Impact of balloon-occluded retrograde transvenous obliteration on management of isolated fundal gastric variceal bleeding

Aim: Although endoscopic injection of cyanoacrylate (CA) is the only effective method for treating isolated fundal gastric variceal bleeding, the rebleeding rate is relatively high. This study investigated the efficacy of balloon‐occluded retrograde transvenous obliteration (B‐RTO) for management of isolated fundal gastric variceal bleeding. Methods: Patients (n = 110) with acute or recent bleeding from isolated fundal gastric varices (GV) were retrospectively studied. Acute bleeding was treated by CA injection or balloon tamponade. 44 patients underwent additional endoscopic injection of CA and ethanolamine oleate (EO) weekly until obturation of GVx from 1994 to 2002 (group A). 42 patients from 2003 to 2010 underwent B‐RTO after initial hemostasis (group B). Both groups were assessed for the number of sessions required to achieve GV obturation, hospital stay, recurrent bleeding rate, morbidity and mortality. Results: Acute gastric variceal bleeding was successfully treated in all patients by CA injection or balloon tamponade. B‐RTO was successfully performed except in two patients in group B. The average number of sessions required for obturation was 3.8 for groups A and 2.2 for B (P < 0.05). Recurrent bleeding was observed in 16 and two patients in groups A and B, respectively. The cumulative non‐rebleeding rate at 5 years was 58.3% and 98.1% in groups A and B, respectively. The cumulative survival rate at 5 years was 53.8% and 87.6% in groups A and B, respectively. Conclusion: Balloon‐occluded retrograde transvenous obliteration may be superior to endoscopic injection with CA and EO for prevention of rebleeding in patients with isolated fundal GVs with a major shunt.     

地方本科院校计算机专业转型发展路径探索

当前,地方本科院校计算机专业规模大,质量和数量失衡,各专业办学定位同质化,专业特色不明显,与地方经济脱节,同时,教师专业实践能力与应用型计算机人才培养目标不匹配,重理论、轻应用,服务地方经济发展能力差。地方本科院校计算机专业实现转型发展,在结构方面需要主动融入行业和地方经济,明确专业定位,构建应用型计算机人才培养目标;在技术方面需要面向行业和地方,构建职业需求驱动的计算机人才培养体系;在制度方面需要制定和完善各种规章制度,形成专业转型发展的良好文化氛围。     

Endoscopic management of gastric varices

Understanding the basic pathophysiology and anatomy of gastric varices is critical to the appropriate management of acute variceal bleeding. The high morbidity and mortality of gastric variceal bleeding combined with poor response to treatments for esophageal variceal bleeding has demanded a highly differentiated approach. This review focuses on gastric fundal varices for which the most recent Baveno VI consensus guidelines recommend endoscopic cyanoacrylate-based therapy as first-line intervention. We discuss the evolution of endoscopic techniques, not only to achieve effective hemostasis but also to limit inherent risks and complications. Long-term data reveal that low rebleeding rates are feasible when gastric varices are completely obliterated. Both primary and secondary prophylaxis should become part of standard treatment algorithms.     

Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices

Rupture of gastric varices(GVs) can be fatal. Balloon-occluded retrograde transvenous obliteration(BRTO), as known as retrograde sclerotherapy, has been widely adopted for treatment of GVs because of its effectiveness, ability to cure, and utility in emergency and prophylactic treatment. Simplifying the route of blood flow from GVs to the gastrorenal shunt is important for the successful BRTO. This review outlines BRTO indications and contraindications, describes basic BRTO procedures and modifications, compares BRTO with other GVs treatments, and discusses various combination therapies. Combined BRTO and partial splenic embolization may prevent exacerbation of esophageal varices and shows promise as a treatment option.     

Endoscopic treatment of esophageal varices in patients with liver cirrhosis

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers(NSBBs) or endoscopic variceal ligation(EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, com-bined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt(TIPS) with polytetrafluoroethylene(PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred op-tion in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhe-sives, endoloops, endoscopic clipping and argon plasmacoagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompa-nying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclu-sion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.     

