内镜套扎术与硬化剂治疗食管及胃底静脉曲张

目的:探讨内镜套扎术与硬化剂治疗食管及胃底静脉曲张的疗效及并发症。方法:用多环结扎器进行内镜下套扎术治疗食管静脉曲张30例,其中14例合并胃底静脉曲张者应用硬化剂治疗。结果:全组30例患者,食管静脉曲张消失或基本消失22例;合并胃底静脉曲张14例,胃底静脉曲张消失或基本消失8例。随访26例,4例出现大出血。结论:内镜套扎术联合硬化剂治疗食管胃底静脉曲张是安全有效、切实可行的,是预防其破裂出血积极有效的措施。     

内镜腹腔镜联合治疗肝硬化门静脉高压症食管胃底曲张静脉出血

目的：探讨内镜腹腔镜联合治疗肝硬化门静脉高压症食管胃底曲张静脉出血的可行性。 方法： 23例肝硬化门静脉高压症食管胃底曲张静脉出血患者行食管曲张静脉套扎或胃底曲张静脉组织胶注射后行手助腹腔镜脾切除11例,门奇静脉断流术12例。 结果：21例术后1年内无上消化道出血,2例因出血行再次套扎。1例于2年后患肝癌死亡,1例3年后上消化道出血死亡。 结论：内镜联合腹腔镜治疗肝硬化门静脉高压症曲张静脉出血创伤小,近期止血效果好,是一种切实可行的治疗门静脉高压症并食管胃底静脉曲张出血的方法。     

内镜注射硬化疗法联合部分脾栓塞术治疗门脉高压症的临床疗效

目的对内镜注射硬化疗法(EIS)联合部分脾栓塞(PSE)治疗肝硬化门脉高压的疗效进行评价。方法对我科于2005年2月至2008年11月收治22例食道胃底静脉曲张合并脾功能亢进的门脉高压患者采用内镜硬化剂注射联合部分脾栓塞的治疗进行回顾性分析。术后定期随访和比较术前术后的消化道出血、肝功能评级及外周血象的变化。结果 EIS平均次数1.8次,所有患者均行1次PSE治疗。术后随访5-30个月,无严重并发症出现,未见有再出血,肝功能部分改善,外周血血小板和白细胞计数明显升高(P<0.05)。结论 EIS联合PSE方法对肝硬化所致的食管胃底静脉曲张出血和门脉高压症是安全有效的。     

手术、内镜下治疗食管胃底静脉曲张出血的近期和远期疗效观察

目的 比较内镜下食管静脉套扎术（EVL）联合硬化剂注射（EVS）和食管胃底静脉断流术对食管胃底静脉曲张破裂出血的近期和远期疗效,探讨EVL结合EVS和两种方法单独应用的适应证。方法12例肝硬化门脉高压症患者行食管胃底静脉断流术,术后胃镜观察曲张静脉消失程度及合并出血的情况,其中6例术后做了EVL或EVS;32例行EVL结合EVS;9例单纯行EVS;5例单纯行EVL。所有病例术后随访3年,观察曲张静脉消失和复发程度以及出血情况。结果 食管胃底静脉断流术为急诊止血的可靠方法,但术后仍存在程度不同的曲张静脉,术后3年内再出血发生率高达66.7％（8/12）,术后择期行EVL或EVS,曲张静脉可完全消退。EVL结合EVS曲张静脉完全消退达93.75％（30/32）,总疗程2-3周。内镜下治疗后3年内观察曲张静脉复发率仅为10.53％（4/38）,再出血发生率为6.52％（3/46）。结论EVL结合EVS对食管胃底静脉曲张破裂出血的近期和远期疗效明显优于手术组。食管胃底静脉断流术后施行EVL和/或EVS可以同时达到降低门脉高压和消除曲张静脉目的。EVL结合EVS明显优于两者单独应用的疗效,同时避免了单纯用EVS容易引起出血的可能性,并且缩短了单纯用EVL的疗程,克服了后期套扎的难度。     

