内镜食管静脉曲张结扎术─—四年经验总结

作者应用内镜结扎术治疗２５０例食管静脉曲张病人。其中２３４例病人有１次或１次以上出血史，７８例病人为活动性出血。急诊结扎止血率达９３．６％，经３～５次结扎治疗，食管静脉曲张被根除或缩小至１°以下者占８１％，未发现与结扎术有关的严重并发症。本组治疗结果表明：内镜食管静脉曲张结扎术止血效果可靠，操作简单安全、损伤小、并发症少、适应症范围广泛，既可紧急止血，也可作为预防食管静脉曲张再出血的长期处理措施。     

EVL治疗食管静脉曲张破裂出血

EVL治疗食管静脉曲张破裂出血39例，结扎时活动性大出血34例，5d内出血5例。39例进行102次963处结扎，其中29例经2～5次密集结扎后15例食管静脉曲张消失，显效率51．7％，13倒退缩到I度，总有效率96．6％。34例活动姓大出血患者40次紧急结扎，40例次立即止血，2例72h内再出血，急诊止血率95％。39例中肝功能ChildC级17例，占43．6％，均能安全接受治疗，水后无1例并发症及肝功能损害加重。存活34例，15例恢复工作。13例14～23月（平均18．4月）复查，2例复发食管静脉曲张再行EVL。EVL治疗食管静脉曲张破裂出血疗效确切、安全、操作简便。     

胃镜结扎及硬化剂注射治疗食管静脉曲张的临床应用

经胃镜下结扎（EVL）后附加硬化剂注射（EIS）联合治疗食管静脉曲张患者106例，101例一个月内无出血，止血率为95．3％。经过1—2次胃镜结扎治疗后再用硬化剂治疗，88例食管静脉曲张完全消失，消失率达83．0％，余18例（17％）静脉曲张明显缩小。结果提示，采用EVL和EIS联合治疗重庆食管静脉曲张与单纯使用EVL或EIS治疗的止血效果和食管静脉曲张消失率两种方法相比有显著的差异（分别为P＜0．01和P＜0．05）。它具有方法简单、安全、能有效地控制急性出血及手术后再出血，降低死亡率，使肝功能差的患者度过出血期，为择期手术创造条件。     

急性食管静脉曲张破裂出血套扎术的治疗体会

目的：探讨食管静脉皮圈结扎术（EVL）治疗急性食管静脉曲张破裂出血的临床价值。方法：将45例食管静脉曲张破裂出血者分为治疗组和对照组，治疗组全部操作在胃镜直视下进行，对食管静脉曲张有活动出血（喷血和渗血）和食管静脉曲张见血泡样斑、血痂或红色症行EVL术。对照组使用垂体后叶素0.2-0.4U/min持续静脉滴注，硝酸甘油根据血压调速。结果：治疗组止血成功率96％，近期再出血率0％，1个月后食管静脉曲张消除率80％。对照组止血成功率75％（P＜0．05），近期再出血率22．2％（P＜0．05）。结论：EVL治疗食管静脉曲张破裂出血疗效可靠，操作简单，安全性高，副作用小，病人顺应性好。     

食管静脉曲张出血的急诊套扎治疗31例体会

目的探讨食管静脉曲张套扎术（EVL）治疗食管静脉曲张破裂出血的临床效果。方法2003年11月～2007年3月我院收治食管静脉曲张破裂出血病人31例，对31例门静脉高压食管静脉曲张破裂出血患者，进行了急诊胃镜下食管静脉曲张套扎术（EVL）。结果100％止血成功，EVL具有设备简单，操作方便，安全有效，不良反应少适合于重度和中度以上食管静脉曲张。结论食管静脉曲张破裂出血属危重症，必须采取积极有效的疗法进行救治，并证实本法治疗是有效的。     