透明帽在消化内镜诊疗中的应用进展

随着消化内镜诊疗技术的快速发展,各种内镜治疗附件的应用越来越普遍。透明帽作为最广泛应用的治疗附件之一,在内镜诊断及治疗中发挥了重要的作用,其中包括透明帽在内镜下黏膜切除术、内镜黏膜下剥离术、内镜下静脉曲张结扎术及硬化剂注射术、内镜诊断及取出食管入口细小异物等中的应用。本文现将透明帽在内镜诊治中的应用作一概述。     

Endoscopic screening for varices in cirrhosis: findings,implications, and outcomes

At least two thirds of cirrhotic patients develop esophageal varices during their lifetime. Severe upper gastrointestinal (UGI) bleeding as a complication of portal hypertension develops in about 30%-40% of cirrhotics. Despite significant improvements in the early diagnosis and treatment of esophagogastric variceal hemorrhage, the mortality rate of first variceal hemorrhage remains high (20%-35%). Primary prophylaxis, the focus of this article, is treatment of patients who never had previous variceal bleeding to prevent the first variceal hemorrhage. The potential of preventing first variceal hemorrhage offers the promise of reducing mortality, morbidity, and associated health care costs. This article (1) reviews endoscopic grading of size and stigmata for esophageal and gastric varices, (2) describes data on prevalence and incidence of esophageal and gastric varices from prospective studies, (3) discusses independent risk factors from multivariate analyses of prospective studies for development of first esophageal or gastric variceal hemorrhage and possible stratification of patients based on these risk factors, (4) comments on the potential cost effectiveness of screening all newly diagnosed cirrhotic patients and treating high-risk patients with medical or endoscopic therapies, and (5) recommends further studies of endoscopic screening, stratification, and outcomes in prospective studies of endoscopic therapy. The author's recommendations are to perform endoscopic screening for the following subgroups of cirrhotics: all newly diagnosed cirrhotic patients and all other cirrhotics who are medically stable, willing to be treated prophylactically, and would benefit from medical or endoscopic therapies. Exclude patients who are unlikely to benefit from prophylactic therapies designed to prevent the first variceal hemorrhage, those with short life expectancy, and those with previous UGI hemorrhage (they should have already undergone endoscopy). For low or very low risk cirrhotic patients-those found to have no varices or small varices without stigmata-repeat endoscopy is recommended because screening for progression may be warranted in 2 or more years.     

内镜疗法后续应用粉防己碱预防食管静脉曲张破裂再出血的研究

目的:研究内镜套扎术和(或)硬化剂治疗后续用粉防己碱预防肝硬化食管静脉破裂出血患者再出血的作用.方法:90例肝硬化并发食管胃底静脉曲张破裂出血患者,分成治疗组及对照组,2组均接受内镜治疗,继而都予以一般对症、保肝治疗,而治疗组加用粉防己碱(20 mg,3次/d),疗程12个月,随访治疗期间出血复发率及静脉曲张复发率,同时实验前及实验结束时2组患者均行血流动力学检测及内镜检查.结果:治疗组患者出血复发率及静脉曲张复发率均明显低于对照组(P＜0.05),治疗组患者血流动力明显改善(P＜0.05),而对照组血流动力学无明显变化.结论:内镜套扎术和(或)硬化剂治疗后续用粉防己碱可明显降低肝硬化并食管静脉曲张出血患者的再出血率及静脉曲张复发率,其作用机制可能与抑制钙离子通道、提高一氧化氮合酶活性及抑制胶原纤维合成有关.     

A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices

OBJECTIVE: Treatment of bleeding gastric varices (GVs) is still controversial, mainly because of anecdotal studies or inclusion of patients with GVs located at different sites that have variable incidences of bleeding. A prospective study was undertaken to compare the efficacy and safety of GV sclerotherapy using alcohol and GV obturation using cyanoacrylate glue. METHODS: Thirty-seven consecutive patients with portal hypertension and endoscopic evidence of isolated GVs, 17 presenting with histories of active bleeding, were randomized to receive endoscopic intervention either with alcohol (n = 17) or with cyanoacrylate glue (n = 20) injection. Variceal obliteration, rebleeding, or death was the endpoint. RESULTS: The glue was significantly more effective in achieving variceal obliteration than alcohol (100% vs 44%, p < 0.05). Furthermore, this could be achieved in a significantly shorter period (2.0 +/- 1.6 vs 4.7 +/- 3.2 wk, p < 0.05) and with a smaller volume of the agent. Cyanoacrylate glue injection could achieve arrest of acute GV bleeding more often than alcohol (89% vs 62%), and the need for rescue surgery was less; the difference was, however, not significant. Six patients died from uncontrolled GV bleeding, four being in the alcohol group. During a mean follow-up of 15.4 +/- 3.7 months there was no recurrence of GVs in either group. CONCLUSIONS: Our results show that cyanoacrylate is more effective and achieves GV obliteration faster than injection sclerotherapy with alcohol. It also appears to be more useful in controlling acute GV bleeding, with less of a need for rescue surgery.     

