内镜下结扎术治疗胃静脉曲张的临床观察

Therapeutic efficacy of endoscopic variceal ligation to treat gastric varices： a study of 63 consecutive cases

目的观察内镜下结扎术（EVL）对不同类型胃静脉曲张（GV）的治疗效果，分析术后复发及再出血的影响因素。方法回顾性分析我院行EVL治疗的GV病例101例，随访1．5～48．0（14．90±9．08）个月，比较各型患者EVL术后止血成功率、早期再出血率、迟发性出血率、总体再出血率、GV消除率和复发率。32例完成腹部CT或CT血管造影术检查的患者，观察GV的供血血管、胃／脾一肾分流情况，测量门静脉、脾静脉直径，并分析其与GV复发之间的关系。计量资料比较用多样本均数方差分析，计数资料样本率比较用x_2检验或Fisher确切概率法，等级资料比较用秩和检验；Kaplan-Meier检验比较各型GV再出血时间，log-rank检验比较再出血率差异。结果1型食管胃静脉曲张（GOVl）63例、2型食管胃静脉曲张（GOV2）18例、GOVl＋GOV211例、1型孤立性胃静脉曲张（IGVl）9例。GOV2、IGVl曲张程度较GOVl重（u值分别为-2．960和-2．871，P值均〈0．05）。EVL治疗GV止血成功率为96．0％，再出血率为19．8％。GOVl的术后复发率20．6％，低于其他各型GV（x_2=7．054，P〈0．05）。CT或CT血管造影术显示GV患者均有胃左静脉供血，IGVl由胃左、胃短／后静脉共同参与供血者为83．3％，胃／脾一肾分流率为100．0％，均较其他各型患者高（Fisher确切概率法，P〈0．01或P〈0．05）。56．3％（18／32）的GV伴胃／脾一肾分流，有、无胃／脾一肾分流患者门静脉直径差异有统计学意义[（13．729±2．632）mm对比（17．164±4．229）mm，t=-2．766，P〈0．051，GV复发率和再出血率差异有统计学意义（复发率比较，61．1％对比28．6％，再出血率比较，33．3％对比7．1％，Fisher确切概率法，尸均值〈0．05）。结论EVL可有效控制各型GV急性出血及防止再出血。各型GV中，EVL治疗GOVl的术后复发率低。GV合并胃／脾一肾分流者更易复发及再出血。

Objective To investigate the therapeutic efficacy of endoscopic variceal ligation （EVL） for treating various types of gastric varices （GV） by reviewing patient cases m order to identify the influencing factors of EVL-related recurrence and rebleeding. Methods The medical records of 101 GV cases treated by EVL in our department between January 2008 and October 2012 were retrospectively reviewed. The cases were grouped according to GV type： type 1 （GOV1, n = 63）, type 2 （GOV2, n = 18）, GOV1 coexisting with GOV2 （n = 11）, isolated GOV1 （IGVI, n = 9）, and GOV2 （IGV2, n = 0）. Data from follow-up examinations （range： 1.5 - 48.0 months, average： 14.9 ± 9.1 months） were extracted for analysis and included early （〈 72 h after EVL） and late （72 h to 6 weeks after EVL） rebleeding and recurrence. In addition, data from computed tomography （CT） or CT angiography （CTA）, performed in 32 of the patients, were extracted to determine the influence of supplying veins, gastrorenal or splenorenal shunts, and portal vein and/or splenic vein diameterson GV recurrence. Data analysis was carried out by ANOVA, Chi-square, Fisher＇s exact or rank-sum tests, as appropriate. Kaplan-Meier analysis was used to evaluate the time of first recurrent bleeding, and the log-rank test was used to compare between-group differences. Results GOV2 and IGV1 varices were more severe than the varices ofGOV1 （GOV2 and GOVI： u = -2.960; IGV1 and GOVI： u = -2.871; bothP〈 0.05）. GOVI had a significantly lower recurrence rate than all other GV types （X2 = 7.054, P 〈 0.05）. The CT and CTA data indicated that all GV were supplied by left gastric veins, while 83.3% of IGV1 had blood supplementation by left gastric veins and short gastric or posterior gastric veins, and 100% of IGV1 had gastrorenal or splenorenal shunts. Approximately one-half of the total GV cases （56.3%, 18/32） had gastrorenal or splenorenal shunts, and this parameter was correlated with portal vein diameter （t = -2.766, P 〈 0.05）. The presence of gastrorenal or splenorenal shunts was correlated with both recurrence and rebleeding （P 〈 0.05）. Conclusion EVL can effectively control bleeding and prevent rebleeding for GV; although, the best therapeutic efficacy and lowest rate of recurrence was achieved in GOV1 cases. The presence of gastrorenal or splenorenal shunts increases the risk of GV recurrence.