α—氰丙烯酸烷基脂注射联合套扎治疗食管胃底静脉曲张出血的效果观察及护理

目的探讨α—氰丙烯酸烷基脂注射联合内镜下食管静脉曲张套扎术(endoscopic variceal ligation,EVL)治疗食管胃底静脉曲张出血患者的效果,并总结护理要点。方法 2006年10月-2009年5月对30例食管胃底静脉曲张患者于出血72h内行注射α—氰丙烯酸烷基脂联合EVL治疗,术前对患者进行心理护理,加强术后护理及并发症的观察及护理。结果急诊止血率达100.0;总治疗有效率为73.3,其中显效7例(23.3),有效15例(50.0),无效8例(26.7),未出现严重并发症。结论α—氰丙烯酸烷基脂内镜下注射联合EVL治疗食管胃底静脉曲张出血患者疗效确切,同时通过对患者进行严密的病情观察、精心的护理,可避免或减少患者再出血及并发症的发生,对治疗成功具有重要意义。     

急诊内镜下套扎应用于肝硬化食管静脉曲张破裂出血的疗效及安全性评价

目的观察急诊内镜下套扎(EVL)治疗肝硬化食管静脉曲张破裂出血的疗效及并发症,评估其安全性。方法对68例肝硬化食管静脉曲张破裂出血患者进行EVL治疗,从胃食管连接处开始螺旋向上套扎曲张静脉;当有活动性出血,首先套扎出血处静脉,如止血不成功,则在其下方套扎;如出血较多视野不清,则从胃食管连接处盲扎。观察止血效果及并发症。结果急诊止血成功率为94.12%(64/68),术中并发症发生率为10.29%(7/68),术后并发溃疡出血发生率为2.92%(2/68),无死亡发生。结论 EVL是一种快速、有效的止血方法,但术中并发症并不少见,应重视术中误吸、出血等并发症。     

内镜下套扎术对老年肝硬化合并食管静脉曲张出血患者的临床疗效观察

<正>食管静脉曲张出血是肝硬化最常见和最严重的并发症之一~([1])。食管静脉曲张出血的常规治疗方法是止血、快速输血和补液,其中内镜下套扎术(EVL)是目前止血的首选方案,其手术操作简单、成功率高、并发症少~([2])。本研究对老年肝硬化合并食管静脉曲张出血患者采取EVL治疗,取得了满意的临床效果,现报告如下。     

食管静脉曲张出血的内镜下套扎治疗

目的总结食管静脉曲张破裂出血患者在急诊内镜下行套扎治疗（EVL）的效果及安全性。方法对49例肝硬化食管静脉曲张破裂出血患者在急诊状态下紧急内镜套扎采用螺旋形套扎法。结果急诊EVL能明确出血部位，急诊止血成功率达98％，套扎过程对生命体征无明显影响，术后无并发症发生，近期再出血1例。结论EVL是急诊抡救食管静脉曲张大出血的安全有效、简便方法。     

食管静脉曲张出血急诊内镜套扎止血84例护理分析

目的探讨急诊内镜下行食管静脉曲张套扎术（EVL）的护理配合与经验。方法使用套扎器对84例食管静脉曲张出血患者的曲张静脉进行套扎治疗。结果84例患者食管曲张静脉均成功套扎,止血成功率达100％,其中3例术后2周内复查胃镜仍有局部食管静脉曲张伴红色征,再行EVL治疗。所有病例患者术后1-3d内均有不同程度的胸骨后疼痛、吞咽困难或异物感、低热等并发症。结论食管静脉曲张套扎术止血可靠、短期再出血率低,设备简单,可重复性强,是肝硬化食管静脉曲张出血的有效止血方法。急诊内镜下套扎每个环节的护理配合均十分重要。     

Three years experience with endoscopic variceal ligation for treatment of bleeding varices.

Endoscopic variceal ligation (EVL) was developed as an alternative to endoscopic variceal sclerosis (ES) because of the high complication rate seen with ES. The new technique involves placement of small elastic bands around the variceal channels in the distal esophagus. The first 146 consecutive patients treated with EVL during the period from August, 1986 to July, 1989 are reported. Portal hypertension was caused by alcoholic liver disease in 93 of these patients. The average age of the patients was 53 years and 66% were males. All of the patients had recently bled from esophageal varices. At the time of treatment, 23% of the patients were actively bleeding. They were all treated acutely with EVL and had repeated treatments with the long-term goal of variceal eradication. The overall survival was 73%. Varices were eradicated or reduced to grade one in 78% of the 125 patients who were followed for more than 30 days. Variceal eradication required a mean of 5.5 sessions. Recurrent bleeding occurred in 44% of the total patient population. There were no major complications from EVL. It is concluded from this non-randomized experience that EVL is an effective treatment for bleeding esophageal varices and that it appears to be as effective as sclerotherapy with fewer complications.     

