Bucrylate treatment of bleeding gastric varices: 12 years' experience

BACKGROUND AND STUDY AIMS: For several years now there has been an increasingly widespread use of a tissue adhesive in the treatment of bleeding gastric varices to achieve rapid, safe control of hemostasis and prevent rebleeding. In this study we report on our experience with the use of Bucrylate (Hystoacryl) for the treatment of gastric varices over a period of more than a decade. PATIENTS AND METHODS: Since 1988, 174 cirrhotic patients with actively bleeding gastric varices have been admitted to our department, where they received emergency treatment with injections of Bucrylate. Any associated nonbleeding esophageal varices were subjected to traditional sclerotherapy in combination with the Bucrylate treatment. The gastric varices were subdivided into four distinct groups according to the method advocated by Sarin in 1989. The patients underwent weekly sclerotherapy sessions until their varices were eradicated, and the follow-up with a mean of 36 months (range 9-90 months) consisted of endoscopy at 3, 6, and 12 months during the first year and then yearly checks to confirm obliteration of the varices. RESULTS: The hemostasis (97.1%), early rebleeding (15.5%), and hospital mortality (19.5%) rates of the patients with bleeding gastric varices, treated with the tissue adhesive, were very similar to those of patients treated for esophageal varices over the same period (98.1%, 13.0%, and 16.4%, respectively). The most frequent cause of death at 30 days was liver failure (76% of cases), followed by hemorrhagic shock (8.8%), and other less frequent causes. Sclerotherapy achieved obliteration rate for gastric varices (70-75%) similar to that for esophageal varices in those patients with portal hypertension due to intrahepatic block (alcoholic and posthepatitis cirrhosis), but a rate of only 32% in the group of patients with prehepatic block (splenoportomesenteric thrombosis), where surgery proved more effective (69%). The medium- and long-term survival rates depended on the stability of the patients' liver conditions, on rapid, effective control of variceal hemostasis, and on complete, lasting obliteration of the gastric varices. CONCLUSIONS: The use of Bucrylate in emergency sclerotherapy achieved results in bleeding gastric varices on a par with those obtained in esophageal varices in cases of alcoholic and posthepatitis cirrhosis. The group of patients with portal hypertension due to prehepatic block (splenoportal thrombosis) showed no benefit from sclerotherapy in terms of obliteration of gastric varices, but benefited from elective surgery. The choice of the obliterating treatment indicated may be facilitated by classifying gastric varices into distinct groups on the basis of anatomicotopographic criteria.     

Life-threatening intraabdominal arterial embolization after histoacryl injection for bleeding gastric ulcer

N-butyl-cyanoacrylate (Histoacryl) injection has become the treatment of choice for acutely bleeding esophagogastric varices, and is the only effective option for endoscopic treatment of gastric varices. Recent reports confirm the ability of Histoacryl injection therapy to achieve immediate hemostasis in cases of gastric ulcer bleeding or Dieulafoy ulcer, where conventional endoscopic hemostatic treatment had failed. Although the overall safety record of Histoacryl injection has been relatively good, there have been scattered cases of serious complications. Here, we present two patients showing life-threatening intraabdominal arterial embolization after Histoacryl injection. They had chronic gastric ulcers with active arterial bleeding. In spite of attempts at hemostatic treatment, complete hemostasis was not achieved. We injected Histoacryl, diluted with Lipiodol, into bleeding gastric ulcers, resulting in successful hemostasis. Soon after the procedure, intraabdominal arterial embolization developed in both patients. One patient survived and the other died. Based on these experiences, we would like to warn gastrointestinal endoscopists to be alert to these fatal complications, and we propose that less diluted Histoacryl seems to be preferable in cases of bleeding peptic ulcers.     

