内镜结扎术治疗食管静脉曲张急性出血

采用内镜结扎术(EVL)治疗食管静脉曲张急性出血78例。首次EVL的实施距出血发作时间:8h以内10例,9～48h 26例,49～72h 37例,超过72h 5例。急性出血被控制后,每隔2周重复EVL直至静脉曲张被根除或缩小至Ⅰ°以下。经该法治疗,近期止血率达93.6％;63例生存病人经平均4次(2～7次)EVL,55例(87％)食管静脉曲张被根除或缩小至Ⅰ°以下;未发现与EVL有关的严重并发症。平均随访25月(8～48月),有11例病人复发出血(17％),这些再出血大多发生在曲张静脉根除之前,且容易被重复EVL控制出血。该组结果显示:EVL止血效果确切,安全易行,并发症少;对食管静脉曲张急性出血,尤其伴有肝功能不良者,EVL可作为首选的有效治疗方法。     

内镜曲张静脉套扎联合脾栓塞治疗食管静脉曲张出血

目的　对内镜曲张静脉套扎 (EVL)联合部分脾栓塞 (PSE)治疗肝硬变食管静脉曲张出血的疗效进行评价。方法　 6 1例肝硬变食管静脉曲张出血并脾功能亢进患者 ,35例采用EVL联合PSE治疗 ,2 6例单用EVL治疗 ,比较两组近、远期静脉曲张根治率及再出血率。结果　①EVL联合PSE组近期静脉曲张根治率及再出血率分别为 97.14 %、2 .86 % ,远期则分别为 76 .4 7%、5 .88% ;②EVL联合PSE治疗组远期静脉曲张根治率显著高于EVL组 (P <0 .0 1) ,再出血率低于EVL组 (P <0 .0 5 ) ,近期两者无显著性差异 (P >0 .0 5 )。结论　EVL联合PSE治疗肝硬变食管静脉曲张出血并脾功能亢进安全有效 ,近期、远期都有较高的食管静脉曲张根治率及较低的再出血率 ,远期疗效优于EVL ,值得推广。     

EVL治疗食管静脉曲张破裂出血

EVL治疗食管静脉曲张破裂出血39例，结扎时活动性大出血34例，5d内出血5例。39例进行102次963处结扎，其中29例经2～5次密集结扎后15例食管静脉曲张消失，显效率51．7％，13倒退缩到I度，总有效率96．6％。34例活动姓大出血患者40次紧急结扎，40例次立即止血，2例72h内再出血，急诊止血率95％。39例中肝功能ChildC级17例，占43．6％，均能安全接受治疗，水后无1例并发症及肝功能损害加重。存活34例，15例恢复工作。13例14～23月（平均18．4月）复查，2例复发食管静脉曲张再行EVL。EVL治疗食管静脉曲张破裂出血疗效确切、安全、操作简便。     

套扎与硬化剂比较治疗肝硬化食管静脉曲张出血的中文随机试验的系统评价

目的系统评价国内有关套扎治疗与硬化剂治疗肝硬化食管静脉曲张出血的有效性和安全性。方法计算机检索CBMdisc(1979～2006)和CNKI (1994～2006),收集有关套扎与硬化剂比较治疗肝硬化食管静脉曲张出血的随机对照试验(RCT)和半随机对照试验(CCT),由两名评价员独立对纳入文献进行质量评价和数据提取,并使用RevMan4．2．7软件进行Meta分析。结果共纳入9个RCT,包括1371例患者,其中套扎组688例,硬化剂组683例。Meta分析结果显示：对于死亡率,两组间差异有统计学意义[RR=0．60,95%CI (0．36,0．98)],套扎治疗组低于硬化剂治疗组；对于急诊止血率、出血复发率和并发症发生率,套扎治疗组也显示出更好的疗效趋势；而对于曲张静脉消失率和曲张静脉复发率,硬化剂治疗组则显示出更好的疗效趋势。结论在治疗肝硬化食管静脉曲张出血患者时,套扎较硬化剂治疗显示出更好的疗效及更少的并发症。但由于纳入研究质量不高,这一结论的强度受到一定的限制,尚需今后开展高质量随机对照试验来进一步验证。     