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。     

内镜曲张静脉结扎联合脾栓塞术76例报告

目的：探讨内镜曲张静脉结扎（EVL）联合脾栓塞术（PSE）治疗门静脉高压症的疗效。方法：对76例门静脉高压症合并食管曲张静脉出血和脾功能亢进病人实施EVL联合PSE治疗。结果：76例病人食管曲张静脉均完全闭塞,平均随访21月（3－48月）,复发出血率为6．6％,脾栓塞术后脾脏明显缩小,外周血白细胞与血小板均显著升高（P＜0．01）,结论：EVL联合PSE疗法是治疗门静脉高压症食管静脉曲张出血和脾功能亢进的安全有效方法,该联合疗法比单独EVL更快闭塞曲张静脉,复发出血率低;较外科手术简单,侵袭性小。     

Variceal bleeding and portal hypertension: still a therapeutic challenge?

In the primary prevention of variceal hemorrhage, beta-blockers continue to be the first-line treatment. Newer nonselective beta-blockers with anti-alpha1-adrenergic activity, such as carvedilol, appear to have a better impact on reducing the hepatic venous pressure gradient than propranolol. The addition of isosorbide mononitrate appears to improve the effectiveness of beta-blockers in primary prophylaxis, but not that of somatostatin in the treatment of acute variceal hemorrhage. The use of vasoactive drugs alone in acute variceal bleeding has not proved to be more effective than endoscopic treatment. The advent of endoscopic variceal ligation (EVL) has strengthened the role of endoscopy in the management of bleeding esophageal varices. EVL has improved the results, particularly in terms of lowering the treatment-related morbidity, compared with endoscopic variceal sclerotherapy (EVS). However, the variceal recurrence rate after initial eradication with EVL is relatively high. In contrast to synchronous combined therapy with EVL plus EVS, metachronous combination of EVL and low-dose EVS may improve the results of EVL alone. For bleeding fundic varices, obliteration using cyanoacrylate is currently the treatment of choice. Endosonography (EUS) is coming into more widespread use in the assessment of variceal eradication and in further attempts to improve the results of endoscopic injection therapy. According to two meta-analysis studies, transjugular intrahepatic portosystemic shunt (TIPS) is not yet capable of replacing endoscopic treatment in the secondary prevention of variceal bleeding.     

密集多点结扎术治疗肝癌合并食管曲张静脉急性出血疗效观察

目的探讨内镜下密集多点结扎术(DEVL)治疗原发性肝癌合并食管曲张静脉急性出血的临床疗效。方法采用内镜下密集多点结扎术治疗原发性肝癌合并食管静脉曲张急性出血患者58例。急性出血控制后,每隔2周重复治疗,直至曲张静脉完全根治。结果50例完成全部结扎治疗,共完成146次、1141点结扎,平均每例结扎2.9次、22.8点。急诊止血率91.4%,近期再出血率20.7%,曲张静脉根治率为82%。结论内镜下密集结扎术能有效地治疗原发性肝癌合并食管静脉曲张急性出血,根治食管曲张静脉和预防再出血。DEVL治疗不受肝功能的影响,并发症少。     

微探头超声在食管静脉曲张腔内外联合断流术中的应用

目的运用微探头超声观察门脉高压症食管静脉曲张患者食管下段壁内外静脉结构治疗前后的变化以及对腔内外联合断流术的疗效、预后进行评价。方法对23例门脉高压食管静脉曲张患者，在接受腔内外联合断流术前后应用微探头超声对食管下段静脉结构情况进行对比观察。随访追踪食管静脉曲张的复发率、再出血率。结果治疗后食管黏膜下曲张静脉消失，食管周围静脉丛曲张程度也明显减轻或消失。短期追踪随访静脉曲张的再发率和出血率分别为5．0％和0。结论腔内外联合断流能有效闭塞食管下段壁内外的静脉，阻断门奇分流，防治食管静脉曲张出血与复发，而且操作简便，值得推广应用。微探头超声检查食管下段静脉的变化在食管静脉曲张治疗的评价中具有重要意义。     

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。     

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.