内镜曲张静脉套扎联合脾栓塞治疗食管静脉曲张出血

目的　对内镜曲张静脉套扎 (EVL)联合部分脾栓塞 (PSE)治疗肝硬变食管静脉曲张出血的疗效进行评价。方法　 6 1例肝硬变食管静脉曲张出血并脾功能亢进患者 ,35例采用EVL联合PSE治疗 ,2 6例单用EVL治疗 ,比较两组近、远期静脉曲张根治率及再出血率。结果　①EVL联合PSE组近期静脉曲张根治率及再出血率分别为 97.14 %、2 .86 % ,远期则分别为 76 .4 7%、5 .88% ;②EVL联合PSE治疗组远期静脉曲张根治率显著高于EVL组 (P <0 .0 1) ,再出血率低于EVL组 (P <0 .0 5 ) ,近期两者无显著性差异 (P >0 .0 5 )。结论　EVL联合PSE治疗肝硬变食管静脉曲张出血并脾功能亢进安全有效 ,近期、远期都有较高的食管静脉曲张根治率及较低的再出血率 ,远期疗效优于EVL ,值得推广。     

内镜下套扎、硬化剂及组织胶栓塞联合治疗食管胃底静脉曲张出血的临床研究

目的 研究内镜下套扎、硬化剂及组织胶栓塞联合治疗食管胃底静脉曲张出血的临床效果.方法 采用回顾性分析方法 ,研究对象为2018年1月至2019年6月西安交通大学第一附属医院收治的220例食管胃底静脉曲张出血患者.根据不同治疗方式分为对照组(n = 100)和研究组(n = 120).对照组单用内镜下套扎治疗,研究组联用...     

内镜下注射聚桂醇和美兰混合液在食管静脉曲张硬化治疗术中的应用*

目的分析内镜下注射聚桂醇和美兰混合液在食管静脉曲张硬化治疗术中的应用价值。方法收集2014年6月-2016年2月于该院接受内镜下治疗的62例食管静脉曲张患者的临床资料,其中26例接受内镜下注射聚桂醇治疗(A组),36例接受内镜下注射聚桂醇+美兰混合液治疗(B组),比较两组治疗效果、止血成功率、安全性、并发症及随访复发情况。结果 (1)B组治疗总有效率、急诊止血成功率略高于A组,但对比差异无统计学意义(P0.05);(2)B组食管静脉曲张清除所需治疗次数少于A组,治疗时间短于A组,差异有统计学意义(P0.05);(3)B组远期再出血率及总出血率均低于A组,差异有统计学意义(P0.05);(4)B组术后并发症发生率及随访复发率均低于A组,差异有统计学意义(P0.05)。结论内镜下注射聚桂醇和美兰混合液在食管静脉曲张硬化治疗术中疗效肯定,止血效果好,患者术后并发症发生率低,复发率低。     

Endoscopic hemostasis of esophageal and gastric variceal bleeding with Histoacryl

Endoscopic injection of the tissue adhesive n-butyl-2-cyano-acrylate (Histoacryl) has been tried for esophageal or fundic variceal bleeding in 23 patients. Definitive hemostasis was achieved in 22 with a single injection of Histoacryl. Throughout the entire hospitalization period, which was completed with at least two weekly sessions of conventional sclerotherapy, only one recurrent bleeding was recorded. Four patients died of hepatic decompensation. It is suggested that Cyanoacrylate could overcome some of the shortcomings of conventional sclerotherapy such as early recurrent hemorrhage and bleeding from fundic varices.     

