Risk Factors For Iatrogenic Mallory-Weiss Tear During Therapeutic Upper Endoscopy

BackgroundAcute upper gastrointestinal bleeding(AUGIB)is a common medical emergency.Mallory-Weiss tear(MWT)is one of the common causes of AUGIB.MWT is characterized by the presence of longitudinal lacerations of the mucous membrane and submucous layer.These tears occur primarily at the gastroesophageal junction;they may extend proximally to involve the lower or even mid esophagus and at times extend distally to involve the proximal portion of the stomach.The classical MWT accounted for7%-14%of AUGIB,including even cirrhotic patients.MWT is usually caused by factors such as retching or intense vomiting,hiccup,gastric lavage and weight-bearing,which cause sudden increase in intra-abdominal pressure or intra-gastric pressure.It is a self-limited disease and does not require urgent endoscopic or surgical intervention in most cases.MWT has been recognized as a complication during upper gastrointestinal endoscopy since the first iatrogenic MWT was reported by Watts in 1976,with a reported incidence of 0.08%-0.49%.Iatrogenic complications during gastrointestinal tract endoscopy have become a problem due to endoscopic advances and increased endoscopy use in recent years.And the attendant risks and adverse events with therapeutic endoscopy are many folds that of diagnostic endoscopy.Obviously,iatrogenic MWT caused by endoscopy is a problem that can not be ignored.Adverse events of endoscopic interventions are diverse and related to the underlying disease,therapeutic modality used and operator’s experience.Many of these adverse events can be prevented.Early recognition of potential adverse events is important to minimize the associated morbidity.In order to avoid deep tissue damage that may lead to perforation,adverse events should be minimized with active proactive steps taken before,during and after the endoscopic procedure.However,there are few literatures on iatrogenic MWT during therapeutic gastrointestinal endoscopy at home and abroad,and its specific pathogenesis and risk factors have not been clarified,which brings difficulties in prevention and treatment.Therefore,this article retrospectively analyzed the clinical data of patients undergoing therapeutic endoscopy in the gastrointestinal endoscopic treatment center of our institution in the past three years,and explored the relevant risk factors of iatrogenic MWT during therapeutic endoscopy,so as to guide clinicians to actively and effectively prevent the occurrence of this complication.ObjectiveTo investigate the risk factors for iatrogenic Mallory-Weiss tear(MWT)caused by therapeutic upper endoscopy and provide a basis for reducing the incidence of iatrogenic MWT.MethodsFrom January 2016 to January 2019,the clinical data of patients undergoing therapeutic upper endoscopy in our institution were retrospectively analyzed.The baseline clinical characteristics were compared between 50 patients with iatrogenic MWTs after therapeutic upper endoscopy(MWT group)and100 patients without MWTs(control group),and the control group was selected randomly.The risk factors for iatrogenic MWT caused by therapeutic upper endoscopy were analyzed by using multivariate logistic regression models.Results1 Univariate analysisThe incidence of iatrogenic MWT was 0.3%(50/16580)during therapeutic upper endoscopy.17 cases of MWT were found in a total of 1409 patients undergoing ESD,for an incidence of 1.21%,which is the highest among the different therapeutic endoscopies.MWT group had older age((66±13)years old),longer operation lasting time(70.00(30.75,112.00)min),and higher percentages of surgical site in the antrum/duodenum(66.0%),endoscopic submucosal dissection(34.0%)and endoscopic retrograde cholangiopancreatography(44.0%)than control group((55±14)years old,14.00(10.00,25.75)min,42.0%,9.0%,18.0%),and the difference was statistically significant(P<0.05).There were no significant differences in the body mass index((23.58±2.02)kg/m~2vs.(24.13±3.19)kg/m~2),percentage of males(56.0%vs.47.0%),and percentages of diabetes,reflux esophagitis/carditis and history of abdomen operation(6.0%,12.0%,28.0%vs.10.0%,11.0%,26.0%)between two groups(P>0.05).Thirty-three of the MWT patients received endoscopic hemostasis.All patients recovered satisfactorily without surgery for the laceration.2 Multivariate logistic regression analysisMultivariate logistic regression analysis showed that the age(OR(Odds Ratio,OR)=3.011,95%CI:1.329-6.818,P=0.008),operation lasting time(OR=1.031,95%CI:1.012-1.050,P=0.001)and operation site in the antrum and duodenum(OR=29.194,95%CI:2.633-323.655,P=0.006)were the risk factors for iatrogenic MWT.ConclusionThe old age,operation site and operation lasting time may be the risk factors for iatrogenic MWT.