精准内镜下组织胶治疗胃静脉曲张的临床效果

目的研究精准内镜下组织胶治疗胃静脉曲张的临床价值。 方法回顾性分析2013年3月至2019年11月浙江中医药大学附属杭州市西溪医院内镜下组织胶治疗食管胃静脉曲张3型（GOV3）患者60例,根据内镜下选择治疗胃静脉曲张（GV）的不同,分为精准组和经典组各30例。采用χ²检验比较2组患者治疗后1、3、6个月再出血率、急性门静脉血栓形成、并发症（包括异位栓塞）和转归（包括TIPS/外科手术、死亡率）等方面的差异;采用t检验比较2组患者GV穿刺点数、组织胶用量和Child-pugh评分等方面的差异。 结果2组患者在年龄、性别、病因、Child-pugh评分、急性门静脉血栓形成、呕血/黑便病史、脾切除术、GV联合钛夹等方面比较,差异均无统计学意义（P＞0.05）。精准组6个月累积GV穿刺点数和组织胶应用支数显著多于经典组［（9.07±3.59）点vs（2.90±1.71）点,（9.27±4.27）支vs（3.90±1.95）支,P均＜0.01］。精准组治疗后1、3、6个月再出血率均低于经典组（0 vs 16.7%,3.3% vs 36.7%,10.0% vs 46.7%,P均＜0.05）。2组患者在治疗后Child-pugh评分、发热、急性门静脉血栓形成、异位栓塞、再出血而死亡或转TIPS/手术等方面均无统计学差异［（6.47±1.48）分vs（6.40±1.54）分,10% vs 10%,0 vs 0,0 vs 0,0 vs 6.7%,0 vs 6.7%,P均＞0.05）］。 结论精准治疗可以减少GV组织胶治疗的再出血率。精准治疗发热、急性门静脉血栓形成、异位栓塞等并发症少见,对肝硬化患者Child-pugh评分亦无影响。     

不同手术时机治疗高血压脑出血与术后再出血相关性研究

目的：探讨不同手术时机治疗高血压脑出血与术后再出血相关性。方法：240例手术治疗的高血压脑出血（HICH）患者根据手术时间分为超早期组（≤6h）,早期组（6-24h）及晚期组（≥24h）,比较不同组别患者近期疗效及再出血发生率。结果：240例患者发生术后再出血30例,发生率为12．5％,其中超早期组为20．83％,早期组为11．20％,晚期组为3．84％,再出血发生率超早期组明显高于早期组与晚期组（P＜0．05）,早期组与晚期组无明显差异（P＞0．05）;格拉斯哥预后评分（GOS）方面三组间优良率及死亡率两两比较未见明显差异（ P＞0．05）。结论：超早期手术治疗与术后再出血有关,对于符合条件的HICH患者,早期手术是较为安全且有效的手术时机。     

急性上消化道出血患者既往出血次数与90 d全因死亡和再出血的关系：一项真实世界研究

目的:探讨既往出血史与急性上消化道出血患者的不良预后的关系。方法:本研究是一项前瞻性多中心真实世界临床研究（AUGUR研究）,收集2020年6月30日至2021年2月10日全国20家三级医院因急性上消化道出血就诊于急诊科患者的资料。根据患者的既往出血次数,将患者分为三组（0次,1~3次和≥4次）,将患者的人口学资料、临床特征、实验室资料、治疗转归等数据进行单因素分析及Logistic回归分析,探究既往的出血次数与消化道出血患者90 d死亡和再出血的关系。结果:本研究共纳入1 072例急性上消化道出血患者,所有患者的全因死亡率和再出血率分别为10.9%（117/1 072）和11.8%（129/1 072）。其中有712例（66.42%）患者既往无出血,有297例患者（27.71%）既往出血1~3次,有63例（5.88%）患者既往出血≥4次。在单因素分析中,年龄、入院生命体征及意识情况、既往肝硬化病史、以呕血起病、入院血红蛋白水平、静脉曲张所致出血、消化道溃疡所致出血、入院后输注红细胞、入院后进行气管插管及使用血管活性药均是90 d全因死亡和再出血的危险因素。经过多因素logistic回归分析显示,既往出血次数≥4次急性上消化道出血的患者90 d死亡（ OR=2.17,95% CI：1.04~4.57, P=0.040）及再出血（ OR=2.32,95% CI：1.19~4.53, P=0.013）的风险更高。 结论:既往出血次数≥4次是影响急性上消化道出血的患者90 d病死率及再出血率的独立危险因素。     