急诊内镜下套扎应用于肝硬化食管静脉曲张破裂出血的疗效及安全性评价

目的观察急诊内镜下套扎(EVL)治疗肝硬化食管静脉曲张破裂出血的疗效及并发症,评估其安全性。方法对68例肝硬化食管静脉曲张破裂出血患者进行EVL治疗,从胃食管连接处开始螺旋向上套扎曲张静脉;当有活动性出血,首先套扎出血处静脉,如止血不成功,则在其下方套扎;如出血较多视野不清,则从胃食管连接处盲扎。观察止血效果及并发症。结果急诊止血成功率为94.12%(64/68),术中并发症发生率为10.29%(7/68),术后并发溃疡出血发生率为2.92%(2/68),无死亡发生。结论 EVL是一种快速、有效的止血方法,但术中并发症并不少见,应重视术中误吸、出血等并发症。     

微探头超声在食管静脉曲张腔内外联合断流术中的应用

目的运用微探头超声观察门脉高压症食管静脉曲张患者食管下段壁内外静脉结构治疗前后的变化以及对腔内外联合断流术的疗效、预后进行评价。方法对23例门脉高压食管静脉曲张患者，在接受腔内外联合断流术前后应用微探头超声对食管下段静脉结构情况进行对比观察。随访追踪食管静脉曲张的复发率、再出血率。结果治疗后食管黏膜下曲张静脉消失，食管周围静脉丛曲张程度也明显减轻或消失。短期追踪随访静脉曲张的再发率和出血率分别为5．0％和0。结论腔内外联合断流能有效闭塞食管下段壁内外的静脉，阻断门奇分流，防治食管静脉曲张出血与复发，而且操作简便，值得推广应用。微探头超声检查食管下段静脉的变化在食管静脉曲张治疗的评价中具有重要意义。     

Variceal bleeding and portal hypertension: still a therapeutic challenge?

In the primary prevention of variceal hemorrhage, beta-blockers continue to be the first-line treatment. Newer nonselective beta-blockers with anti-alpha1-adrenergic activity, such as carvedilol, appear to have a better impact on reducing the hepatic venous pressure gradient than propranolol. The addition of isosorbide mononitrate appears to improve the effectiveness of beta-blockers in primary prophylaxis, but not that of somatostatin in the treatment of acute variceal hemorrhage. The use of vasoactive drugs alone in acute variceal bleeding has not proved to be more effective than endoscopic treatment. The advent of endoscopic variceal ligation (EVL) has strengthened the role of endoscopy in the management of bleeding esophageal varices. EVL has improved the results, particularly in terms of lowering the treatment-related morbidity, compared with endoscopic variceal sclerotherapy (EVS). However, the variceal recurrence rate after initial eradication with EVL is relatively high. In contrast to synchronous combined therapy with EVL plus EVS, metachronous combination of EVL and low-dose EVS may improve the results of EVL alone. For bleeding fundic varices, obliteration using cyanoacrylate is currently the treatment of choice. Endosonography (EUS) is coming into more widespread use in the assessment of variceal eradication and in further attempts to improve the results of endoscopic injection therapy. According to two meta-analysis studies, transjugular intrahepatic portosystemic shunt (TIPS) is not yet capable of replacing endoscopic treatment in the secondary prevention of variceal bleeding.     