Variceal bleeding and portal hypertension: much to learn, much to explore

The newer diagnostic and therapeutic options continue to evolve and important developments have been made in the field of variceal bleeding and portal hypertension. A meeting was held at Baveno to update consensus on different terminologies in relation to portal hypertension. beta-blockers continue to be the mainstay for primary prophylaxis of variceal bleeding, and endoscopic variceal ligation (EVL) is fast emerging as a strong contender. The role of vasoactive drugs in the management of variceal bleeding was assessed. Octreotide and terlipressin were shown to be as effective as sclerotherapy in achieving initial hemostasis, and octreotide was shown to be safe and efficacious in the prevention of rebleeding. EVL was superior to endoscopic sclerotherapy (EST) for obliteration of esophageal varices. Sequential and simultaneous ligation and sclerotherapy were more effective than ligation alone, in reducing the recurrence rate after variceal obliteration. For gastric varices, cyanoacrylate glue continues to be the first line of treatment, and band ligation is being assessed further. Bleeding ectopic varices were dealt by appropriate endoscopic means. Endosonography has developed strongly in the assessment of variceal eradication and prediction of variceal recurrence. Transjugular intrahepatic portosystemic shunting (TIPS) significantly reduces rebleeding rates compared to EVL.     

N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy

We report on our two years' experience with the tissue adhesive n-butyl-2-cyanoacrylate. During this period 202 patients suffering from esophagogastric varices were treated endoscopically. With the aid of the tissue adhesive the conventional sclerotherapy with Polidocanol 1% has been clearly improved. Problems concerning early recurrent bleeding and fundic varices are satisfactorily solved. The endoscopic hemostasis of severe variceal bleedings has become safer and surer. The overall hospital mortality of these patients has sunk from 31.5 to 17.5%. Cyanoacrylate is a very useful substance for obliterating large esophagogastric varices. However, the complete elimination of esophageal varices, which is the guarantee for a long-term freedom from recurrent bleeding, can only be achieved by using a genuine sclerosing agent.     

内镜下套扎治疗用于肝硬化胃静脉曲张出血二级预防的疗效及安全性分析

目的 通过队列研究比较两种内镜下治疗（套扎治疗vs 组织胶注射）用于胃静脉曲张出血二级预防的疗效及安全性。 方法 筛选2017年1月至2019年12月因肝硬化食管胃静脉曲张入住复旦大学附属中山医院,并行胃静脉曲张套扎治疗的患者,患者既往有食管胃静脉曲张出血史。筛选食管胃静脉曲张患者样本库同一时期行组织胶治疗的患者,并通过倾向性评分匹配筛选,共纳入118例患者。中位随访时间为24.03个月,采用单因素与多因素Cox比例风险回归模型分析食管胃静脉曲张再出血影响因素。绘制Kaplan-Meier曲线比较套扎治疗与仅组织胶注射治疗的再出血及生存情况。 结果 套扎组与组织胶组患者食管胃静脉曲张根除率无明显统计学差异(82.76% vs. 78.95%, P=0.778）,而套扎组根除静脉曲张所需的内镜治疗次数（2 vs. 3次,P=0.017）及组织胶用量明显少于组织胶组（0.70 vs. 2.67 ml, P<0.001）。Cox多因素回归分析显示门体分流是食管胃静脉曲张再出血的危险因素（HR: 3.14, 95%CI: 1.02-9.68, P=0.046）,而胃曲张静脉套扎治疗是再出血的保护因素（HR: 0.25, 95%CI: 0.08-0.71, P=0.010）。相较于组织胶注射,套扎治疗并不增加患者2年食管胃静脉曲张再出血风险（18.69% vs. 36.29%, P=0.067）与死亡风险（1.69% vs. 3.39%, P=1.000）。相较于单纯组织胶治疗,GOV1型患者经套扎治疗后食管胃静脉曲张再出血风险较低（0% vs. 40.27%,P=0.012）。经过套扎治疗后GOV2 型患者食管胃静脉曲张出血风险（13.27% vs. 34.16%,P=0.056）存在降低趋势,但差异无统计学意义。 结论 对于胃静脉曲张出血的二级预防,套扎治疗根除静脉曲张效率较高,且并不增加出血、死亡等事件风险,可考虑作为胃静脉曲张患者的二级预防手段。     

Randomized trial of N-butyl-2-cyanoacrylate compared with injection of hypertonic saline-epinephrine in the endoscopic treatment of bleeding peptic ulcers

