肝硬化食管胃静脉曲张的内镜治疗

肝硬化食管胃静脉曲张出血是危及生命的门脉高压并发症。食管静脉曲张一级预防策略为非选择性β受体阻滞剂（non selective beta blockers,NSBBs）或内镜下静脉曲张套扎术（endoscopic variceal ligation,EVL）,急性出血时首选EVL,其二级预防推荐NSBBs联合EVL。胃静脉曲张出血中,食管胃静脉曲张1型（gastroesophageal varices type 1,GOV1）应用EVL,食管胃静脉曲张2型（gastroesophageal varices type 2,GOV2）和孤立胃静脉曲张（isolated gastric varices,IGV）推荐内镜下组织胶注射术。预防胃静脉曲张再出血方面,内镜下组织胶注射术和经颈静脉肝内门体分流术（transjugular intrahepatic portosystemic shunt,TIPS）可应用于GOV2型和IGV,EVL、NSBBs或内镜下组织胶注射术可应用于GOV1型。胃静脉曲张一级预防可选用NSBBs或内镜下组织胶注射术。     

内镜套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血疗效观察

目的观察内镜套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血的疗效。方法选择73例食管胃底静脉曲张破裂出血的患者,药物+内镜(生长抑素+内镜套扎术联合组织胶注射)治疗组34例,内科保守治疗(生长抑素+普洛奈尔)组39例,观察两组止血有效率和再出血率。结果药物+内镜治疗组止血有效率94.12%,再出血率5.88%;内科保守治疗止血有效率74.36%,再出血率27.27%。两组止血有效率差异无统计学意义(P>0.05),药物+内镜治疗组再出血率发生率明显低于内科保守治疗组,差异有统计学意义(P<0.05)。结论内镜下套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血安全有效。     

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。     

内镜下套扎与硬化剂治疗食管静脉曲张破裂出血疗效的Meta分析

目的系统评价内镜下套扎疗法(EVL)与硬化剂治疗(EVS)食管静脉曲张破裂出血的疗效与安全性。方法全面检索Pubmed、Web of Science、The Cochrane Library(2016年2期)、CNKI、Wan Fang Data数据库,检索时限均为1980年1月-2016年3月,纳入内镜下治疗食管静脉曲张破裂出血的随机对照试验,采用Rev Man5.3软件进行Meta分析。结果最终纳入24项研究,共计2 020例患者。Meta分析结果显示两组食管静脉曲张根除率差异无统计学意义[相对危险度(RR)=1.04,95%CI(0.99,1.09),P=0.090],EVL组较EVS组更能减少食管静脉曲张再出血率[RR=0.69,95%CI(0.59,0.81),P=0.000]、病死率[RR=0.76,95%CI(0.63,0.90),P=0.002]和并发症发生率[RR=0.41,95%CI(0.26,0.63),P=0.000],且差异具有统计学意义,但是在减少食管静脉曲张复发率方面,EVS组有更好的优越性,差异具有统计学意义[RR=1.67,95%CI(1.40,2.01),P=0.000]。结论现有证据表明,与内镜下EVS比较,EVL治疗食管静脉曲张破裂出血的静脉曲张根除率与EVS法相当,但EVL法的食管静脉曲张再出血率、病死率及并发症发生率更小。     

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.     

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.     

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。     

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。     

ESVD联合EIS治疗食管-胃连通型静脉曲张的安全性及可行性分析

目的探讨内镜下贲门胃底静脉曲张精准断流术(ESVD)联合内镜下食管静脉曲张硬化剂注射治疗术(EIS)在食管-胃连通型静脉曲张治疗中的临床疗效及安全性。方法选择该院肝硬化合并食管-胃连通型静脉曲张破裂出血的患者260例,根据不同治疗方法分为3组:食管静脉曲张套扎治疗组(EVL组)、EIS治疗组(EIS组)及ESVD联合EIS组(联合治疗组)。术后随访2年,比较3组的静脉曲张改善率(3个月后)、早期再出血率(2周内)、迟发性再出血率(3个月内)、总再出血率(2年内)、并发症发生情况和治疗费用。结果 3组患者静脉曲张总改善率为93.5%(243/260),联合治疗组高于其他两组(P 0.05);3组患者早期再出血率比较,差异无统计学意义(P 0.05),联合治疗组迟发性再出血率和总再出血率均较其他两组低(P 0.05);3组均未发生异位栓塞,联合治疗组术后发热发生率明显高于其他两组(P 0.05),EVL组术后疼痛感强于其他两组(P 0.05);联合治疗组治疗费用明显高于其他两组(P 0.05)。结论对于食管-胃连通型静脉曲张,ESVD联合EIS治疗可取得较好疗效,且未明显增加并发症发生率,但治疗费用可能偏高。     