内镜治疗食管静脉曲张破裂出血（附385例报告）

目的：探讨经内镜治疗食管静脉曲张破裂出血的最佳治疗方案,方法：自1988年2月－2000年5月收治肝硬化门脉高压食管静脉曲线破出血385例。临床随机分成3组：单纯硬化组（EVS）103例,内镜直视下向静脉内和静脉旁注射1％乙氧硬化醇,单纯结扎组（EVL）105例,分单次结扎和五连环连续结扎;联合治疗组（结扎加硬化治疗,EVL＋EVS）,经1－2次结扎后14天作硬化治疗,间隔1－3月对静脉曲张未消失者重复硬化治疗,结果：6个月内无出血者硬化组66％,结扎组83％,联合治疗组92％,3－6个月内随访,食管静脉曲张消失率硬化组86％,结扎组68％,联合治疗组91％,结论：联合结扎和硬化不同步良管静脉曲张破裂出血能增加止血效果,提高食管静脉曲张消失率,减内内镜治疗次数和硬化剂用量,为目前内镜治疗食管静脉曲线破裂出血较为安全有效的方法。     

Magnetic resonance angiography for monitoring prophylactic endoscopic treatment of high risk esophageal varices

BACKGROUND AND STUDY AIMS: Endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) are used worldwide as the treatment for esophageal varices. We evaluated portal hemodynamics using magnetic resonance angiography (MRA) in these two forms of treatment. PATIENTS AND METHODS: The study was carried out in 50 cirrhotic patients. MRA was performed to identify the hepatofugal supply vein selectively for esophageal varices. Those who showed a positive MR angiogram for the supply vein were randomly allocated to one of two groups, using the sealed envelope method, and underwent either EIS or EVL. On the other hand, those with a negative angiogram received only EVL. EIS was done to embolize esophageal varices as well as their feeders by intravariceal injection of sclerosant under fluoroscopic guidance. RESULTS: A positive MR angiogram of the hepatofugal left gastric vein as the supply vein was observed in 41 patients. Nine patients showed negative MRA results. Among those with positive angiograms, the rate of eradication of the left gastric vein was higher in the EIS-treated group than in the EVL treated group (50% vs. 8.6%). After either treatment, the recurrence-free rate for high risk esophageal varices was higher in patients with complete eradication of the left gastric vein than in those without (88% vs. 35%). In patients with negative angiogram results, who only underwent EVL, high risk esophageal varices did not reappear over a long period. CONCLUSION: MRA is useful for evaluating portal hemodynamics. With the aim of avoiding recurrence of esophageal varices, EIS was suitable for patients who had a hepatofugal supply vein for the varices because recurrence could be prevented by embolization of the supply vein. EVL may be expected to be efficacious in patients where no image of a hepatofugal supply vein is found on MRA.     

微探头超声内镜对肝硬化患者行食管静脉曲张套扎术 治疗的预后价值评估*

目的应用微探头超声内镜(EUS)对肝硬化患者食管静脉曲张套扎术(EVL)治疗的预后评估。方法选择2015年8月-2017年8月于天津市第二人民医院住院治疗的肝硬化患者64例,均进行EVL根治术治疗。EVL根治术后,患者每半年复查胃镜及EUS,随访1年,胃镜观察有无食管静脉复发。EUS观察食管黏膜下静脉曲张及侧枝静脉的最大直径,记录其曲张程度。结果①EVL根治术后1年内,死亡2例,其余62例均完成随访。其中,复发30例,复发率48.4%(30/62);再次出现食管静脉曲张破裂出血患者4例,出血率6.5%(4/62);②与治疗前相比,EVL根治术后食管黏膜下静脉曲张中/重度例数、食管旁静脉曲张及周围静脉曲张重度例数,差异无统计学意义(P0.05);③EVL根治术后,与食管静脉曲张未复发组相比,复发组食管黏膜下静脉曲张中/重度例数明显增多,食管旁静脉曲张及周围静脉曲张重度例数明显增多,差异有统计学意义(P=0.000)。结论应用微探头EUS随访EVL根治术患者,观察食管黏膜下静脉曲张及食管侧枝静脉的程度,对EVL术后食管静脉曲张复发有一定的预测价值。     