门静脉高压断流术后上消化道再出血的治疗策略：附56例报告

目的：探讨门静脉高压断流术后上消化道再出血的原因及分流术的治疗作用。方法：回顾性分析10年间收治的门静脉高压断流术后上消化道再出血56例患者的临床资料。其中54例再次行分流手术，其中急诊手术5例，择期手术49例，包括肠系膜上静脉－下腔静脉人工血管反C型分流术(肠腔分流术)45例，门静脉－下腔静脉分流术5例，肠系膜下静脉－下腔静脉人工血管分流术4例。结果：54例手术治疗者术后出现乳糜漏13例，均治愈;肝性脑病5例，治疗好转4例，死亡1例;术后3d，死于肝衰竭1例。另非手术治疗2例中1例死于肝衰竭;1例死于失血性休克。随访52例，随访时间6个月至9年;随访期间无上消化道再出血病例;死亡7例，其中2死于原发性肝癌，3例死于肝衰竭、肝性脑病，2例死于非相关性疾病。结论：对于门静脉高压断流术后上消化道再出血患者首先采取积极的非手术治疗，然后行择期手术;积极非手术治疗48h无效者，应急诊手术治疗。手术方式首选肠系膜上静脉－下腔静脉人工血管反C型分流术(肠腔分流术)，尤其对伴有门静脉血栓、门脉高压性胃病患者。     

基底节区高血压脑出血手术治疗的新选择

目的：探讨基底节区高血压脑出血手术方式的选择及对预后的影响。方法：我院2004年9月～2012年10月经CT证实为基底节区高血压脑出血且量在35～62 ml的患者170例,分别采取开颅手术清除血肿（ A组）60例、CT定向脑内血肿微创清除术（B组）72例、脑内血肿微创清除术＋开颅血肿清除术（C组）38例,比较3组患者术后再出血率、3个月内病死率及术后生活能力恢复程度（ADL）。结果：3组患者术后再出血率、3个月内病死率及术后恢复能力比较均具有统计学意义（P＜0．05）。C组术后再出血率13．15％（5/38）明显低于B组34．72％（25/72）、（P＜0．05）,和A组相近15％（9/60）（P≧0．05）,C组3个月内病死率5．26％（2/38）低于A组12．0％（5/60）和B组20．83％（15/72）（P＜0．05）;3个月后ADL1-3级患者C组81．58％（31/38）明显多于A组58．33％（35/60）和B组68．06％（49/72）,（P＜0．05）。结论：基底节区高血压脑出血的病患,采取微创＋开颅脑内血肿清除术,可有效降低患者2次出血率和病死率,提高术后ADL1-3级患者比例,明显改善患者预后。     

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.     

心得安、硬化剂及两者联合预防食管胃底静脉曲张再出血的研究

目的比较心得安、硬化剂及两者联合预防食管胃底静脉曲张再出血的临床疗效。方法115例食管胃底静脉曲张破裂出血患者,随机分为三组,其中接受心得安治疗40例,硬化剂治疗35例,硬化剂联合心得安治疗40例,比较三组患者3个月、6个月、1年、2年不同时间段的再出血率、死亡率和并发症情况。结果3个月和6个月内三组患者再出血率比较,差异均无统计学意义（P〉0．05）;1年和2年内硬化剂联合心得安组再出血率均低于心得安组,差异有统计学意义（P〈0．05）;1年内硬化剂组与心得安组的再出血率无明显差异（P〉0．05）,而2年内硬化剂组再出血率低于心得安组,差异有统计学意义（P〈0．05）,三组患者的死亡率和并发症比较,无明显差异（P〉0．05）。结论硬化剂联合心得安预防再出血疗效最好,硬化剂次之,心得安最差。     

内镜下套扎联合硬化剂注射治疗乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血患者疗效及其再出血危险因素分析*

目的 研究内镜下套扎联合硬化剂注射治疗乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血（EGVB）患者的疗效,并分析引起治疗后再出血的危险因素。 方法 2012年2月~2016年2月收治的120例乙型肝炎肝硬化并发EGVB患者,采用内镜下食管静脉曲张套扎术（EVL）联合内镜下静脉曲张硬化剂注射术（EIS）治疗,对胃底静脉曲张出血患者采用组织黏胶内镜下注射联合EIS治疗,术后给予心得安治疗。采用Logistic回归分析再出血的危险因素。 结果 在手术过程中止血成功率为100.0%,33例EGVB1型患者治疗后静脉曲张消失率明显高于而静脉曲张复发率显著低于2型或1型/2型患者（P<0.05）;不同类型静脉曲张患者治疗后再出血率比较无显著性差异（P>0.05）;35例再出血患者男性占（85.7%）,明显高于85例未再出血组的49.4%（P<0.05）,年龄明显大于未出血患者（P<0.05）,门静脉内径和Child-Pugh评分分别为（1.5±0.5）cm和（10.3±2.1）分,显著高于未出血患者[分别为（1.1±0.2） cm和（7.3±1.3） 分,P<0.05],而血清白蛋白和血钠浓度分别为（23.4±5.5） g/L和（124.67±31.47） mmol/L,显著低于未出血患者[（33.6±6.7）g/L和（137.5±36.2） mmol/L,P<0.05];经Logistic回归分析,发现门静脉内径和Child-Pugh评分是诱发再出血的危险因素[OR=3.713（1.253~10.999）、OR=4.267（1.311~13.886）],而白蛋白水平和血钠浓度是再出血发生的保护因素[OR=0.236（0.062~0.902）、OR=0.143（0.026~0.785）]。 结论 内镜下套扎联合硬化剂注射治疗乙型肝炎肝硬化并发EGVB患者临床疗效显著,并且对EGVB1型患者疗效最好。门静脉内径宽或Child-Pugh评分高说明肝储备功能差,发生再出血的风险就大。因此,针对这样的患者,更应该做好防治再出血治疗。     

