食管胃底静脉曲张破裂出血预后的队列研究

Prognosis of patients with bleeding caused by rupture of esophageal and gastric varices: a cohort study

目的 探讨影响食管胃底静脉曲张破裂出血患者长期生存的预后因素 ,评价手术、内镜硬化剂或套扎治疗、经颈静脉肝内门体静脉分流术 (TIPS)治疗及联合治疗等干预措施对病人长期生存的影响。方法 以回顾性队列研究方式分析了 1992～ 1999年 2 0 2例以食管胃底静脉曲张破裂出血入院的患者。首次接受干预措施时或因食管胃底静脉曲张破裂出血首次入院为研究起点 ,死亡、发生肿瘤或研究截止日为终点。平均随访时间 34个月。按接受干预措施的不同分为未干预组、手术组、内镜组、TIPS组及联合干预组 ,比较各组生存曲线 ;评价影响肝硬化食管静脉曲张破裂出血病人长期生存的预后因素。结果 生存率曲线 (Kaplan Meier曲线 )分析显示 ,联合干预组和手术组病人预后明显优于内镜治疗组和无干预组 (P <0 .0 5 ) ,而内镜治疗组和未干预组无明显差异 (P >0 .0 5 ) ,联合干预组与手术组也无明显差异。采用Child Pugh分级分层后显示 :对于ChildA或ChildB级者 ,结果相似。而ChildC级病人由于病例数较少无法比较各组之间的差异。Cox比例风险模型的多因素分析显示 ,4个变量和预后独立相关 :凝血酶原时间、HBV DNA、腹水、手术治疗。

Objectives To determine the factors of long term survival in patients with bleeding caused by rupture of esophageal and gastric varices and evaluate the effects of surgical treatment, endoscopic treatment, TIPS, and combined therapy on the long term survival. Methods Retrospective cohort study was used to analyze 202 patients with bleeding caused by rupture of esophageal and gastric varices who were admitted to Zhongshan Hospital from 1992 to 1999. All of the patients were divided into several groups according to the intervention they received: no intervention group, surgery group, endoscopy group, TIPS group, and combined treatment group. The survival curves of different groups were compared. Multivariate analysis was conducted. Results Kaplan Meier curves demonstrated that the combined treatment group and surgery group had better prognosis than the endoscopy group and control group ( P <0.01). There was no statistically significant difference in survival rate between the combined treatment group and surgery group and between the endoscopy group and control group. Child Pugh stratification showed that the results were the same for patients in Child Pugh A class and B class. Multivariate analysis based on Cox proportional hazard model showed that there were four independent variables associated with prognosis: prothrombin time, HBV DNA, ascites, and operation. Conclusions Surgery, sometimes combined with other treatment, may improve the prognosis of patients with bleeding caused by rupture of esophageal and gastric varices. The four factors associated with the prognosis of patients with bleeding caused by rupture of esophageal and gastric varices are: prothrombin time, HBV DNA, ascites, and operation.