Variceal bleeding and portal hypertension: much to learn, much to explore

The newer diagnostic and therapeutic options continue to evolve and important developments have been made in the field of variceal bleeding and portal hypertension. A meeting was held at Baveno to update consensus on different terminologies in relation to portal hypertension. beta-blockers continue to be the mainstay for primary prophylaxis of variceal bleeding, and endoscopic variceal ligation (EVL) is fast emerging as a strong contender. The role of vasoactive drugs in the management of variceal bleeding was assessed. Octreotide and terlipressin were shown to be as effective as sclerotherapy in achieving initial hemostasis, and octreotide was shown to be safe and efficacious in the prevention of rebleeding. EVL was superior to endoscopic sclerotherapy (EST) for obliteration of esophageal varices. Sequential and simultaneous ligation and sclerotherapy were more effective than ligation alone, in reducing the recurrence rate after variceal obliteration. For gastric varices, cyanoacrylate glue continues to be the first line of treatment, and band ligation is being assessed further. Bleeding ectopic varices were dealt by appropriate endoscopic means. Endosonography has developed strongly in the assessment of variceal eradication and prediction of variceal recurrence. Transjugular intrahepatic portosystemic shunting (TIPS) significantly reduces rebleeding rates compared to EVL.     

内镜曲张静脉结扎联合脾栓塞术76例报告

目的：探讨内镜曲张静脉结扎（EVL）联合脾栓塞术（PSE）治疗门静脉高压症的疗效。方法：对76例门静脉高压症合并食管曲张静脉出血和脾功能亢进病人实施EVL联合PSE治疗。结果：76例病人食管曲张静脉均完全闭塞,平均随访21月（3－48月）,复发出血率为6．6％,脾栓塞术后脾脏明显缩小,外周血白细胞与血小板均显著升高（P＜0．01）,结论：EVL联合PSE疗法是治疗门静脉高压症食管静脉曲张出血和脾功能亢进的安全有效方法,该联合疗法比单独EVL更快闭塞曲张静脉,复发出血率低;较外科手术简单,侵袭性小。     

食管静脉曲张出血急诊内镜套扎止血84例护理分析

目的探讨急诊内镜下行食管静脉曲张套扎术（EVL）的护理配合与经验。方法使用套扎器对84例食管静脉曲张出血患者的曲张静脉进行套扎治疗。结果84例患者食管曲张静脉均成功套扎,止血成功率达100％,其中3例术后2周内复查胃镜仍有局部食管静脉曲张伴红色征,再行EVL治疗。所有病例患者术后1-3d内均有不同程度的胸骨后疼痛、吞咽困难或异物感、低热等并发症。结论食管静脉曲张套扎术止血可靠、短期再出血率低,设备简单,可重复性强,是肝硬化食管静脉曲张出血的有效止血方法。急诊内镜下套扎每个环节的护理配合均十分重要。     

Clinical evaluation of combined endoscopic variceal ligation and sclerotherapy of gastric varices in liver cirrhosis

BACKGROUND AND STUDY AIMS: Endoscopic injection sclerotherapy (EIS) using cyanoacrylate and balloon-occluded retrograde transvenous obliteration (B-RTO) are the main procedures used to treat gastric varices. However, neither technique is free of problems. EIS for gastric varices may cause embolism in other organs; B-RTO requires a gastrorenal shunt and may aggravate esophageal varices. We have developed a combined form of endoscopic therapy involving band ligation and sclerotherapy which is an effective and safe procedure for treating gastric varices. PATIENTS AND METHODS: Fifty-six patients with gastric varices and liver cirrhosis were treated at Almeida Memorial Hospital from June 1997 to May 2002 using the combined procedure. Each gastric varix was tightly ligated with O-rings, and 1 % polidocanol was injected into the submucosa around the ligated varix. If necessary, additional sclerotherapy was carried out after the initial treatment. RESULTS: The rate of hemostasis for variceal bleeding was 100 %, and no critical complications were noted. Complete disappearance of the gastric varices was observed endoscopically in all cases. Computed tomography showed that collateral vessels outside the gastric wall were not occluded by the treatment. Endoscopic follow-up examinations were carried out, and gastric varices recurred in seven patients (12.5 %). Only two of the patients (3.6 %) had a small amount of oozing bleeding. Additional endoscopic variceal ligation (EVL) and/or EIS were performed in these seven cases, and none of the patients died as a result of a bleeding gastric varix. CONCLUSIONS: The combined procedure was easily performed immediately after endoscopic examination, and required no special apparatus. It was found to be a safe and effective method of treating gastric varices.     