药物治疗与内镜套扎预防肝硬化食管静脉曲张再出血的对比研究

目的比较口服普奈洛尔联合5-单硝酸异山梨醇酯与内镜套扎对肝硬化食管静脉曲张再出血的预防效果。方法2000-2005年间，146例肝硬化食管静脉曲张患者分别给予口服普奈洛尔联合5-单硝酸异山梨醇酯与内镜套扎治疗，追踪随访2年，比较两组再出血率、病死率、并发症发生率的情况。结果药物治疗组与内镜套扎组的再出血率分别为34．3％、36．2％；病死率为12．9％、15．9％，两者差别无统计学意义（P〉0．05）。并发症发生率分别为7．1％、24．6％，药物治疗组低于内镜套扎（P〈0．05）。对于肝功能较好者（Child—Pugh分级A和B）药物治疗的再出血率较内镜套扎治疗要低（11．1％／36．2％，P〈0．05）；而肝功能较差者（Child-Pugh分级C），内镜套扎治疗的再出血率较药物治疗要低（93．8％／36．4％，P〈0．05）。结论普奈洛尔联合5-单硝酸异山梨醇酯与内镜套扎相比，再出血率、病死率相当，但并发症发生率较低。对于肝功能Child-Pugh分级A和B的肝硬化患者，药物治疗能更有效的预防食管静脉曲张再出血；而肝功能Child—Pugh分级C的患者，内镜套扎治疗更有效。     

Tripartite intensive intervention for prevention of rebleeding in elderly patients with hypertensive cerebral hemorrhage

BACKGROUNDHypertensive cerebral hemorrhage (HICH) is the rupture and bleeding of vessels of the cerebral parenchyma caused by continuously elevated or violently fluctuating blood pressure. The condition is characterized by high disability and high mortality. Hematoma formation and resulting space-occupying effects following intracerebral hemorrhage are among the key causes of impaired neurological function and disability. Consequently, minimally invasive clearance of the hematoma is undertaken for the treatment of HICH because it can effectively relieve intracranial hypertension. Therefore, special attention should be given to the quality of medical and nursing interventions in the convalescent period after minimally invasive hematoma clearance.AIMThe study aim was to determine the value of intensive intervention, including doctors, nurses, and patient families, for the prevention of rebleeding in elderly patients with HICH during the first hospitalization for rehabilitation after the ictal eventMETHODSA total of 150 elderly HICH patients with minimally invasive hematoma evacuation in our hospital between May 2018 and May 2020 were selected and equally divided into two groups of 75 each by their planned intervention. The control group was given conventional nursing intervention and the observation group was given tripartite intensive intervention. The length of hospital stay, cost, complication rate, satisfaction rate, and rebleeding rate during hospitalization were recorded. Changes in cerebral blood flow indicators were recorded in both groups. Changes in the National Institutes of Health Stroke Scale (NIHSS) score, quality of life index (QLI) score, and health behavior score were evaluated at the National Institutes of Health.RESULTSDuration of hospitalization was shorter in the in the observation group than in the control group, the hospitalization cost was less than in the control group, and the rate of rebleeding during hospitalization was lower than in the control group (all P < 0.05). There were no significant differences between the two groups before treatment (all P > 0.05). The mean flow rate (Q_mean) and mean velocity (V_mean) of the two groups increased (P < 0.05), and the dynamic resistance and peripheral resistance decreased (P < 0.05). The Q_mean and V_mean in the intervention group were higher than those in the control group (P < 0.05). Moreover, the dynamic resistance and peripheral resistance of the blood vessels were also lower in the intervention group than in the control group (P < 0.05). The difference in health behavior scores between the two groups before treatment was not significant (P > 0.05). In both groups, the scores for healthy behaviors such as emotion control, medication adherence, dietary management, exercise management, and self-monitoring were higher after than before treatment (P < 0.05), and the scores of healthy behaviors in the intervention group were higher than those in the control group (P < 0.05). There was no significant difference in the NIHSS and QLI scores between the two groups before treatment (P > 0.05). The QLI scores of the two groups increased (P < 0.05), and the NIHSS scores decreased (P < 0.05). The QLI scores of the intervention group were higher than those of the control group (P < 0.05), and the NIHSS score was correspondingly lower than that of the control group (P < 0.05). The incidence of respiratory infections, pressure sores, central hyperpyrexia, and deep venous thrombosis was lower in the intervention group than in the control group. Accordingly, the satisfaction rate was higher in the treatment group than that in the control group (P < 0.05).CONCLUSIONIntensive intervention by doctors, nurses, and families of elderly patients with HICH reduced the rate of rebleeding during hospitalization. It also reduced the incidence of complications, promoted rehabilitation, improved the quality of life, and enhanced nerve function. Additionally, it improved satisfaction and promoted healthy behaviors.