BACKGROUND AND STUDY AIMS: Theoretically, the injection of cyanoacrylate may be effective for peptic ulcer bleeding, but randomized clinical trials are rare. The aim of this study was to compare the efficacy of N-butyl-2-cyanoacrylate (Histoacryl) and hypertonic saline-epinephrine (HSE) in the endoscopic treatment of major peptic ulcer hemorrhage. PATIENTS AND METHODS: A total of 126 patients with major peptic ulcer hemorrhage and active bleeding or a nonbleeding visible vessel were randomly allocated to endoscopic injection with HSE (63 patients; group 1) or to injection with Histoacryl (63 patients; group 2). The two groups were well matched for age, sex, initial hemoglobin values, ulcer size and location, and bleeding stigmata. RESULTS: Initial hemostasis was achieved in 58 cases (92.1%) in group 1 and in 60 cases (95.2%) in group 2 (P=0.717). Rebleeding rates were 16 of 58 in group 1 and seven of 60 in group 2 (P=0.051). There were no significant differences regarding the rates of permanent hemostasis (51 of 63 in group 1 vs. 57 of 63 in group 2, P=0.203), emergency surgery (seven of 58 in group 1 vs. three of 60 in group 2, P=0.200), or hospital mortality due to bleeding (0 in group 1 and 0 in group 2). With regard to the rebleeding rate, there was a significant difference between group 1 and group 2 in the subgroup with active arterial bleeding (11 of 26 in group 1 and four of 29 in group 2, P=0.039) but not in the subgroup with a nonbleeding visible vessel (five of 32 in group 1 and three of 31 in group 2, P=0.708). There were no statistically significant differences in hemostatic results between the two treatment groups in the subgroups with gastric ulcers or duodenal ulcers. Although no complications followed HSE therapy, arterial embolization with infarction occurred in two patients in the Histoacryl group, of whom one died. CONCLUSIONS: Compared with HSE injection, Histoacryl injection showed no statistically significant differences in hemostatic results, except for decreasing the rebleeding rate in the patients with active arterial bleeding. However, the use of Histoacryl to control peptic ulcer bleeding should be reserved as a last resort before surgery, because of possible embolic complication.     

组织黏合剂注射联合套扎治疗食管胃底静脉曲张破裂出血的临床观察

【目的】观察组织黏合剂注射联合套扎治疗食管胃底静脉曲张破裂出血的临床疗效及安全性。【方法】对32例食管胃底静脉曲张破裂出血患者进行内镜下治疗,胃底曲张静脉采用“三明治夹心法”行组织黏合剂注射,对合并的食管曲张静脉同时行套扎治疗。术后观察不良反应、并发症和近期疗效。【结果】组织黏合剂注射量1．0～3．5mL,平均1．8mL,套扎5～12点,平均8．2点。治疗成功率100％。6例出现胸痛（18．8％）,2例出现上腹不适（6．3％）,全组未有异位栓塞的发生,追踪3个月未有再出血病例,28例3个月后复查胃镜,见胃底曲张静脉消失或明显减轻,食管曲张静脉减轻与红色征消失。【结论】组织黏合剂注射联合套扎治疗食管胃底静脉曲张破裂出血安全、有效。     

内镜下聚桂醇注射液硬化治疗食管静脉曲张破裂出血的效果观察*

目的探讨内镜下不同的硬化剂治疗食管静脉曲张破裂出血(EVB)的效果。方法肝硬化EVB的患者66例,随机分为药物治疗A组、内镜下聚桂醇硬化剂治疗B组和内镜下德国1%乙氧硬化醇硬化剂治疗C组,观察成功止血情况,静脉曲张疗效,以及随访患者出血、发热等不良情况的发生。结果 B组和C组患者止血成功率较A组有明显优势,差异有统计学意义(P0.05);B组患者静脉曲张疗效总有效率明显高于A组患者,差异有统计学意义(P0.05);B组在早期再出血、迟发性再出血方面较C组少,差异无统计学意义(P0.05);B组发热、溃疡、疼痛情况较C组少,差异有统计学意义(P0.05)。结论内镜下聚桂醇注射液硬化治疗EVB是一种安全、迅速、及时、有效且可重复的治疗方法,值得临床上大力推广应用。     

