内镜下胃静脉曲张注射点定位准确性的影响因素初探

Influencing factors for the accuracy of injection site selection for gastric varices under endoscopy

摘要:

目的 比较内镜与超声内镜联合印度墨汁标记定位胃曲张静脉注射点的一致性，探讨内镜下胃静脉曲张特征对注射点定位的影响。方法 前瞻性纳入2021年8月至2022年10月在安徽医科大学第一附属医院确诊胃静脉曲张需行内镜下组织胶治疗的患者。首先使用内镜观察胃静脉曲张并测量大小、判断注射点部位；再使用超声内镜探查血管，并寻找穿通支来源静脉，应用印度墨汁标记靶血管注射点，给予组织胶治疗；然后改用内镜观察治疗后情况、寻找标记点。观察标记点是否清晰，比较内镜下注射点部位与印度墨汁标记部位是否一致，根据内镜下标记和超声内镜下标记点是否吻合分为吻合组和不吻合组，探讨内镜下胃静脉曲张特征对注射点定位的影响，并统计治疗疗效、术后相关不良事件等。结果 最终纳入34例患者，均一次性在超声内镜引导下完成标记，过程顺利无并发症。共40个标记点，内镜下印度墨汁染色均清晰可见。超声内镜与内镜吻合组的标记点与不吻合组的标记点之间分布差异有统计学意义（χ2=9.103，P=0.003）。血管完全闭塞率100.00%（40/40）。术后发生13例不良事件，主要为发热、腹痛、恶心，无过敏和异位栓塞等严重不良事件发生。吻合组血管直径（10.84±4.02）mm，不吻合组（8.80±1.61）mm，差异有统计学意义（t=1.870，P=0.031）。吻合组隆起血管占88.00%（22/25），高于不吻合组的53.33%（8/15），差异有统计学意义（χ2=6.009，P=0.024）。结论 内镜下胃静脉曲张注射点定位准确性受到血管直径及隆起形态影响，对于隆起不明显、直径较小的血管，内镜下注射点定位准确性下降。

Abstract:

Objective To compare the accuracy of endoscopy and endoscopic ultrasonography (EUS) combined with Indian ink marking in locating injection sites for gastric varices, and to explore the influence of the features of gastric varices under endoscopy on the injection sites. Methods Consecutive patients with gastric varices scheduled for EUS-guided glue injection therapy at the First Affiliated Hospital of Anhui Medical University from August 2021 to October 2022 were perspectively included. Firstly, gastric varices were assessed under endoscopy, where the size of the veins were estimated while the injection site was preliminarily judged during the procedure. Then EUS was used to identify perforating feeding veins and mark injection sites with Indian ink. After tissue adhesive was injected into identified varices, the change of varices after injection was observed and the marking was identified under endoscopy again. The clarity of the markinges was confirmed and the consistency between EUS-guided Indian ink mark and that under endoscopy was compared. Patients were divided into anastomosis group and non-anastomosis group based on marking consistency to investigate the effect of gastric varices features on the location of injection sites under endoscopy. Treatment efficacy and postoperative adverse events were counted. Results Finally, 34 patients were included and all of them underwent successful marking under EUS guidance without complications. A total of 40 marker sites were clearly visible with Indian ink staining under endoscopy. The difference in distribution between the anastomotic group and non-anastomotic group marker points between EUS and endoscopy was statistically significant (χ2=9.103, P=0.003). Vascular occlusion rate was 100.00% (40/40). There were 13 adverse events after operation, mainly fever, abdominal pain and nausea, and no serious adverse events such as allergy and ectopic embolization occurred. There was significant difference between the blood vessel diameter of the anastomotic group (10.84±4.02 mm) and that of the non-anastomotic group (8.80±1.61 mm, t=1.870, P=0.031). The percentage of raised vessels in the anastomotic group was 88.00% (22/25), higher than that in the non-anastomotic group [53.33% (8/15)], and the difference was statistically significant (χ2=6.009, P=0.024). Conclusion Accuracy in positioning under endoscopy is influenced by variceal diameter and bulge shape, being less precise in varices with smaller diameters and less pronounced bulges.