肝硬化患者内镜预防食管胃静脉曲张再出血:10年经验
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摘要
目的评估肝硬化食管胃静脉曲张(gastroesophageal varice, GOV)患者内镜治疗的预后。方法从数据库中检索2004年1月1日至2013年12月31日,年龄>18岁,至复旦大学附属中山医院就诊,经胃镜检查确诊存在GOV且曾有过出血的肝硬化患者。通过随访再出血、治疗转变和生存情况,评估预后变化及其预后影响因素。结果共纳入患者558例,2004年1月1日至2010年12月31日共235例,2011年1月1日至2013年12月31日共323例。年龄18～84岁,中位年龄55岁,男364例(65.2%)。Child评分中位数为7分(5～13分)。肝硬化常见病因乙肝230例(57.9%),乙肝肝硬化发生率从2004-2010年的63.8%下降到2011-2013年的53.6%。在2004-2010年行单纯食管静脉曲张套扎治疗182例(77.4%),食管套扎联合胃组织黏合剂治疗28例(11.9%)。2011-2013年行食管套扎联合胃组织黏合剂治疗194例(60.1%),单纯食管静脉曲张套扎治疗90例(27.9%)。共62例患者发生了治疗转换,脾切除联合断流的患者从87.9%逐渐减少至62.1%。两个时间段累积未再出血率比较,差异有统计学意义(P=0.010)。两组的累积生存率比较,差异有统计学意义(P<0.001)。两个时间段治疗无效者分别为78例(33.2%)和77例(23.8%)(P=0.015)。结论随着以食管套扎为主逐渐转变为联合食管套扎与胃组织黏合剂治疗为主的内镜治疗方式的转变,内镜治疗GOV患者的预后得到了显著改善。
Objective To evaluate the prognosis of patients with gastroesophageal varice(GOV) due to cirrhosis treated by endoscopy. Methods The database was searched from Jan. 1 st, 2004 to Dec. 31 st, 2013 in Zhongshan Hospital, Fudan University. The study included patients who were older than 18 years old and diagnosis of cirrhosis with GOV hemorrhage. The prognostic changes and prognostic factors were evaluated by follow-up of rebleeding. Results A total of 558 patients were enrolled, 235 patients from 2004 to 2010, and 323 patients from 2011 to 2013. The median age was 55 years old(18-84 years old) and 364 males(65.2%). Median Child score was 7 points(5-13 points). The major cause of cirrhosis was hepatitis [230 cases(57.9%)]. From 2004-2010 to 2011-2013, the incidence rate of post-hepatitis B cirrhosis decreased from 63.8% to 53.6%. In 2004-2010, 182 patients(77.4%) were treated with esophageal band ligation and 28 cases(11.9%) were treated with esophageal ligation combined with gastric tissue adhesive treatment. In 2011-2013, 194 cases(60.1%) were treated with esophageal ligation combined with gastric tissue adhesive treatment, and 90 cases(27.9%) were treated with esophageal band ligation. A total of 62 patients had a conversion of treatment, patients with splenectomy and esophagogastric devascularization were gradually reduced from 87.9% to 62.1%. The cumulative non-rebleeding rates were statistically significant difference between two groups(P=0.010). The difference of cumulative survival rates were statistically significant between two groups(P<0.001). The ineffective rates of treatment in two time groups were 78 cases(33.2%) and 77 cases(23.8%) respectively(P=0.015). Conclusion The outcomes of patients with GOV have been significantly improved with the transition from esophageal ligation-based treatment to esophageal ligation combined with gastric tissue adhesive injection.