硬化剂治疗食管静脉曲张破裂出血临床分析

目的:比较硬化剂联合生长抑素与单用生长抑素治疗食管静脉曲张破裂出血,总结急诊硬化剂治疗的疗效特点。方法:39例患者采用联合治疗方案,42例接受生长抑素单独治疗,分别观察并记录出血情况及并发症。结果:治疗组急诊止血率92.3%,并发症发生率10.25%,近期再出血率为7.87%;而对照组则分别为81.0%、2.38%及37.5%,近期再出血率比较有统计学意义(P<0.01)。结论:硬化剂与生长抑素联用治疗食管静脉曲张破裂出血,止血效果好、适应证宽、并发症少及近期再出血率低。     

药物治疗对内镜下食管静脉曲张套扎术后的远期影响

目的观察和评估药物治疗对食管静脉曲张套扎术后的影响。方法将99例食管静脉曲张患者随机分为治疗组(50例)和对照组(49例)，分别口服普萘洛尔和单硝酸异山梨酯及安慰剂，并于治疗后卜3个月、12—15个月使用胃镜观察。结果1—3个月治疗组在食管静脉曲张和门脉高压性胃病的程度、肝源性溃疡和消化道再出血的发生率与对照组相同，而12—15个月后治疗组在上述几个指标均比对照组低。结论食管静脉曲张套扎术后，通过长期的药物治疗能够缓解门脉高压所致的食管静脉曲张和门脉高压性胃病，降低肝源性溃疡的发生率，预防再出血。     

肝硬化食管胃静脉曲张破裂出血与再出血危险性预测的研究进展

肝硬化食管静脉曲张破裂出血与再出血危险性预测有门静脉高压、食管胃静脉曲张出血史、瞬时弹性成像术、多层螺旋CT成像、肝硬化脾肝体积比、内镜下食管静脉曲张套扎术后、内镜治疗后随访的顺应性、血清腹水白蛋白梯度、血小板计数进行性下降、出血的控制时间、细菌感染和病毒复制。本文就这些方面作一综述。     

改良三明治法同步与序贯联合套扎治疗食管胃底静脉曲张的疗效比较

目的探讨改良三明治法同步与序贯联合套扎治疗食管胃底静脉曲张(EGV)的疗效。方法 42例EGV患者随机分为同步治疗组(22例)和序贯治疗组(20例),同步治疗组采用内镜下改良三明治法治疗胃底曲张静脉后,同时行食管曲张静脉套扎术(EVL),序贯治疗组采用内镜下改良三明治法治疗胃底曲张静脉后,隔一周分次行EVL。比较两组患者内镜下止血成功率、再出血率、胃底静脉曲张(GV)改善率、套扎器应用数目及腹痛、发热、菌血症和异位栓塞等不良反应发生率。结果两组患者内镜下止血成功率、再出血率、GV改善率差异无统计学意义,两组患者胸腹痛、发热、菌血症发生率差异无统计学意义。所有患者均未出现异位栓塞。两组患者分别平均应用(8.19±2.01)与(7.81±1.78)枚套扎环,食管静脉曲张(EV)消失率分别为59.09%与70.00%,差异均无统计学意义(P0.05)。结论内镜下一次性注射组织胶+聚桂醇同步联合套扎治疗EGV安全有效,并发症发生率低,且可减少内镜检查次数,减少患者痛苦及医疗费用,值得进一步研究。     