Low power diode laser treatment using indocyanine green for eradication of esophageal varices

BACKGROUND AND STUDY AIMS: Endoscopic variceal ligation (EVL) is an alternative to sclerotherapy for the treatment of esophageal varices, but is associated with higher rates of recurrence and subsequent bleeding than sclerotherapy. To prevent recurrence of varices after EVL, we have developed a low-dose diode laser therapy combined with the injection of indocyanine green, which allows enhanced tissue absorption of the laser beam selectively around varices. In this study we investigated the efficacy and safety of this technique. PATIENTS AND METHODS: Eight patients with F2 or F3 esophageal varices were enrolled. At 1 week after EVL, indocyanine green solution (1 mg/ml) was injected submucosally around the remaining varices. A diode laser (power 10 watts) was applied to the surface from the esophagogastric junction to 5 cm above it. The spot size was kept to 5 mm in diameter. RESULTS: Laser irradiation was performed safely, without bleeding from the varices, or perforation. There were no major complications. Endoscopy 1 month later showed F0 forms in seven patients, F1 in one patient, and no red color sign in any patient. No recurrence of varices has been observed in any of the patients during the follow-up period of at least 12 months. CONCLUSION: This technique may provide a simple, safe and effective procedure, as an additional treatment to EVL, for the prevention of recurrence of esophageal varices.     

密集多点结扎术治疗肝癌合并食管曲张静脉急性出血疗效观察

目的探讨内镜下密集多点结扎术(DEVL)治疗原发性肝癌合并食管曲张静脉急性出血的临床疗效。方法采用内镜下密集多点结扎术治疗原发性肝癌合并食管静脉曲张急性出血患者58例。急性出血控制后,每隔2周重复治疗,直至曲张静脉完全根治。结果50例完成全部结扎治疗,共完成146次、1141点结扎,平均每例结扎2.9次、22.8点。急诊止血率91.4%,近期再出血率20.7%,曲张静脉根治率为82%。结论内镜下密集结扎术能有效地治疗原发性肝癌合并食管静脉曲张急性出血,根治食管曲张静脉和预防再出血。DEVL治疗不受肝功能的影响,并发症少。     

α-氰丙烯酸烷基酯栓塞治疗胃静脉曲张破裂出血的临床观察

目的评价经内镜注射组织黏合剂α-氰丙烯酸烷基酯栓塞治疗胃静脉曲张的临床疗效及不良反应。方法 18例临床确诊的肝硬化合并急性胃静脉曲张破裂出血的患者中,活动出血5例,近期出血13例,胃静脉曲张Sarin分类胃食管静脉曲张Ⅰ型（GOV1）7例,胃食管静脉曲张Ⅱ型（GOV2）8例,孤立性胃静脉曲张Ⅰ型（IGV1）7例,在静脉滴注奥曲肽的同时,经内镜首先选择靶静脉及穿刺点,根据曲张静脉的直径确定组织黏合剂的剂量,依次对胃曲张静脉采用三明治法进行组织黏合剂栓塞治疗,11例合并食管静脉曲张的患者在栓塞治疗后联合食管曲张静脉套扎治疗,术后进行内镜随访,观察止血成功率、早期再出血率、病死率、静脉曲张消退情况以及不良反应。结果急诊止血成功率100%,早期再出血率0%、静脉曲张消退显效13例（72.2%）,有效3例（16.7%）,无效2例（11.1%）;3例出现术后低热,1例出现大肠杆菌败血症;11例注射部位出现糜烂,4例注射部位形成溃疡;1例术中出血。结论经内镜注射组织黏合剂α-氰丙烯酸烷基酯栓塞治疗胃静脉曲张破裂出血是一种简便、安全、有效的方法。     