Objective To evaluate the prognosis of patients with gastroesophageal varice(GOV) due to cirrhosis treated by endoscopy. Methods The database was searched from Jan. 1 st, 2004 to Dec. 31 st, 2013 in Zhongshan Hospital, Fudan University. The study included patients who were older than 18 years old and diagnosis of cirrhosis with GOV hemorrhage. The prognostic changes and prognostic factors were evaluated by follow-up of rebleeding. Results A total of 558 patients were enrolled, 235 patients from 2004 to 2010, and 323 patients from 2011 to 2013. The median age was 55 years old(18-84 years old) and 364 males(65.2%). Median Child score was 7 points(5-13 points). The major cause of cirrhosis was hepatitis [230 cases(57.9%)]. From 2004-2010 to 2011-2013, the incidence rate of post-hepatitis B cirrhosis decreased from 63.8% to 53.6%. In 2004-2010, 182 patients(77.4%) were treated with esophageal band ligation and 28 cases(11.9%) were treated with esophageal ligation combined with gastric tissue adhesive treatment. In 2011-2013, 194 cases(60.1%) were treated with esophageal ligation combined with gastric tissue adhesive treatment, and 90 cases(27.9%) were treated with esophageal band ligation. A total of 62 patients had a conversion of treatment, patients with splenectomy and esophagogastric devascularization were gradually reduced from 87.9% to 62.1%. The cumulative non-rebleeding rates were statistically significant difference between two groups(P=0.010). The difference of cumulative survival rates were statistically significant between two groups(P<0.001). The ineffective rates of treatment in two time groups were 78 cases(33.2%) and 77 cases(23.8%) respectively(P=0.015). Conclusion The outcomes of patients with GOV have been significantly improved with the transition from esophageal ligation-based treatment to esophageal ligation combined with gastric tissue adhesive injection.
引文
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[11] 中华医学会消化内镜学分会.食管胃静脉曲张内镜下诊断和治疗规范试行方案(2003年)[J].中华消化内镜杂志,2004,21(3):149-151.DOI:10.3760/cma.j.issn.1007-5232.2004.03.001.
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[14] 李萍,刘冰熔.食管胃底静脉曲张出血的内镜下治疗[J].胃肠病学和肝病学杂志,2018,27(1):105-110.DOI:10.3969/j.issn.1006-5709.2018.01.024.LI P,LIU B R.Endoscopic treatment of esophageal gastric variceal bleeding [J].Chin J Gastroenterol Hepatol,2018,27(1):105-110.DOI:10.3969/j.issn.1006-5709.2018.01.024.
[15] TRIPATHI D,STANLEY A J,HAYES P C,et al.U.K.guidelines on the management of variceal haemorrhage in cirrhotic patients [J].Gut,2015,64(11):1680-1704.DOI:10.1136/gutjnl-2015-309262.
[16] NERY F,CHEVRET S,CONDAT B,et al.Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis:results of a longitudinal study [J].Hepatology,2015,61(2):660-667.DOI:10.1002/hep.27546.
[17] AMITRANO L,GUARDASCIONE M A,SCAGLIONE M,et al.Splanchnic vein thrombosis and variceal rebleeding in patients with cirrhosis [J].Eur J Gastroenterol Hepatol,2012,24(12):1381-1385.DOI:10.1097/MEG.0b013e328357d5d4.
[18] AMITRANO L,GUARDASCIONE M A,MANGUSO F,et al.The effectiveness of current acute variceal bleed treatments in unselected cirrhotic patients:refining short-term prognosis and risk factors [J].Am J Gastroenterol,2012,107(12):1872-1878.DOI:10.1038/ajg.2012.313.
[19] DE FRANCHIS R,BAVENO VI FACULTY.Expanding consensus in portal hypertension:report of the baveno Ⅵ consensus workshop:stratifying risk and individualizing care for portal hypertension [J].J Hepatol,2015,63(3):743-752.DOI:10.1016/j.jhep.2015.05.022.
[2] WILLIAMS R,ALEXANDER G,ASPINALL R,et al.Gathering momentum for the way ahead:fifth report of the Lancet Standing Commission on Liver Disease in the UK [J].Lancet,2018,392(10162):2398-2412.DOI:10.1016/S0140-6736(18)32561-3.
[3] CHANG B,LI B,SUN Y,et al.Changes in etiologies of hospitalized patients with liver cirrhosis in beijing 302 hospital from 2002 to 2013 [J].Mediators Inflamm,2017,2017:5605981.DOI:10.1155/2017/5605981.
[4] BERZIGOTTI A,SEIJO S,REVERTER E,et al.Assessing portal hypertension in liver diseases [J].Expert Rev Gastroenterol Hepatol,2013,7(2):141-155.DOI:10.1586/egh.12.83.
[5] GARCíA-PAGáN J C,GRACIA-SANCHO J,BOSCH J.Functional aspects on the pathophysiology of portal hypertension in cirrhosis [J].J Hepatol,2012,57(2):458-461.DOI:10.1016/j.jhep.2012.03.007.