内镜治疗食管胃静脉曲张的效果分析

目的探讨内镜下套扎、硬化剂、组织粘合剂治疗食管胃静脉曲张的临床疗效。方法选择有食管、胃静脉曲张破裂出血史的患者107例,进行胃镜检查,依据LDRf分型结果选择内镜下套扎、硬化剂或者组织粘合剂治疗食管胃静脉曲张并随访。结果进行内镜下套扎治疗52例,硬化剂治疗18例,组织粘合剂治疗8例,硬化剂加组织粘合剂治疗15例,未进行内镜下治疗14例。结论内镜下治疗食管胃底静脉曲张破裂出血操作简单、疗效可靠、止血率高、静脉曲张消失快、并发症少,是治疗食管胃底静脉曲张破裂出血的有效方法。LDRf内镜下分型简单明了、规范、统一,对于食管胃静脉曲张的内镜下治疗有指导意义。     

手术、内镜下治疗食管胃底静脉曲张出血的近期和远期疗效观察

目的：比较内镜下食管静脉套扎术（EVL）联合硬化剂注射（EVS）和食管胃底静脉断流术对食管胃底静脉曲经破裂出血的近期和无期疗效，探讨EVL结合EVS和两种方法单独应用的适应证。方法：12例肝硬化门脉高压症患行食管胃底静脉断流术，术后胃镜观察曲张静脉消失程度及合并出血的情况，其中6例术后做了EVL或EVS；32例行EVL结合EVS；9例单纯行EVS；5例单纯行EVL。所有病例术后随访3年，观察曲张静脉消失和复发程度以及出血情况。结果：食和胃底静脉断流术为急诊止血的可靠方法，但术后仍存在程度不同的曲张静脉，术后3年内再出血发生率高达66.7%（8/12），术后择期行EVL或EVS，曲张静脉可完全消退。EVL结合EVS曲张静脉完全消退达93.75%(30/32)，总疗程2-3周。内镜下治疗后3年内观察曲张静脉复发率仅为10.53%(4/38)，再出血发生率为6.52%(3/46)。结论：EVL结合EVS对食管胃底静脉曲张破裂出血的近期和远期疗效明显优于手术组。食管胃底静脉断流术后施行EVL和/或EVS可以同时达到降低门脉高压和消除曲张静脉目的。EVL结合EVS明显优于两单独应用的疗效，同时避免了单纯用EVS容易引起出血的可能性，并且缩短了单纯用EVL的疗程，克服了后期套扎的难度。     

内镜食管静脉套扎联合腹腔镜脾切除术治疗门静脉高压症

目的:探讨内镜食管静脉套扎联合腹腔镜脾切除术治疗门静脉高压症的疗效和安全性、有效性.方法:对48例肝硬化门静脉高压症胃底食管静脉曲张破裂出血及脾功能亢进患者先行内镜下食管曲张静脉套扎术,1～2周后行腹腔镜脾切除术.结果:42例手术成功,6例中转开腹.42例脾切除患者手术时间平均为140 min.术中出血平均为240 mL,术中输血200～600 mL,术后切口愈合良好,无严重术后并发症.48例患者均痊愈出院.结论:对门脉高压症患者,腹腔镜脾切除联合术前内镜套扎术具有微创的优点,安全、有效.     

内镜下套扎联合硬化术应用于肝硬化食管静脉曲张出血患者中的疗效观察

目的探讨内镜下套扎联合硬化术治疗肝硬化食管静脉曲张出血患者的效果。方法 68例肝硬化食管静脉曲张出血患者随机分组为对照组与观察组,各34例。对照组行内镜下套扎术止血治疗;观察组采用内镜下套扎术联合硬化术治疗。记录两组止血成功人数和术后并发症情况;观察两组患者静脉曲张消失状况。术后随访6个月,记录两组复发人数。结果观察组止血成功率为97.06%(33/34)与对照组94.12%(32/34)比较,χ2=0.35,P=0.55;观察组术后并发症率为8.82%(3/34)明显低于对照组20.59%(7/34),χ2=1.88,P=0.17;观察组术后静脉曲张消失总有效率为97.06%(33/34)与对照组88.24%(30/34)比较,χ2=3.09,P=0.21。术后随访6个月显示观察组静脉曲张复发率为2.94%(1/34)明显低于对照组17.65%(6/34),χ2=3.98,P=0.04。结论内镜下套扎联合硬化术与单纯内镜下套扎术治疗肝硬化食管静脉曲张出血的近期疗效相当,但前者术后静脉曲张复发率少,具有长期疗效,值得推广。     