内镜套扎与普萘洛尔预防肝硬化食管静脉曲张首次出血效能的Meta分析

目的比较内镜下套扎术（EVL）和普萘洛尔预防肝硬化食管静脉曲张首次出血的疗效和安全性。方法计算机检索1999至2012年12月31日PubMed、EBMBASE、万方数据库中关于EVL和普萘洛尔预防肝硬化食管静脉曲张首次出血的随机对照试验,同时追索纳入文献的参考文献。使用RevMan 5.1专业Meta分析软件对治疗后首次出血率,出血病死率,总病死率和不良反应发生率进行Meta分析。结果纳入6个随机对照试验,包括EVL组280例和普萘洛尔组301例患者。文献的Cochrane质量评价均为B级,属于较高质量文献。Meta分析结果显示,EVL在预防肝硬化食管静脉曲张患者的首次出血率、出血病死率、总病死率和不良反应发生率分别为16.4%、4.3%、22.5%和25.0%,与普萘洛尔组的21.6%（P=0.07）、6.3%（P=0.27）、20.9%（P=0.56）和31.9%（P=0.33）相比均无显著性差异;漏斗图存在不对称的现象,提示可能存在发表性偏倚;敏感性分析表明纳入研究具有稳定性。结论EVL与普萘洛尔在预防肝硬化食管静脉曲张破裂的效能无显著性差异。     

Emergency balloon-occluded retrograde transvenous obliteration for gastric varices

Background We evaluated the efficacy of emergency balloon-occluded retrograde transvenous obliteration (B-RTO) performed within 24 h after initial hemostasis for the prevention of rebleeding from ruptured gastric varices. Methods From December 1995 to March 2003, 11 patients who had undergone B-RTO within 24 h after the control of gastric variceal bleeding at Maebashi Red Cross Hospital were investigated. They were followed up for complete eradication, recurrence of varices, and rebleeding. Efficacy was determined by endoscopic examination and computed tomography. Results The 4 patients with acute bleeding from ruptured gastric varices were treated with endoscopic therapy—endoscopic variceal ligation (EVL) in 2 patients, and clipping treatment in 2. Initial hemostasis was achieved in all 4; the other 7 patients had already stopped bleeding at endoscopy. After hemostasis was achieved, emergency B-RTO was immediately performed within 24 h and was successful in all 11 patients. Ten (90.9%) of the 11 gastric varices were obliterated and the other 1 (9.1%) was diminished in size. During the mean follow-up period of 1136 days, no rebleeding or recurrence as found. Four patients died during the follow-up period, but none died from variceal bleeding. Survival rates were 90.9% and 70.7%, respectively, at 1 year and 3 years. In 6 patients, development of esophageal varices appeared during the follow-up period, all of which were controlled by usual endoscopic therapy. No severe side effects were found after the B-RTO treatment. Conclusions Emergency B-RTO is an effective treatment for the prevention of rebleeding from ruptured gastric varices.     

高位食管静脉曲张破裂出血患者内镜诊治经验:10年单中心回顾性分析

目的 探索高位食管静脉曲张破裂出血(SEVB)患者内镜诊治特点及预后。方法 2010年1月～2020年1月哈尔滨医科大学附属第二医院内镜中心行内镜诊治的食管胃静脉曲张(GEV)患者25539例,其中SEVB者12例(0.4‰),其中采用急诊内镜下止血5例,非急诊内镜下止血7例。结果 12例SEVB患者中,乙型肝炎肝硬化5例,丙型肝炎肝硬化4例,酒精性肝炎肝硬化2例,不明原因性肝硬化1例;11例有明显的呕血、黑便、便血或周围循环障碍临床表现;5例急诊内镜下即时止血均成功,7例非急诊内镜下即时止血成功6例,无统计学差异(P>0.05);9例单用食管静脉曲张套扎术(EVL)治疗,其他采取硬化剂注射、EVL联合组织胶注射、EVL联合硬化剂和组织胶注射各1例;术后发生不良反应7例;随访8例患者(31.0±28.5)个月,近期再出血1例,远期再出血5例。在7例全程随访患者中,择期行脾切除术者1例,脾切除术联合贲门周围血管离断术2例,全因病死率为42.9%。结论 对于SEVB患者多采用EVL治疗,即时止血效果好,但远期预后仍差。术后需联合其他方法治疗以长期控制门脉高压症,降低远期再出血和死亡风险。     