[6] GARCIA-TSAO G,SANYAL A J,GRACE N D,et al.Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis [J].Hepatology,2007,46(3):922-938.DOI:10.1002/hep.21907.
[7] GARCíA-PAGáN J C,VILLANUEVA C,ALBILLOS A,et al.Nadolol plus isosorbide mononitrate alone or associated with band ligation in the prevention of recurrent bleeding:a multicentre randomised controlled trial [J].Gut,2009,58(8):1144-1150.DOI:10.1136/gut.2008.171207.
[8] ZENG X Q,MA L L,TSENG Y J,et al.Endoscopic cyanoacrylate injection with or without lauromacrogol for gastric varices:a randomized pilot study [J].J Gastroenterol Hepatol,2017,32(3):631-638.DOI:10.1111/jgh.13496.
[9] CHEN J,ZENG X Q,MA L L,et al.Long-term efficacy of endoscopic ligation plus cyanoacrylate injection with or without sclerotherapy for variceal bleeding [J].J Dig Dis,2016,17(4):252-259.DOI:10.1111/1751-2980.12331.
[10] 黄晓铨,陈世耀.用循证医学观点看食管胃静脉曲张处理中的争议[J].胃肠病学和肝病学杂志,2018,27(9):976-978.DOI:10.3969/j.issn.1006-5709.2018.09.005.HUANG X Q,CHEN S Y.Controversy in the treatment of gastroesophageal varices from the view of evidence-based medicine [J].Chin J Gastroenterol Hepatol,2018,27(9):976-978.DOI:10.3969/j.issn.1006-5709.2018.09.005.
[11] 中华医学会消化内镜学分会.食管胃静脉曲张内镜下诊断和治疗规范试行方案(2003年)[J].中华消化内镜杂志,2004,21(3):149-151.DOI:10.3760/cma.j.issn.1007-5232.2004.03.001.
[12] SARIN S K,LAHOTI D,SAXENA S P,et al.Prevalence,classification and natural history of gastric varices:a long-term follow-up study in 568 portal hypertension patients [J].Hepatology,1992,16(6):1343-1349.
[13] BOSCH J,GARCíA-PAGáN J C.Prevention of variceal rebleeding [J].Lancet,2003,361(9361):952-954.DOI:10.1016/S0140-6736(03)12778-X.
[14] 李萍,刘冰熔.食管胃底静脉曲张出血的内镜下治疗[J].胃肠病学和肝病学杂志,2018,27(1):105-110.DOI:10.3969/j.issn.1006-5709.2018.01.024.LI P,LIU B R.Endoscopic treatment of esophageal gastric variceal bleeding [J].Chin J Gastroenterol Hepatol,2018,27(1):105-110.DOI:10.3969/j.issn.1006-5709.2018.01.024.
[15] TRIPATHI D,STANLEY A J,HAYES P C,et al.U.K.guidelines on the management of variceal haemorrhage in cirrhotic patients [J].Gut,2015,64(11):1680-1704.DOI:10.1136/gutjnl-2015-309262.
[16] NERY F,CHEVRET S,CONDAT B,et al.Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis:results of a longitudinal study [J].Hepatology,2015,61(2):660-667.DOI:10.1002/hep.27546.
[17] AMITRANO L,GUARDASCIONE M A,SCAGLIONE M,et al.Splanchnic vein thrombosis and variceal rebleeding in patients with cirrhosis [J].Eur J Gastroenterol Hepatol,2012,24(12):1381-1385.DOI:10.1097/MEG.0b013e328357d5d4.
[18] AMITRANO L,GUARDASCIONE M A,MANGUSO F,et al.The effectiveness of current acute variceal bleed treatments in unselected cirrhotic patients:refining short-term prognosis and risk factors [J].Am J Gastroenterol,2012,107(12):1872-1878.DOI:10.1038/ajg.2012.313.
[19] DE FRANCHIS R,BAVENO VI FACULTY.Expanding consensus in portal hypertension:report of the baveno Ⅵ consensus workshop:stratifying risk and individualizing care for portal hypertension [J].J Hepatol,2015,63(3):743-752.DOI:10.1016/j.jhep.2015.05.022.