食管静脉曲张套扎术治疗肝硬化食管静脉曲张破裂出血的效果观察

摘要

目的：观察内镜下食管静脉曲张套扎术（EVL）治疗肝硬化食管静脉曲张破裂出血（EVB）的临床疗效。方法收集2010年12月－2013年7月广东医科大学附属深圳市第三人民医院收治的肝硬化 EVB 患者84例，随机分为套扎组（A 组，应用 EVL 联合生长抑素、埃索美拉唑治疗）、对照组（B 组，应用生长抑素、埃索美拉唑治疗），每组42例。观察2组止血率、再出血率、并发症发生率、病死率等，了解 EVL 后静脉曲张根除率、早期再出血相关危险因素。符合正态分布的计量资料2组间比较采用 t 检验，多组间比较采用方差分析；不符合正态分布的计量资料2组间比较采用 Mann －Whitney U 检验，组内两两比较采用 Wilcoxn 符号秩和检验，多组间比较采用 Kruskal －Wallis H 检验。计数资料组间比较采用χ2检验或 Fisher 确切概率法。生存率的计算采用 Kaplan －Meier 法，比较不同组别的生存情况采用 log －rank 检验。二分类资料的影响因素分析采用 logistic 回归方法。结果 A、B 2组止血率分别为97．62％、80．95％，差异有统计学意义（P ＝0．029）。A 组1年～2年（15．38％ vs 38．89％，χ2＝5．323，P ＝0．021）、2～3年（15．38％ vs 48．48％，χ2＝10．448，P ＝0．001）再出血率均低于 B 组。A 组14例（33．33％）有不良反应，B 组7例（16．67％）有不良反应。A 组3年内死亡4例，B 组3年内死亡9例。A 组治疗后1周的 ALT、AST 水平较治疗前1周明显改善（Z 值分别为－2．177、－2．044，P 值分别为0．029、0．041），2组治疗后1周的 PTA、PT、国际标准化比值（INR）、Alb 均较治疗前1周明显改善（A组：Z ＝－4．007，t ＝3．866，Z ＝－4．152，t ＝－4．623，P 值均＜0．001；B 组：t ＝－5．069，Z ＝－3．870，Z ＝－3．909，Z ＝－5．245，P 值均＜0．001），2组治疗后1周的 PTA 水平比较差异有统计学（Z ＝－3．902，P ＜0．001）。A 组 EV 总消失率为85．71％，复发率为14．29％，肝功能分级与门静脉内径之间有明显关系（F ＝3．319，P ＝0．047）。入院症状、住院天数、Child －Pugh 分级、合并自发性腹膜炎、门静脉内径、PT、INR、ALT 是套扎后早期再出血危险因素（P 值均＜0．05）。结论 EVL 是治疗肝硬化 EVB 的一种安全、有效且并发症少的重要手段。%Objective To investigate the clinical effect of endoscopic esophageal variceal ligation (EVL)in the treatment of esophageal variceal bleeding (EVB)in patients with liver cirrhosis.Methods A total of 84 liver cirrhosis patients with EVB who were admitted to The Third People′s Hospital of Shenzhen,Guangdong Medical University,from December 2010 to July 2013 were divided into ligation group (group A,treated with EVL combined with somatostatin and esomeprazole)and control group (group B,treated with somatostatin and es-omeprazole),with 42 patients in each group.The hemostasis rate,rebleeding rate,incidence rate of complications,and mortality rate were observed in both groups,as well as the variceal eradication rate after EVL and risk factors for early rebleeding.The t -test was used for com-parison of normally distributed continuous data between two groups,and an analysis of variance was used for comparison between multiple groups;the Mann -Whitney U test was used for comparison of non -normally distributed continuous data between two groups,the Wilcoxon signed -rank sum test was used for comparison within each group,and the Kruskal -Wallis H test was used for comparison between multiple groups.The chi -square test or Fisher′s exact test was used for comparison of categorical data between groups.The Kaplan -Meier method was used to calculate survival rates,and the log -rank test was used to compare survival rates between groups.The logistic regression meth-od was used to investigate the influencing factors for dichotomous data.Results There was a significant difference in the hemostasis rate be-tween groups A and B (97.62% vs 80.95%,P =0.029).Compared with group B,group A had significantly lower rebleeding rates in 1 -2 years (15.38% vs 38.89%,χ2 =5.323,P =0.021)and 2 -3 years (15.38% vs 48.48%,χ2 =10.448,P =0.001).A total of 14 patients (33.33%)in group A and 7 patients (16.67%)in group B experienced adverse events,and 4 patients in group A and 9 patients in group B died within 3 years.Group A had significant improvements in the levels of alanine aminotransferase (ALT)and aspartate amin-otransferase at 1 week after treatment (Z =-2.177 and -2.044,P =0.029 and 0.041).Both groups had significant improvements in pro-thrombin time activity (PTA),prothrombin time (PT),international normalized ratio (INR),and albumin at 1 week after treatment (group A:Z =-4.007,t =3.866,Z =-4.152,t =-4.623,all P <0.001;group B:t =-5.069,Z =-3.870,Z =-3.909,Z =-5.245,all P <0.001).There was a significant difference in PTA at 1 week after treatment between the two groups (Z =-3.902,P <0.001).In group A,the overall disappearance rate of varices was 85.71% and the recurrence rate was 14.29%,and there was a signifi-cant correlation between the Child -Pugh score and diameter of the portal vein (F =3.319,P =0.047).Symptoms on admission,length of hospital stay,Child -Pugh score,spontaneous bacterial peritonitis,diameter of the portal vein,PT,INR,and ALT were risk factors for ear-ly rebleeding after ligation (all P <0.05).Conclusion EVL is a safe and effective method for the treatment of EVB in patients with liver cirrhosis and causes few complications.