗仍不清楚.我们进行了系统评价和荟萃分析,以比较内镜治疗和保守治疗以治疗粘附性溃疡。
方法:我们系统地搜索了PubMed,Embase,和WebofScience数据库,直到2022年10月,包括所有比较内窥镜和保守治疗方法治疗有粘连性凝块的出血性溃疡的研究。我们的主要结果是再出血(总体和30天)。次要结局是死亡率(总体和30天),需要手术,住院时间(LOS)。随机效应模型用于计算比例和连续变量的合并优势比(OR)和平均差(MD)以及相应的置信区间(CI)。分别。
结果:11项研究(9项随机对照试验)共833例患者(431例接受内镜治疗与402人接受保守治疗)。总的来说,内镜治疗与较低的总再出血相关(OR0.41,95%CI0.22-0.79,P=0.007),30天再出血(OR0.43,95%CI0.21-0.89,P=0.002),总死亡率(OR0.47,95%CI0.23-0.95,P=0.04),30天死亡率(OR0.43,95%CI0.21-0.89,P=0.002),需要手术(OR0.44,95%CI0.21-0.95,P=0.04),和LOS(MD-3.17天,95%CI-4.14,-2.19,P<0.00001)。然而,随机对照试验(RCT)的亚组分析显示,两种策略之间的总死亡率没有显着差异(OR0.78,95%CI0.24-2.52,P=0.68),总体再出血率在数值上较低,但在统计学上不显着(7.2%vs.18.5%,分别为OR0.42,95%CI0.17-1.05,P=0.06),与保守治疗相比,内镜治疗的手术需求率在统计学上较低(OR0.28,95%CI0.08-0.96,P=0.04).
结论:我们的荟萃分析表明,内镜治疗总体上与较低的再出血率(总体和30天)相关。死亡率(总体和30天),需要手术,还有LOS,与保守治疗相比,治疗有粘连性血块的出血性溃疡。然而,RCTs的亚组分析显示,与保守治疗相比,内镜治疗在总体死亡率相似的情况下,总体再出血率在数值上较低,但在统计学上无显著意义,需要手术的发生率在统计学上较低.热疗法和注射疗法的联合治疗是降低再出血风险的最有效的治疗方式。需要进一步的大规模RCT来验证我们的发现。
Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic
review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots.
We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively.
Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22-0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21-0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23-0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21-0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and LOS (MD - 3.17 days, 95% CI - 4.14, - 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24-2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17-1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08-0.96, P = 0.04) with endoscopic therapy compared to conservative therapy.
Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.