内镜下套扎硬化序贯治疗食管曲张静脉疗效及预后影响因素的探讨

摘要

目的 观察内镜下套扎(EVL)及硬化序贯治疗在肝硬化食管静脉曲张患者中应用的疗效,并研究预后的相关危险因素.方法 收集未进行内镜下治疗的食管静脉曲张破裂出血患者设为对照组,仅进行药物治疗,共106例,研究组为内镜下治疗+药物治疗患者,入组共113例,研究组中又随机分为单纯套扎组(EVL组)和套扎硬化序贯组,观察治疗后曲张静脉消除率、再出血率、总治疗次数、死亡率和术中及术后并发症,进行比较.并比较对照组和研究组肝功能Child-Turcotte-Pugh(CTP)分级和终末期肝病模型(MELD)不同评分的再出血率和死亡率,分析预后影响因素,评价其对预后的诊断价值.结果 对照组、EVL组和套扎硬化序贯组再出血率分别为41.51%、10.53%和10.64%,对照组与套扎硬化序贯组比较,差异有统计学意义(P=0.000);3组的死亡率分别为15.09%、5.26%和2.13%,对照组与EVL组、对照组与序贯组、EVL与序贯组比较,分别为P>0.05、P=0.001和P>0.05;套扎硬化序贯治疗的半年内复发率44.68%,EVL组复发率73.68%,两者比较差异有统计学意义(P=0.021);无论是对照组还是EVL组和序贯治疗组,肝功能CTP C级的再出血、死亡率明显高于A级;MELD模型中,受试者工作特征曲线(ROC)的曲线下面积(AUC)再出血率对照组、序贯组分别为0.944和0.851,死亡率两组分别为0.881和0.984,而复发率EVL组、序贯组分别为0.914和0.765,MELD评分对再出血和死亡的预测具有重要价值.结论 套扎硬化序贯治疗能明显降低肝硬化食管曲张静脉患者的再出血率和死亡率,且套扎硬化序贯治疗的复发率要低于单纯套扎.肝功能CTP评分评级和MELD评分对再出血和死亡的预测均具有重要价值,套扎硬化序贯治疗能明显降低CTP为B级和C级静脉曲张的再出血和死亡率,并提高再出血和死亡的MELD阈值.%Objective To explore the efficacy of sequential endoscopic variceal ligation plus endoscopic variceal sclerotheropy and the factors associated with the prognosis.Methods 106 cases with esophageal varices in control group was treated with drugs alone;study group had 113 cases, was given endoscopic therapy add drugs, The study group randomly divided into two groups, one was treated with endoscopic variceal ligation all the time (EVL group), another was treated with sequential endoscopic variceal ligation plus endoscopic variceal sclerotheropy (sequential group). After the treatment, the rate of removal of varicose veins, the rate of rebleeding, the number of total treatment,mortality and intra-operative complications and postoperative complications were compared. And compared rebleeding rate and mortality with the control group and study groups with different CTP and MELD, analyze the factors of prognosis, and evaluate their prognostic value.Results Rebleeding, rate in control group, EVL group and sequential group were 41.51%,10.53% and 10.64%,sequential group was significantly better than control group (P = 0.000); mortality in control group, EVL group and sequential group were 15.09%, 5.26% and 2.13%, sequential group was also significantly better than control group (P = 0.001); rate of recurrence in EVL group and sequential group within half a year were 73.68% and 44.68%, sequential group was significantly better than EVL group (P = 0.021). In all control group and EVL group and the sequential group, rebleeding rate and mortality of the liver function Child-Turcotte-Pugh (CTP) class C was significantly higher than that of calss A; In MELD model, AUC area under the ROC curve of rebleeding rate in control group and sequential group were 0.944 and 0.851, mortality of the two groups were 0.881 and 0.984, while the rate of recurrence in the EVL group and sequential group were respectively 0.914 and 0.765, the MELD score has the important value to the prediction of rebleeding and death.Conclusion The rebleeding rate and mortality in cirrhotic patients with esophageal varices treated with sequential endoscopic variceal ligation plus endoscopic variceal sclerotheropy were significantly decreased and the recurrence rate was lower than that of the patients with endoscopic variceal ligation all the time. Liver function Child-Turcotte-Pugh (CTP) score and the MELD score have important value in prediction of rebleeding and death, ligation and sclerosing sequential therapy can significantly reduced rebleeding and mortality in CTP class B and C, and improve the MELD threshold of rebleeding and death.