食管静脉曲张首次套扎术后早期再出血的危险因素分析

Risk factors for early rebleeding after first-time endoscopic variceal ligation

目的探讨首次食管静脉曲张套扎(EVL)对肝硬化患者肝功能的影响及术后早期再出血的危险因素。方法收集2013年12月-2016年12月于吉林大学中日联谊医院接受EVL治疗的125例肝硬化食管静脉曲张患者临床资料。所有患者按照不同肝功能Child-Pugh评分进行分级,观察EVL手术前与术后1周的肝功能情况,分析EVL术后早期再出血患者的特点。符合正态分布的计量资料2组间比较采用t检验,多组间比较采用单因素方差分析;非正态分布的计量资料比较采用Wilcoxon检验。计数资料组间比较采用χ~2检验。采用Cox回归风险模型分析术后出血的危险因素,Kaplan-Meier曲线分析各观察指标与术后出血的关系,log-rank检验其差异。结果不同Child-Pugh分级患者EVL治疗前后肝功能指标差异均无统计学意义(P值均>0.05)。125例患者中11例发生早期再出血,早期再出血率为8.8%。Cox单因素分析结果显示,出血患者与未出血患者术前血红蛋白、PT、AST、TBil、Alb、有无门静脉血栓、腹水量及肝功能分级比较,差异均有统计学意义(P值均<0.05);多因素Cox风险模型分析显示,Child-Pugh C级[风险比(HR)=6.363,95%可信区间(95%CI):1.629~26.580,P=0.021]、腹水量(HR_(少量)=6.581,95%CI:1.060~66.681,P=0.046;HR_(中/大量)=8.447,95%CI:1.763~11.641,P=0.022)、术前PT越长(HR=1.146,95%CI:1.039~1.264,P=0.006)及伴有门静脉血栓(HR=9.691,95%CI:1.185~19.281,P=0.034)均是导致EVL术后早期再出血的独立危险因素。将多因素Cox回归分析结果进行Kaplan-Meier曲线分析和log-rank检验,验证了Child-Pugh C级(χ~2=3.972,P=0.046)、腹水量阳性(χ~2=20.916,P<0.001)、PT延长(χ~2=21.302,P<0.001)及伴有门静脉血栓(χ~2=10.608,P=0.001)是EVL术后早期再出血的危险因素。结论 EVL不会在短期内对患者的肝功能造成损伤,较为安全有效。应在术前及时纠正患者的肝功能、减少腹水量、改善凝血功能,从而降低EVL早期再出血的发生率。

Objective To investigate the effect of endoscopic variceal ligation（ EVL） for the first time on liver function in patients with liver cirrhosis and the risk factors for early rebleeding after surgery. Methods A retrospective analysis was performed for the clinical data of 125 cirrhotic patients with esophageal varices who underwent EVL in China-Japan Union Hospital of Jilin University from December 2013 to December 2016. They were divided into different groups according to Child-Pugh score. Liver function was observed before EVL and at 1 week after EVL. The features of patients who experienced early rebleeding after EVL were analyzed. The t-test was used for comparison of normally distributed continuous data between two groups,and a one-way analysis of variance was used for comparison between multiple groups; the Wilcoxon test was used for comparison of non-normally distributed continuous data between two groups. The chi-square test was used for comparison of categorical data between groups. The Cox regression model was used to analyze the risk factors for postoperative bleeding,the Kaplan-Meier curve was used to analyze the association of observation indices with postoperative bleeding,and the log-rank test was used for difference analysis. Results There were no significant differences in liver function parameters between the patients with different Child-Pugh classes before and after EVL（ all P〉0. 05）. Of all 125 patients,11 experienced early rebleeding,resulting in an early rebleeding rate of8. 8%. The univariate Cox regression analysis showed that there were significant differences in hemoglobin,prothrombin time（ PT）,aspartate aminotransferase,total bilirubin,albumin,the presence or absence of portal vein thrombosis,amount of ascites,and liver function classification between the patients with bleeding and those without（ all P〈0. 05）. The multivariate Cox regression analysis showed that Child-Pugh class C（ hazard ratio [HR]= 6. 363,95% confidence interval [CI]： 1. 629-26. 580,P = 0. 021）,amount of ascites（ small： HR = 6. 581,95% CI： 1. 060-66. 681,P = 0. 046; middle/large： HR = 8. 447,95% CI： 1. 763-11. 641,P = 0. 022）,long PT before surgery（ HR =1. 146,95% CI： 1. 039-1. 264,P = 0. 006）,and the presence of portal vein thrombosis（ HR = 9. 691,95% CI： 1. 185-19. 281,P = 0. 034）were independent risk factors for early rebleeding after EVL. The Kaplan-Meier curve analysis was performed for the results of the multivariate Cox regression analysis,and the results showed that Child-Pugh class C（ χ-2= 3. 972,P = 0. 046）,presence of ascites（ χ-2= 20. 916,P〈0. 001）,prolonged PT（ χ-2= 21. 302,P〈0. 001）,and presence of portal vein thrombosis（ χ-2= 10. 608,P = 0. 001） were risk factors for early rebleeding after EVL. Conclusion EVL does not cause damage to patients＇ liver function within a short period of time and is safe and effective. Liver function should be corrected,the amount of ascites should be reduced,and coagulation function should be improved before surgery to reduce the incidence rate of early rebleeding after EVL.