门静脉高压断流术后再出血的治疗

目的探讨和分析门静脉高压断流术后再出血的治疗措施。方法对武汉大学中南医院自2013年1月至2015年6月收治门静脉高压断流术后再出血病人60例的临床治疗进行回顾性分析。60例病人中,25例病人采用内镜下套扎止血,20例病人行经颈静脉肝内门静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS),10例病人行肝移植,5例复发重度食管静脉曲张行再次断流术。结果内镜套扎组8例病人因再次出血行第2次内镜下套扎,其中1例病人再次大出血死亡;行TIPS组2例发生间断性肝性脑病,其中1例发生再次出血行内镜下套扎治疗;肝移植组术后恢复较好;再次行断流手术组,1例病人因出血无法控制死亡。结论对门静脉高压断流术后再出血的病人以上方法均有效,其中最有效的治疗方法是肝移植,对肝衰竭以及顽固性食管胃底静脉曲张上消化道出血的病人疗效好;肝功能较好且无肝性脑病者,或断流术后效果欠佳反复消化道出血病人可考虑行TIPS术;肝功能较差者,或病人急性消化道大出血身体状况较差者可选择内镜下套扎止血;再次手术难度大,风险高,再次行断流手术需慎重。     

内镜下氰基丙烯酸酯注射法与套扎法治疗胃底食管静脉曲张的Meta分析

目的 对于食管胃底静脉曲张,目前国际上经典方法为套扎法,随着组织胶水被广泛应用临床,氰基丙烯酸酯被较多用在内镜下该病的硬化治疗.本文旨在对比两者在治疗食管胃底静脉曲张的优劣.方法 通过数据统计、定性分析、异质性分析、Meta分析,偏倚分析对已获得文献进行分析.结果 两组间急性出血止血率、根治率和死亡率差异无统计学意义,再出血率套扎组高于胶水组,食管静脉曲张组并发症胶水组高于套扎组.结论 氰基丙烯酸酯注射法和套扎法是治疗胃食管静脉曲张的有效方法.治疗胃底静脉曲张时注射法较套扎法再出血率低而并发症发生率相似,所以首选注射法.治疗食管静脉曲张时对于复发倾向较高的患者,在权衡并发症的情况下可以考虑使用注射法.     

Hassab手术联合食管曲张静脉套扎术治疗食管曲张血管破裂出血

目的观察Hassab手术联合食管曲张静脉套扎术治疗门静脉高压症食管静脉曲张破裂出血的临床疗效。方法将近5年间收治的93例门静脉高压症食管静脉曲张破裂出血的患者随机分成3组，分别实施单纯性内窥镜食管曲张静脉套扎术（endoscopic variceal ligation，EVL）、贲门周围血管离断术（Hassab手术）及EVL联合Hassab手术（联合治疗组），对其临床效果进行比较分析。结果3组急性止血率无差异（P〉0．05）；联合手术组术后近期无出血，远期再出血率为5．7％明显低于EVL组和Hassab手术组（P〈0．05）；术后EVL组、Hassab手术组、联合手术组的奇静脉血流量分别下降22．7％，30．4％，45．7％。结论联合手术组同时阻断了胃食管腔内外的异常门奇静脉分流，食管曲张静脉获得根治，且有脾功能亢进消失、奇静脉血流量降低明显、止血效果确切、再出血率低等优点，是治疗门静脉高压症食管静脉曲张破裂出血的合理而可行的术式。     

Stoma-related variceal bleeding: an under-recognized complication of biliary atresia

The medical records of 52 children with biliary atresia treated by portoenterostomy and evaluated for liver transplantation were reviewed to determine the frequency of stoma variceal bleeding and the optimal strategies for prevention and treatment. Eighteen patients had had prior stoma closure, four by preperitoneal closure without takedown from the abdominal wall. Three of the four developed occult variceal bleeding from the stoma closure site. Twenty-two patients had a stoma present at evaluation. All 22 patients with stomas (100%) had at least one bleeding episode requiring transfusion. Treatment included transfusion and local pressure (9), suture ligation of the bleeding site (5), and stoma closure and/or takedown (11). Local treatment led to recurrences in eight of 14 (57%) of the cases. To reduce the high mortality in patients with biliary atresia awaiting liver transplantation, multiple variceal bleeding episodes should be prevented. To eliminate one source, stoma variceal bleeding, the stoma, whether functioning or nonfunctioning should be taken down and closed. Preperitoneal closure alone does not prevent stoma bleeding.     