药物治疗与内镜套扎预防肝硬化食管静脉曲张再出血的对比研究

目的比较口服普奈洛尔联合5-单硝酸异山梨醇酯与内镜套扎对肝硬化食管静脉曲张再出血的预防效果。方法2000-2005年间，146例肝硬化食管静脉曲张患者分别给予口服普奈洛尔联合5-单硝酸异山梨醇酯与内镜套扎治疗，追踪随访2年，比较两组再出血率、病死率、并发症发生率的情况。结果药物治疗组与内镜套扎组的再出血率分别为34．3％、36．2％；病死率为12．9％、15．9％，两者差别无统计学意义（P〉0．05）。并发症发生率分别为7．1％、24．6％，药物治疗组低于内镜套扎（P〈0．05）。对于肝功能较好者（Child—Pugh分级A和B）药物治疗的再出血率较内镜套扎治疗要低（11．1％／36．2％，P〈0．05）；而肝功能较差者（Child-Pugh分级C），内镜套扎治疗的再出血率较药物治疗要低（93．8％／36．4％，P〈0．05）。结论普奈洛尔联合5-单硝酸异山梨醇酯与内镜套扎相比，再出血率、病死率相当，但并发症发生率较低。对于肝功能Child-Pugh分级A和B的肝硬化患者，药物治疗能更有效的预防食管静脉曲张再出血；而肝功能Child—Pugh分级C的患者，内镜套扎治疗更有效。     

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。     

Ruptured gastric fundal varices treated with endoscopic variceal ligation and transjugular retrograde obliteration: case report

Therapeutic modalities for the obliteration of collateral vessels connecting the portal venous system with the systemic circulation, transjugular retrograde obliteration (TJO) and balloon-occluded retrograde transvenous obliteration have recently been developed, and several satisfactory results have been reported with their use. We report a case of ruptured gastric fundal varices treated with TJO after endoscopic variceal ligation (EVL). In our case, variceal bleeding was controlled successfully with EVL and varices were eradicated with TJO.     

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。     

食管静脉曲张破裂出血内镜套扎术后联合生长抑素预防近期再出血的临床研究

目的：观察食管静脉曲张破裂出血行食管静脉曲张内镜套扎术（EVL）后联合使用生长抑素对预防近期再出血的有效性。方法：144例静脉曲张破裂引起上消化道大出血的患者,予以内镜套扎术治疗后,56例使用生长抑素治疗患者设为观察组,88例未使用生长抑素治疗患者设为对照组,比较两组近期再出血发生率。结果：两组初次止血成功率均为100％。144例食管静脉曲张破裂出血患者经EVL治疗后,观察组近期再出血率为23．2％,对照组近期再出血率为6．8％,观察组近期再出血率高于对照组,但比较差异无统计学意义（P〉0．05）。结论：EVL联合使用生长抑素对预防食管静脉曲张破裂出血近期再出血可能无优势,提示对轻症病例可不推荐使用生长抑素。     

Endoscopic variceal ligation plus propranolol vs. transjugular intrahepatic portosystemic stent shunt: a long-term randomized trial

BACKGROUND AND STUDY AIMS: After a first variceal bleeding episode in patients with cirrhosis of the liver, treatment with transjugular intrahepatic portosystemic stent shunt (TIPS) and endoscopic variceal ligation (EVL) plus propranolol were compared, with regard to prevention of variceal rebleeding, complications, and mortality. PATIENTS AND METHODS: 85 patients were randomly allocated to receive TIPS (n = 43) or EVL (n = 42). The groups were comparable regarding age, sex, etiology of liver cirrhosis, and liver function. RESULTS: The mean observation times were 4.1 years in the TIPS group and 3.6 years in the EVL group. Although the probability of rebleeding was higher in the EVL group (29.9%) than in the TIPS group (19.4%), the difference was not statistically significant. Three of five patients of the EVL group successfully underwent TIPS placement after treatment failure. The probability of TIPS dysfunction requiring shunt revision was 89 %. Hepatic encephalopathy was observed more often in the TIPS group (40.5%) than in the EVL group (20.5%; P < 0.05). The probability of survival was similar in both groups (TIPS group 75.9%, EVL group 82.2%; n.s.). CONCLUSIONS: In view of its good efficacy and the lower cost of treatment, endoscopic ligation plus propranolol may be recommended as initial procedure for prevention of recurrent variceal hemorrhage, whereas TIPS seems to be the preferable procedure in patients with recurrent bleeding after adequate endoscopic and pharmacological treatment.     