心得安单纯或联合使用在二级预防食管静脉曲张出血中的疗效比较

目的比较单纯心得安、套扎＋心得安、硬化剂＋心得安二级预防食管静脉曲张出血的疗效,探寻心得安二级预防食管静脉曲张出血的最佳组合。方法78例食管静脉曲张出血患者随机分成3组,每组26例,止血后分别给予心得安（心得安组）、套扎＋心得安（套扎组）、硬化剂＋心得安（硬化剂组）,比较各组12个月内再出血率、死亡率,以及各组门脉高压性胃病、胃底静脉曲张发生率、食管曲张静脉复发率。结果12个月内再出血率套扎组为30．77％,明显低于心得安组（53．85％）及硬化组（42．31％）（P均〈0．05）;套扎组和心得安组门脉高压性胃病及胃底静脉曲张发生率相似,都明显低于硬化组（P均〈0．05）;而食管静脉曲张再发率高于硬化组（P〈0．05）。结论在应用心得安的基础上进行套扎治疗可能是目前食管静脉曲张出血最有效的二级预防方法。     

内镜下套扎和组织胶注射分别治疗食管和胃底静脉曲张患者的临床观察

目的 探讨内镜下套扎和组织胶注射治疗食管胃底静脉曲张的疗效和价值.方法 予184例重度食管静脉曲张患者内镜下套扎治疗,其中32例伴胃底静脉曲张者还进行内镜下组织胶注射治疗.随访6个月并观察内镜下套扎和组织胶注射治疗的疗效和并发症.结果 内镜下套扎治疗重度食管静脉曲张的有效率为71.74％(132/184),急诊止血率为95.00％(57/60),并发症(食管套扎部位瘢痕狭窄需行扩张治疗)发生率为2.17％(4/184).内镜下组织胶注射治疗胃底静脉曲张的有效率为100％(32/32),并发症(注射部位难治性溃疡7例,其中难治性溃疡并出血2例)发生率为21.88％(7/32).均无穿孔、重度感染并发症发生.结论 内镜下套扎和组织胶注射治疗食管和胃底静脉曲张疗效良好.     

Management of gastric varices

Gastric varices (GV) area common (20%) accompaniment of portal hypertension; they are more often seen in those patients who bleed than in those who do not (27% versus 4%, p < 0.01). They can develop in both segmental and generalized portal hypertension. Depending on their location and relation with oesophageal varices, GVs can be classified as gastro-oesophageal varices (GOV) and isolated gastric varices (IGV); each of these can be further subdivided as follows: GOV1 (extension of oesophageal varices along lesser curve) and GOV2 (extension of oesophageal varices towards fundus); and IGV1 (varices in the fundus) and IGV2 (isolated varices anywhere in the stomach). The common presentation of GVs is variceal bleeding and encephalopathy. In comparison with oesophageal varices, GVs bleed significantly less often (64% versus 25%, p < 0.01) but more severely (2.9±0.3 versus 4.8±0.6 transfusion units, p< 0.01). Patients with GOV2 and IGV1 bleed more often than patients with other types of GVs. Sclerotherapy for oesophageal varices can significantly influence the natural history of GVs. GOV1, or lesser curve varices, disappear in the majority of cases (59%) after obliteration of oesophageal varices. In those with persisting GOV1, the incidence of bleeding and mortality is high and these patients require gastric variceal sclerotherapy (GVS). During oesophageal variceal sclerotherapy, bleeding can occasionally be induced from GVs. After obliteration of oesophageal varices, recurrence as GVs (secondary GVs) can occur in about 9% of patients. Emergency GVS is quite effective in controlling acute bleeding from GVs, more so than balloon tamponade. Potent sclerosants like tetradecyl sulphate and alcohol and a glue, bucrylate, have been quite effective. Elective GVS can achieve obliteration of GVs in nearly 70% of patients. Rebleeding and ulceration are common complications of GVS; probably related to incomplete obliteration and mucosal injury respectively. Splenectomy is quite effective in treating GVs due to segmental portal hypertension. For GV bleeding due to generalized portal hypertension, a shunt operation is often effective. TIPS procedure appear to be a very promising therapy for GV bleeding. Liver transplantation may be a superior alternative to sclero-therapy and shunt surgery for gastric varices.     

Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage:A meta-analysis

AIM:To compare the effect of endoscopic variceal ligation(EVL)with that of endoscopic injection sclerotherapy(EIS)in the treatment of patients withesophageal variceal bleeding.METHODS:We performed a systematic literature search of multiple online electronic databases.Metaanalysis was conducted to evaluate risk ratio(RR)and95%confidence interval(CI)of combined studies for the treatment of patients with esophageal variceal bleeding between EVL and EIS.RESULTS:Fourteen studies comprising 1236 patients were included in the meta-analysis.The rebleeding rate in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group(RR=0.68,95%CI:0.57-0.81).The variceal eradication rate in actively bleeding varices patients in the EVL group was significantly higher than that in the EIS group(RR=1.06,95%CI:1.01-1.12).There was no significant difference about mortality rate between the EVL group and EIS group(RR=0.95,95%CI:0.77-1.17).The rate of complications in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group(RR=0.28,95%CI:0.13-0.58).CONCLUSION:Our meta-analysis has found that EVL is better than EIS in terms of the lower rates of rebleeding,complications,and the higher rate of variceal eradication.Therefore,EVL is the first choice for esophageal variceal bleeding.     

奥曲肽联合内镜套扎术治疗食管静脉曲张破裂出血的疗效观察

目的观察奥曲肽联合内镜套扎术对食管静脉曲张破裂出血的治疗效果。方法30例病人随机分为两组,内镜治疗前分别给予奥曲肽或垂体后叶素,然后行内镜套扎治疗。观察两组的止血率、再出血率和不良反应发生率。结果奥曲肽组与垂体后叶素组相比,止血率明显提高,再出血率和不良作用明显下降(P<0.05),治疗效果明显优于后者。结论奥曲肽联合内镜套扎术可以明显提高食管静脉曲张破裂出血的治疗效果和安全性。     

Successful treatment of giant rectal varices by modified percutaneous transhepatic obliteration with sclerosant： Report of a case

INTRODUCTIONEctopic varices outside the esophagogastric lesion are rare in patients with portal hypertension[1]. Among ectopic varices, rectal varices are comparatively common, but their rupture is often fatal although it is rarely reported[2]. Though the…     

普萘洛尔和经内镜硬化治疗预防肝硬化静脉曲张再出血的荟萃分析

目的:系统评价普萘洛尔和经内镜硬化疗法预防肝硬化静脉曲张再出血的有效性和安全性.方法:计算机检索PubMed、EMBASE、Cochrane Library、CBM、CNKI、VIP数据库2009-02前发表的有关普萘洛尔和经内镜硬化疗法预防肝硬化静脉曲张再出血的随机对照试验,2名评价员独立对纳入文献进行质量评价和数据提取,用RevMan5.0软件统计分析.结果:共纳入9篇随机对照试验共计740例患者,Meta分析结果显示:两组在生存率(RR=0.97,95%CI:0.86-1.10)、病死率(RR=1.20.95%CI:0.90-1.59)方面差异均无统计学意义;普萘洛尔组再出血率高于经内镜硬化治疗组(RR=1.33,95%CI:1.14-1.54),但普萘洛尔组不良反应发生率低(RR=0.48,95%CI:0.26-0.86).结论:普萘洛尔与经内镜硬化治疗在预防再出血,再出血发生率高但不良反应发生率低.     

药物联合内镜治疗预防肝硬化门静脉高压食管胃静脉曲张再出血的疗效观察

目的观察药物（普奈洛尔）联合内镜（套扎或/和组织胶）治疗预防肝硬化门静脉高压食管胃静脉曲张再出血的疗效。方法将65例肝硬化门静脉高压食管胃静脉曲张出血经内科药物治疗出血停止的患者随机分为2组：治疗组34例,采用普奈洛尔联合内镜治疗（对单纯食管静脉曲张行套扎治疗,对食管胃静脉曲张行套扎治疗＋组织胶治疗）;对照组31例,单用普奈洛尔治疗。随访12个月,观察治疗后患者再出血率、死亡率等。结果随访12个月期间再出血率治疗组20.6%（7/34）,对照组32.3%（10/31）,差异有统计学意义（P〈0.05）;死亡率治疗组8.8%（3/34）,对照组9.7%（3/31）,差异无统计学意义（P〉0.05）。结论药物联合内镜治疗可以有效预防肝硬化门静脉高压食管胃静脉曲张再出血,提高患者生活质量,值得临床推广。