超声内镜引导下弹簧圈置入联合组织胶注射对瘤型胃底静脉曲张破裂出血的二级预防价值

Value of endoscopic ultrasound‑guided coil implantation combined with glue injection for the secondary prevention of tumorous gastric fundal variceal bleeding

摘要:

目的 评价超声内镜（endoscopic ultrasonography，EUS）引导下弹簧圈置入联合组织胶注射预防瘤型胃底静脉曲张再发破裂出血的临床疗效及安全性。方法 回顾性分析2017年9月至2020年12月浙江大学医学院附属第一医院因瘤型胃底静脉曲张破裂出血行EUS引导下弹簧圈置入联合组织胶注射治疗的住院患者的临床资料，统计接受该项治疗患者的基本特征以及内镜下表现，分析治疗的技术成功率、组织胶和弹簧圈的使用量、曲张静脉闭塞率以及肺栓塞等并发症发生率。并对患者进行长期随访，获得再发出血相关数据。同时根据患者治疗后内镜下表现将患者分为完全闭塞组和非完全闭塞组，对比两组再发出血情况。结果 纳入本研究的41例患者中单纯孤立性胃底曲张静脉1型者18例（43.90%），合并食管胃静脉曲张者23例（56.10%）。内镜下观察瘤型曲张静脉表面有血栓头、溃疡等近期出血征象者14例，合并门静脉高压性胃病者13例。患者均成功完成EUS引导下弹簧圈置入联合组织胶注射操作，首次技术成功率为92.68%（38/41），其中弹簧圈一次性预装成功率为95.12%（39/41），EUS引导下靶血管穿刺成功率为100.00%（41/41），弹簧圈释放成功率为97.56%（40/41）。弹簧圈使用量（1.12±0.33）个，置入弹簧圈后组织胶使用量（1.54±0.46）mL。瘤型胃底静脉曲张栓塞术后靶血管闭塞率97.56%（40/41），胃底静脉曲张完全闭塞率51.22%（21/41）。术中出血2例（4.88%），1例自行停止，1例内镜直视下补充注射组织胶后止血成功。术中患者均无氧饱和度下降等肺栓塞表现，术后行肺CT血管造影或肺部CT检查24例，1例（4.17%）提示肺动脉远端栓塞，但无相关临床表现。41例患者术后随访（21.64±16.86）个月（1~50个月）。术后再发消化道出血共13例（31.71%），其中5 d内患者均无再发出血，3个月内再发出血2例，3~12个月再发出血5例，1年以上再发出血6例。术后再发出血的13例中，完全闭塞组术后再发出血率23.81%（5/21）低于非完全闭塞组40.00%（8/20），但差异无统计学意义（χ2=1.240，P=0.265）。结论 EUS引导下弹簧圈置入联合组织胶注射对瘤型胃底静脉曲张破裂出血具有良好的二级预防价值和安全性，值得临床推广应用。

Abstract:

Objective To evaluate the clinical efficacy and safety of endoscopic ultrasound (EUS)-guided coil implantation combined with glue injection for preventing rebleeding of tumorous gastric fundal varices. Methods A retrospective analysis was performed on the clinical data of patients who underwent EUS-guided coil implantation combined with glue injection due to tumorous gastric fundal variceal bleeding from September 2017 to December 2020 in the First Affiliated Hospital, Zhejiang University School of Medicine. The basic characteristics and endoscopic manifestations of patients treated with this technique were analyzed, and the success rate of this technique, the usage of tissue glue and coil, the variceal obliteration rate and the incidence of complications such as pulmonary embolism were analyzed. Patients were followed up over a long period of time to obtain data on rebleeding. At the same time, patients were divided into complete obliteration group and incomplete obliteration group according to the endoscopic performance after the treatment, and the rebleeding rate in the two groups was compared. Results Among the 41 patients included in this study, 18 cases (43.90%) had single isolated gastric varices type 1, and 23 cases (56.10%) had gastroesophageal varices combined. Fourteen cases had signs of recent bleeding such as thrombi and ulcers under endoscopy, and 13 cases had combined portal hypertensive gastropathy. All patients successfully completed the operation of EUS-guided coil implantation combined with glue injection. The technical success rate for the first attempt was 92.68% (38/41). The one-time pre-installation success rate of coils was 95.12% (39/41). The success rate of target vessel aspiration under EUS guidance was 100.00% (41/41). The release success rate of coil was 97.56% (40/41). The number of coils used was 1.12±0.33, and the amount of tissue glue used after inserting the coils was 1.54±0.46 mL. The target vessel obliteration rate after operation was 97.56% (40/41), and the complete gastric fundal variceal obliteration rate was 51.22% (21/41). There were 2 cases (4.88%) of intraoperative bleeding, 1 case stopped spontaneously, and 1 case successfully stopped bleeding after additional injection of tissue glue under direct endoscopic vision. No patient had symptoms of pulmonary embolism such as decreased oxygen saturation during the operation. Postoperative computed tomography angiography of pulmonary artery or lung computed tomography was performed in 24 cases, of which 1 case (4.17%) showed distal pulmonary artery embolism, but there were no relevant clinical manifestations. The patients were followed up for 21.64±16.86 months (1-50 months) after the surgery. There were 13 cases (31.71%) of recurrent gastrointestinal bleeding after the surgery, no rebleeding within 5 days, 2 cases of rebleeding within 3 months, 5 cases from 3 to 12 months, and 6 cases more than 1 year. Among the 13 cases of recurrent bleeding after the surgery, the recurrence rate of bleeding after operation in the complete obliteration group was 23.81% (5/21), which was lower than that in the incomplete obliteration group with 40.00% (8/20), but there was no statistically significant difference (χ2=1.240, P=0.265). Conclusion EUS-guided coil implantation combined with glue injection has good secondary prevention value and safety for tumorous gastric fundal variceal bleeding, and is worthy of clinical promotion and application.