肝硬化门静脉高压症食管胃底曲张静脉破裂出血医院内死亡原因分析

摘要：目的:探讨肝硬化门静脉高压症食管胃底曲张静脉破裂出血患者住院期间的死亡原因。方法:对近 3年收治的186例患者及在住院期内死亡的24例患者的临床资料进行回顾性分析。结果:186中择期手术130例，3例（2.31 %）因术后肝衰竭或其他并发症死亡；急诊手术28例，术后因肝衰竭或其他并发症死亡5例（17.86 %）；未行手术治疗28例，16例死亡，其中12例死于出血无法控制。结论:大出血非手术治疗无法控制而又未及时手术是导致肝硬化门静脉高压症食管胃底曲张静脉破裂出血患者最重要的医院内死亡原因，对此类患者及时采取急诊手术对降低门静脉高压症大出血患者的病死率具有重要意义。     

Endoscopic sclerotherapy in acute variceal hemorrhage

Acute variceal hemorrhage in patients with alcoholic cirrhosis and poor liver function is associated with a high mortality. A nonoperative treatment, endoscopic sclerotherapy, was employed in 22 patients with cirrhosis and poor liver function who had 24 episodes of acute variceal hemorrhage over a 20 month period. Portal hypertension was secondary to alcoholic cirrhosis in 21 patients and cystic fibrosis in 1 patient. Of the 24 patient admissions, 21 were of patients in Child's class C and 3 were class B. Endoscopic sclerotherapy was performed under endotracheal general anesthesia using a modified Negus rigid esophagoscope. The sclerosant (5 percent sodium morrhuate) was injected into all visible varices near the gastroesophageal junction using a MacBeth needle. Definitive control of variceal hemorrhage for the entire hospitalization was achieved in 19 of 24 admissions (79 percent). The in-hospital mortality for acute variceal bleeding was 29 percent; 81 percent of the patients were discharged after control of hemorrhage. There were two major and five minor complications related to sclerotherapy. Based on this preliminary experience it is concluded that injection sclerotherapy controls bleeding and reduces mortality associated with acute variceal hemorrhage in patients with poor liver function.     

A randomized study comparing ligation with propranolol for primary prophylaxis of variceal bleeding in candidates for liver transplantation.

Whether beta-blockers (BB) or banding is the best therapy for primary prophylaxis of variceal bleeding is subject to debate. A randomized comparison between the 2 treatments was performed in candidates for liver transplantation (LT). A total of 62 patients with Child-Turcotte-Pugh B-C cirrhosis and high risk varices received propranolol (31) or variceal banding (31). The primary endpoint was variceal bleeding. There were 2 variceal hemorrhages (6.5%) in the banding group, related to postbanding ulcers, and 3 (9.7%) in the propranolol group (P = not significant [n.s.]). Deaths and bleeding related deaths were 3 and 1 for banding and 3 and 2 for BB, respectively (P = n.s.). A total of 14 patients underwent LT in the banding group and 10 in the propranolol group (P = n.s.). Adverse events were 2 postbanding ulcer bleedings in ligated patients (1 fatal) and 5 were intolerant to propranolol (P = n.s.). Mean costs per patient were higher with banding than with propranolol treatment (4,289 +/- 285 vs. 1,425 +/- 460 U.S. dollars, P < 0.001). In conclusion, propranolol and banding are similarly effective in reducing the incidence of variceal bleeding in candidates for LT, but ligation can be complicated by fatal bleeding and is more expensive. Our results suggest that banding should not be utilized as primary prophylaxis in transplant candidates who can be treated with BB.     

食道静脉曲张套扎结合大剂量聚桂醇治疗体会

目的探讨在密集套扎疗法的基础上进行硬化治疗对于食管静脉曲张复发的防治作用。方法对食管静脉曲张套扎治疗后食管曲张静脉消失或基本消失的患者进行硬化剂治疗。结果套扎加大剂量聚桂醇治疗组与单纯套扎组再出血率有明显差异（P〈0.05）。结论套扎治疗后大剂量硬化剂治疗可显著减少套扎术后残留的食管曲张静脉、延缓静脉曲张的复发。     

Current indication of a modified Sugiura procedure in the management of variceal bleeding