A new approach to esophageal varices: endoscopic variceal ligation

Bleeding from esophageal varices is a devastating complication of portal hypertension and is associated with a high mortality rate. The management goals for this group of patients are to achieve hemostasis in the acute phase, reduce variceal size, reduce the potential of rebleeding and eliminate varices with a follow-up program. For the past two decades, the gold standard of treatment has been endoscopic sclerotherapy but at the expense of many complications, which often cause serious morbidity. Endoscopic variceal ligation was developed as an alternative to endoscopic sclerotherapy. The experience to date shows that the goals of therapy can be achieved with fewer complications than those associated with sclerotherapy.     

改良Sugiura术与选择性断流术治疗门脉高压症致食管胃底静脉曲张的有效性和安全性比较

目的:比较改良Sugiura术和选择性断流术治疗门静脉高压症(portal hypertension, PHT)合并食管胃底静脉曲张破裂出血(esophageal and gastric varices bleeding, EGVB)的临床疗效。方法:回顾性分析2005年9月1日至2019年12月1日45例行改良Sugiura术(改良组)和65例行选择性断流术(选择组)的PHT致EGVB患者的临床资料,比较两组患者术后累计生存率、再出血率及食管胃底静脉曲张缓解率。结果:改良组与选择组术后3个月死亡率分别为2.22%、1.54%;两组术后并发症发生率及死亡率差异均无统计学意义。随访截至2019年12月1日,改良组累计1、3、5年生存率分别为97.14%、84.62%、78.26%,累计1、3、5年再出血率分别为2.78%、12.00%、18.18%,术后3～6个月、1年及至随访截止日食管胃底静脉曲张缓解率分别为92.68%、87.80%、82.93%;选择组累计1、3、5年生存率分别为98.00%、89.19%、71.43%,累计1、3、5年再出血率分别为3.85%、21.95%、43.75%,术后3～6个月、1年及至随访截止日食管胃底静脉曲张缓解率分别为92.86%、87.50%、64.29%。两组术后远期累计生存率、并发症发生率差异无统计学意义;两组术后远期累计再出血率及食管胃底静脉曲张缓解率差异均有统计学意义(P0.05)。结论:两种断流术均为治疗PHT合并EGVB患者的有效术式,术后患者近、远期疗效相似,但对于食管胃底静脉曲张中、重度且伴有出血史的患者,改良Sugiura术的远期疗效更好,应优先选择。     

不同Child-Pugh分级的原发性肝癌并发食管静脉曲张破裂出血套扎术后患者的生存分析

目的 分析不同Child-Pugh分级的原发性肝癌并发食管静脉曲张破裂出血并接受套扎术后患者的预后与生存情况。 方法 入选患者74例作为观察组,以未接受套扎的53例作为对照组,比较两组的预后与生存时间。 结果 随访期内对照组的再出血高于观察组（54.7% vs 17.6%,P=0.000）,且再出血量大于观察组（P<0.05）。观察组的生存期均数及中位数分别为31及32月,而对照组分别为21及16月,Kaplan-Meier分析显示两组患者的生存期差异具有统计学意义（χ2=9.499,P=0.002）。接受内镜下静脉曲张套扎术治疗的Child-Pugh A级B级患者的再出血时间间隔延长、再出血率降低、再出血量减少、患者的生存期延长,但对Child-Pugh C级患者的疗效尚有待更多病例验证。 结论 食管静脉曲张破裂出血肝功能为Child-Pugh A、B级患者应尽早行内镜下静脉曲张套扎术,Child-Pugh C级患者采用内镜下静脉曲张套扎术的并不会缩短患者的生存时间。       

Three years experience with endoscopic variceal ligation for treatment of bleeding varices.

Endoscopic variceal ligation (EVL) was developed as an alternative to endoscopic variceal sclerosis (ES) because of the high complication rate seen with ES. The new technique involves placement of small elastic bands around the variceal channels in the distal esophagus. The first 146 consecutive patients treated with EVL during the period from August, 1986 to July, 1989 are reported. Portal hypertension was caused by alcoholic liver disease in 93 of these patients. The average age of the patients was 53 years and 66% were males. All of the patients had recently bled from esophageal varices. At the time of treatment, 23% of the patients were actively bleeding. They were all treated acutely with EVL and had repeated treatments with the long-term goal of variceal eradication. The overall survival was 73%. Varices were eradicated or reduced to grade one in 78% of the 125 patients who were followed for more than 30 days. Variceal eradication required a mean of 5.5 sessions. Recurrent bleeding occurred in 44% of the total patient population. There were no major complications from EVL. It is concluded from this non-randomized experience that EVL is an effective treatment for bleeding esophageal varices and that it appears to be as effective as sclerotherapy with fewer complications.     

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。