非急诊状态食管静脉曲张套扎联合胃静脉曲张密集套扎的有效性及安全性

Efficacy and safety of esophageal variceal ligation combined with gastric variceal intensive ligation in non⁃emergency settings

摘要:

目的 评价肝硬化食管胃静脉曲张破裂出血非急诊状态下食管静脉曲张行内镜下曲张静脉套扎术（endoscopic variceal ligation，EVL）联合胃静脉曲张行内镜下曲张静脉密集套扎术（endoscopic variceal intensive ligation，EVIL）的疗效和安全性。方法 2017年1月至2023年3月间，因肝硬化伴食管胃静脉曲张破裂出血在河南省人民医院消化内科住院治疗的643例连续病例纳入回顾性研究，排除451例后，纳入192例，其中149例食管曲张静脉EVL联合胃静脉曲张EVIL治疗者纳入EVIL组，43例食管曲张静脉EVL联合胃静脉曲张内镜下组织胶注射术（endoscopic tissue adhesive injection，ETAI）治疗者纳入ETAI组，对比分析2组内镜治疗成功率、食管曲张静脉套扎环数、内镜治疗操作时间、住院时间、再出血率、死亡率和不良事件发生率。结果 EVIL组内镜治疗成功率明显高于ETAI组［100.0%（149/149）比95.3%（41/43），P=0.049］，食管曲张静脉套扎环数略多于ETAI组［8（6，11）环比7（6，9）环，Z=-1.29，P=0.196］，内镜治疗操作时间明显短于ETAI组［27.0（20.5，34.0）min比36.0（21.0，51.0）min，Z=-2.30，P=0.021］，住院时间明显短于ETAI组［10（7，13）d比13（9，15）d，Z=-3.02，P=0.003］。EVIL组术后24、72、120 h内，早期、迟发性和总再出血率分别为0.0%（0/149）、0.0%（0/149）、0.7%（1/149）、2.0%（3/149）、12.8%（19/149）和14.8%（22/149），ETAI组对应分别为4.7%（2/43）（P=0.049）、9.3%（4/43）（P=0.002）、9.3%（4/43）（χ2=6.69，P=0.010）、4.7%（2/43）（χ2=0.17，P=0.679）、30.2%（13/43）（χ2=7.34，P=0.007）和44.2%（19/43）（χ2=17.20，P<0.001）。2组均无与再出血相关的术后6周内死亡。EVIL组术后1年内再出血死亡率、随访期内再出血死亡率分别为1.3%（2/149）、3.4%（5/149），ETAI组对应分别为0.0%（0/43）（P=1.000）、2.3%（1/43）（χ2=0.02，P=0.876）。EVIL组术后发热、胸痛、恶心或呕吐发生率分别为12.1%（18/149）、14.1%（21/149）、13.4%（20/149），ETAI组对应分别为11.6%（5/43）（χ2=0.01，P=0.936）、16.3%（7/43）（χ2=0.13，P=0.721）、18.6%（8/43）（χ2=0.72，P=0.396）。EVIL组有2例（1.3%）发生胃曲张静脉脱环，ETAI组有1例（2.3%）发生异位栓塞。结论 对于肝硬化食管胃静脉曲张破裂出血适合非急诊内镜下治疗者，相比食管静脉曲张EVL联合胃静脉曲张ETAI治疗，食管静脉曲张EVL联合胃静脉曲张EVIL治疗同样安全，且疗效更优，具有治疗成功率高、操作用时少、住院时间短、再出血率及再出血死亡率低的优势。

Abstract:

Objective To evaluate the efficacy and safety of endoscopic variceal ligation (EVL) of esophageal varices combined with endoscopic variceal intensive ligation (EVIL) of gastric varices for gastroesophageal variceal bleeding with liver cirrhosis under non-emergency settings. Methods Data of 643 consecutive patients with gastroesophageal variceal bleeding due to liver cirrhosis admitted to the Department of Gastroenterology, Henan Provincial People''s Hospital from January 2017 to March 2023 were included in the retrospective study. A total of 192 patients were included after excluding 451 patients. One hundred and forty‑nine patients who underwent EVL of esophageal varices combined with EVIL of gastric varices were enrolled into the EVIL group, while 43 patients who underwent EVL of esophageal varices combined with endoscopic tissue adhesive injection (ETAI) of gastric varices were enrolled into the ETAI group. The endoscopic treatment success rate, esophageal variceal ligations number, operation time of endoscopic treatment, hospitalization time, rebleeding rate, mortality and the incidence of adverse events were compared between the two groups. Results Compared with the ETAI group, the EVIL group exhibited significantly higher endoscopic treatment success rate [100.0% (149/149) VS 95.3% (41/43), P=0.049], slightly greater esophageal variceal ligations number [8 (6, 11) rings VS 7 (6, 9) rings, Z=-1.29, P=0.196], shorter operation time of endoscopic treatment [27.0 (20.5, 34.0) min VS 36.0 (21.0, 51.0) min, Z=-2.30, P=0.021], and significantly shorter hospitalization time [10 (7, 13) d VS 13 (9, 15) d, Z=-3.02, P=0.003]. The rebleeding rate within 24, 72, 120 hours after the operation, early, delayed and total rebleeding in the EVIL group were 0.0% (0/149), 0.0% (0/149), 0.7% (1/149), 2.0% (3/149), 12.8% (19/149) and 14.8% (22/149) respectively, and 4.7% (2/43) (P=0.049), 9.3% (4/43) (P=0.002), 9.3% (4/43) (χ2=6.69, P=0.010), 4.7% (2/43) (χ2=0.17, P=0.679), 30.2% (13/43) (χ2=7.34, P=0.007) and 44.2% (19/43) (χ2=17.20, P<0.001) in the ETAI group, respectively. No death related to rebleeding occurred within 6 weeks after the operation in 2 groups. The mortality related to rebleeding within 1 year after the operation and during the follow-up period in the EVIL group were 1.3% (2/149) and 3.4% (5/149) respectively, and 0.0% (0/43) (P=1.000) and 2.3% (1/43) (χ2=0.02, P=0.876) in the ETAI group, respectively. The incidences of fever, chest pain, nausea or vomiting in the EVIL group were 12.1% (18/149), 14.1% (21/149) and 13.4% (20/149) respectively, and 11.6% (5/43) (χ2=0.01, P=0.936), 16.3% (7/43) (χ2=0.13, P=0.721) and 18.6% (8/43) (χ2=0.72, P=0.396) in the ETAI group, respectively. Two patients (1.3%) in the EVIL group had gastric variceal ring loss. Ectopic embolism occurred in 1 patient (2.3%) in the ETAI group. Conclusion For patients with gastroesophageal variceal bleeding due to liver cirrhosis who are suitable for non-emergency endoscopic treatment, EVL of esophageal varices combined with EVIL of gastric varices is also safe, and more effective than EVL of esophageal varices combined with ETAI of gastric varices. This approach offers improved treatment success rate, reduced operation and hospitalization time, lower rebleeding rates, and decreased rebleeding-related mortality.