套扎与硬化"夹心"联合法治疗食管静脉曲张出血的近远期疗效分析

[目的]探讨经内镜套扎与硬化“夹心”联合法(套扎—硬化—套扎)治疗食管静脉曲张出血(EVB)的疗效与安全性。[方法]对166例EVB患者采用“夹心”联合法治疗,其中10例在首次内镜治疗中同时进行食管静脉造影检查术。间隔10～12d后重复1次内镜治疗,直至静脉曲张消除。[结果]食管静脉造影检查显示。硬化剂在食管曲张静脉内滞留的时间超过30min。夹心法对活动性EVB止血成功率为100％(19／19),静脉曲张消除率93．4％(155／166)。达到消除的平均治疗次数1．9次。所需平均时间18．8d。并发症发生率8．4％(14／166)。随访时间6～60个月,平均36个月。随访期内静脉曲张复发率11．7％(7／60),再出血率13．3％(8／60)。[结论]套扎与硬化“夹心”联合法是治疗食管静脉曲张出血安全而有较的方法。     

胃镜结扎及硬化剂注射治疗食管静脉曲张的临床应用

经胃镜下结扎（EVL）后附加硬化剂注射（EIS）联合治疗食管静脉曲张患者106例，101例一个月内无出血，止血率为95．3％。经过1—2次胃镜结扎治疗后再用硬化剂治疗，88例食管静脉曲张完全消失，消失率达83．0％，余18例（17％）静脉曲张明显缩小。结果提示，采用EVL和EIS联合治疗重庆食管静脉曲张与单纯使用EVL或EIS治疗的止血效果和食管静脉曲张消失率两种方法相比有显著的差异（分别为P＜0．01和P＜0．05）。它具有方法简单、安全、能有效地控制急性出血及手术后再出血，降低死亡率，使肝功能差的患者度过出血期，为择期手术创造条件。     

内镜下套扎硬化序贯治疗食管曲张静脉疗效及预后影响因素的探讨

目的观察内镜下套扎(EVL)及硬化序贯治疗在肝硬化食管静脉曲张患者中应用的疗效,并研究预后的相关危险因素。方法收集未进行内镜下治疗的食管静脉曲张破裂出血患者设为对照组,仅进行药物治疗,共106例,研究组为内镜下治疗+药物治疗患者,入组共113例,研究组中又随机分为单纯套扎组(EVL组)和套扎硬化序贯组,观察治疗后曲张静脉消除率、再出血率、总治疗次数、死亡率和术中及术后并发症,进行比较。并比较对照组和研究组肝功能Child-Turcotte-Pugh(CTP)分级和终末期肝病模型(MELD)不同评分的再出血率和死亡率,分析预后影响因素,评价其对预后的诊断价值。结果对照组、EVL组和套扎硬化序贯组再出血率分别为41.51%、10.53%和10.64%,对照组与套扎硬化序贯组比较,差异有统计学意义(P=0.000);3组的死亡率分别为15.09%、5.26%和2.13%,对照组与EVL组、对照组与序贯组、EVL与序贯组比较,分别为P0.05、P=0.001和P0.05;套扎硬化序贯治疗的半年内复发率44.68%,EVL组复发率73.68%,两者比较差异有统计学意义(P=0.021);无论是对照组还是EVL组和序贯治疗组,肝功能CTP C级的再出血、死亡率明显高于A级;MELD模型中,受试者工作特征曲线(ROC)的曲线下面积(AUC)再出血率对照组、序贯组分别为0.944和0.851,死亡率两组分别为0.881和0.984,而复发率EVL组、序贯组分别为0.914和0.765,MELD评分对再出血和死亡的预测具有重要价值。结论套扎硬化序贯治疗能明显降低肝硬化食管曲张静脉患者的再出血率和死亡率,且套扎硬化序贯治疗的复发率要低于单纯套扎。肝功能CTP评分评级和MELD评分对再出血和死亡的预测均具有重要价值,套扎硬化序贯治疗能明显降低CTP为B级和C级静脉曲张的再出血和死亡率,并提高再出血和死亡的MELD阈值。