超声内镜引导下曲张静脉精准断流术治疗食管胃底静脉曲张有效性及安全性的初步研究（含视频）

Preliminary research of the therapeutic efficacy and safety of endoscopic ultrasound‑guided selective varices devascularization for the treatment of esophagogastric varices (with video)

摘要:

目的 初步评估超声内镜引导下曲张静脉精准断流术（endoscopic ultrasound⁃guided selective varices devascularization，EUS⁃SVD）治疗食管胃底静脉曲张的疗效及安全性。方法 2021年2月—12月在安徽医科大学第一附属医院行传统胃镜下硬化剂组织胶注射或EUS⁃SVD治疗的43例肝硬化食管胃底静脉曲张病例纳入回顾性研究，按内镜治疗方式分为EUS⁃SVD治疗组（超声内镜组，n=22）和传统胃镜下硬化剂组织胶注射治疗组（传统胃镜组，n=21），比较硬化剂用量、组织胶用量、术后2个月内食管静脉曲张治疗有效率、术后3个月内再出血率以及不良反应发生率。结果 患者平均年龄、性别构成、肝硬化病因构成、肝功能Child⁃Pugh分级构成、食管静脉曲张分级构成、内镜治疗指征构成以及胃底曲张静脉平均最大直径方面，2组间比较差异均无统计学意义（P>0.05），基线资料具有可比性。超声内镜组术中可检测胃底曲张静脉的胃壁外穿通支静脉，注射治疗后可检测胃底曲张静脉是否消失，而传统胃镜组无法检测以上2个指标。硬化剂、组织胶用量超声内镜组分别为（7.54±3.10）mL和（1.30±0.57）mL，传统胃镜组对应分别为（7.57±3.50）mL（t=0.026，P=0.980）和（1.38±0.67）mL（t=-0.452，P=0.654）；术后2个月内食管静脉曲张治疗有效率超声内镜组为63.6%（14/22），高于传统胃镜组的52.4%（11/21），但差异无统计学意义（χ2=0.559，P=0.455）；术后3个月内再出血率超声内镜组为4.5%（1/22），明显低于传统胃镜组的33.3%（7/21）（P=0.021）。2组均未发生异位栓塞和死亡事件。术后疼痛、发热、恶心呕吐发生率以及术后72 h内再出血率方面，2组间比较差异均无统计学意义（P>0.05）；胃底排胶溃疡发生率超声内镜组为9.1%（2/22），明显低于传统胃镜组的42.9%（9/21）（χ2=6.435，P=0.011）。结论 EUS⁃SVD治疗食管胃底静脉曲张安全、有效，能够清楚显示深层的胃壁内外穿通支血管，测量血管腔直径，准确注射组织胶，闭塞曲张静脉及穿通支血管，减少术后溃疡及再出血的发生。

Abstract:

Objective To evaluate the efficacy and safety of endoscopic ultrasound-guided selective varices devascularization (EUS-SVD) for the treatment of esophagogastric varices. Methods A total of 43 cases of liver cirrhosis with esophageal and gastric varices at the First Affiliated Hospital of Anhui Medical University from February to December 2021 were included in a retrospective cohort study. The cases were divided into two treatment groups based on endoscopic treatment: EUS⁃SVD group (n=22) and conventional endoscopic sclerosant injection group (conventional gastroscopy group, n=21). The doses of sclerosants and tissue glue, effective rate of esophageal varice treatment within 2 months after surgery, rebleeding rate within 3 months after surgery, and adverse reactions were compared. Results The differences in terms of mean patient age, gender composition, etiology of liver cirrhosis, Child‑Pugh classification of liver function, classification of esophageal varices, composition of endoscopic treatment indications, and mean maximum diameter of gastric varices were not statistically significant between the two groups (P>0.05), indicating the comparability of baseline data. Perforating veins outside the gastric wall of gastric varices could be detected during the procedure in the EUS‑SVD group, and disappearance of gastric varices after injection treatment could be determined, while these two indicators could not be detected in the conventional gastroscopy group. The amounts of sclerosing agents and tissue adhesives used in the EUS‑SVD group were 7.54±3.10 mL and 1.30±0.57 mL, respectively, while the corresponding amounts in the conventional gastroscopy group were 7.57±3.50 mL (t=0.026, P=0.980) and 1.38±0.67 mL (t=-0.452, P=0.654), respectively. The effective treatment rate for esophageal varice within 2 months after surgery was 63.6% (14/22) in the EUS‑SVD group and 52.4% (11/21) in the conventional gastroscopy group, but the difference was not statistically significant (χ2=0.559, P=0.455). The rebleeding rate within 3 months after surgery was 4.5% (1/22) in the EUS‑SVD group, significantly lower than the rate of 33.3% (7/21) in the conventional gastroscopy group (P=0.021). Neither group experienced events of ectopic embolism or death. There was no statistically significant difference between the two groups in terms of postoperative pain, fever, nausea and vomiting, or rebleeding rate within 72 hours after surgery (P>0.05). The incidence of gastric fundus ulcers was 9.1% (2/22) in the EUS‑SVD group, significantly lower than the rate of 42.9% (9/21) in the conventional gastroscopy group (χ2=6.435, P=0.011). Conclusion EUS‑SVD treatment for esophagogastric varices is safe and effective. It can clearly display the deep‑seated intramural vessels of the gastric wall, measure the diameter of the blood vessels, accurately inject tissue glue, occlude the varicose veins and perforating vessels, and reduce the occurrence of postoperative ulcers and rebleeding.