不同Child-Pugh分级的原发性肝癌并发食管静脉曲张破裂出血套扎术后患者的生存分析

目的分析不同Child-Pugh分级的原发性肝癌并发食管静脉曲张破裂出血并接受套扎术后患者的预后与生存情况。方法入选患者74例作为观察组,以未接受套扎的53例作为对照组,比较两组的预后与生存时间。结果随访期内对照组的再出血高于观察组（54.7% vs 17.6%,P=0.000）,且再出血量大于观察组（P<0.05）。观察组的生存期均数及中位数分别为31及32月,而对照组分别为21及16月,Kaplan-Meier分析显示两组患者的生存期差异具有统计学意义（χ²=9.499,P=0.002）。接受内镜下静脉曲张套扎术治疗的Child-Pugh A级B级患者的再出血时间间隔延长、再出血率降低、再出血量减少、患者的生存期延长,但对Child-Pugh C级患者的疗效尚有待更多病例验证。结论食管静脉曲张破裂出血肝功能为Child-Pugh A、B级患者应尽早行内镜下静脉曲张套扎术,Child-Pugh C级患者采用内镜下静脉曲张套扎术的并不会缩短患者的生存时间。     

肝硬化食管静脉曲张破裂出血患者门静脉血流动力学与IGF-I关系的研究

目的　探讨肝硬化食管静脉曲张破裂出血患者的门静脉血流动力学特点及其与血清IGF I的关系。方法　选择肝硬化食管静脉曲张破裂出血患者 2 1例为出血组 ,同期住院的肝硬化非出血患者 17例作为对照组。采用B超和彩色多普勒超声测定门静脉血流动力学的各项参数 ,并作血清IGF I检测。结果　出血组门静脉主干最高血流速度 ,门静脉血主干血流量与对照组相比均有显著差异 (P <0 0 5) ;IGF I出血组与对照组相比无明显差异 (P >0 0 5) ;Q分流量出血组和对照组与IGF I测值相关分析 ,两组均显示负相关。IGF I与食管静脉曲张程度、有无胃静脉曲张及门脉高压性胃病的程度均无明显差异 (P >0 0 5)。结论　彩色多普勒超声监测门静脉主干最高血流速度和每分钟血流量对预测肝硬化食管静脉曲张破裂出血是一项有前景的非创伤性指标 ,IGF I测定对预测门静脉分流情况有一定帮助     

普萘洛尔联合5-单硝酸异山梨醇酯预防食管静脉曲张再出血68例临床疗效观察

目的观察普萘洛尔与5-单硝酸异山梨醇酯联用预防食管静脉曲张破裂出血的疗效。方法对36例治疗组患者和32例对照组患者进行对照,观察2组患者再出血的情况。结果治疗组在随访两年再出血率明显低于对照组（P〈0．01）。结论普萘洛尔与5。单硝酸异山梨醇酯联用能预防食管静脉曲张破裂再出血的发生率。     

套扎与硬化剂比较治疗肝硬化食管静脉曲张出血的中文随机试验的系统评价

目的系统评价国内有关套扎治疗与硬化剂治疗肝硬化食管静脉曲张出血的有效性和安全性。方法计算机检索CBMdisc(1979～2006)和CNKI (1994～2006),收集有关套扎与硬化剂比较治疗肝硬化食管静脉曲张出血的随机对照试验(RCT)和半随机对照试验(CCT),由两名评价员独立对纳入文献进行质量评价和数据提取,并使用RevMan4．2．7软件进行Meta分析。结果共纳入9个RCT,包括1371例患者,其中套扎组688例,硬化剂组683例。Meta分析结果显示：对于死亡率,两组间差异有统计学意义[RR=0．60,95%CI (0．36,0．98)],套扎治疗组低于硬化剂治疗组；对于急诊止血率、出血复发率和并发症发生率,套扎治疗组也显示出更好的疗效趋势；而对于曲张静脉消失率和曲张静脉复发率,硬化剂治疗组则显示出更好的疗效趋势。结论在治疗肝硬化食管静脉曲张出血患者时,套扎较硬化剂治疗显示出更好的疗效及更少的并发症。但由于纳入研究质量不高,这一结论的强度受到一定的限制,尚需今后开展高质量随机对照试验来进一步验证。