BACKGROUND: The role of gastroesophageal devascularization (Sugiura-rype procedures) for the treatment of variceal bleeding remains controversial. Although Japanese series reported favorable longterm results, the technique has nor been widely accepted in the Western Hemisphere because of a high postoperative morbidity and mortality. The reasons for the different outcomes are unclear. In a multidisciplinary team approach we developed a therapeutic algorithm for patients with recurrent variceal bleeding. STUDY DESIGN: The Sugiura procedure was offered only to patients with well-preserved liver function (Child A or Child B cirrhosis without chronic ascites) who were not candidates for distal splenorenal shunt, transhepatic porto-systemic shunt, or liver transplantation. RESULTS: Fifteen patients with recurrent variceal bleeding underwent a modified Sugiura procedure between September 1994 and September 1997. All but one patient (operative mortality 7%) are alive after a median followup of 4 years. Recurrent variceal bleeding developed in one patient; esophageal strictures, which were successfully treated by endoscopic dilatation, developed in three patients; and one patient experienced mild encephalopathy. Major complications were noted only in patients with impaired liver function (Child B cirrhosis) or when the modified Sugiura was performed in an emergency setting. The presence of cirrhosis or the cause of portal hypertension had no significant impact on the complication rate. CONCLUSIONS: This series was performed during the last decade when all modern therapeutic options for variceal bleeding were available. Our results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.     

肝硬化伴食管静脉曲张破裂出血行脾切除加断流治疗与内镜治疗的疗效对比分析

目的探讨外科手术治疗(脾切除+门奇静脉断流术)与内镜下治疗(内镜下套扎和硬化剂治疗)对肝硬化所致食管静脉曲张破裂出血的疗效,并寻找导致术后再出血的危险因素。方法回顾性分析陆军军医大学大坪医院2012年1月至2017年11月收治的肝硬化伴食管静脉曲张破裂出血病人的资料。将行脾切除、门奇静脉断流术者纳入外科手术治疗组(54例);将内镜下行套扎、硬化剂治疗者纳入内镜治疗组(63例)。根据搜集所得资料及电话随访结果,统计病人治疗后的再出血率、治疗后再出血的平均间隔时间等。数据采用SPSS(23.0版)软件进行处理。结果手术治疗组术后1、3、5年再出血率分别为9.3%、20.5%、23.1%,内镜治疗组术后1、3、5年再出血率分别为39.7%、73.0%、74.8%,手术治疗组再出血率明显低于内镜治疗组(P<0.001)。COX多因素分析显示:内镜治疗术后再出血的风险是手术治疗的7.2倍(P<0.001)。曲张的食管静脉距门齿的距离、脾脏的大小、脾功能亢进的程度与术后再出血与否无统计学相关性。结论外科手术治疗相比内镜治疗可更好地控制曲张食管静脉的破裂出血,其1、3、5年再出血率明显小于内镜治疗组。治疗方式是病人术后再次出血的危险因素。     

内镜下硬化与套扎治疗食管静脉曲张破裂出血疗效比较

目的：对比内镜下硬化治疗（EIS）、套扎治疗（EVL）及套扎联合硬化治疗（ESL）3种方法对食管静脉曲张破裂出血的临床疗效。方法：回顾分析中日友好医院消化内科2001—2005年内镜下治疗肝硬化单纯食管静脉曲张破裂出血149例,其中EIS46例、EVL32例、ESL71例,对3种方法的止血率、静脉曲张消失率及再出血率进行比较。结果：3种治疗方法止血率均在90%以上;静脉曲张消失率分别为EIS80.4%、EVL68.8%、ESL87.3%;2年内再出血率分别为EIS52.2%、EVL59.3%、ESL43.6%,差异无统计学意义（P〉0.05）。结论：内镜下EIS、EVL及ESL治疗肝硬化食管曲张静脉出血均可达到较好效果,临床实践中可结合患者实际情况综合考虑后选择。     

Esophageal transection fails to salvage high-risk cirrhotic patients with variceal bleeding

A small proportion of portal hypertensive patients with acute variceal bleeding do not respond to medical management and require emergency control of hemorrhage, yet are not candidates for shunt surgery. Transgastric esophageal transection and stapling of the esophagus has been suggested as a rapid, simple means to halt variceal bleeding in such high-risk patients. This should theoretically allow a hemorrhage-free interval for resuscitation and improvement in metabolic and cardiopulmonary status before definitive shunt surgery. We tested this hypothesis in 10 high-risk patients with variceal bleeding who underwent transection of the esophagus, sometimes with splenectomy and coronary vein ligation, over a 4 year period. In our experience, esophageal transection in high-risk patients with variceal bleeding controlled acute variceal hemorrhage, was neither rapid nor free of technical misadventures, was associated with a high rate of serious postoperative complications resulting in death in nearly all patients, and consistently failed to result in sufficient metabolic improvement to permit shunt surgery.