普萘洛尔联合内镜下静脉曲张套扎术对肝硬化伴食管静脉曲张患者长期结局的影响探讨

Effect of propranolol combined with endoscopic variceal ligation on the long-term outcome of patients with liver cirrhosis and esophageal varices

目的比较内镜下静脉曲张套扎术(EVL)治疗与普萘洛尔联合EVL治疗对肝硬化伴食管静脉曲张患者长期结局的影响。方法回顾性分析166例肝硬化伴食管静脉曲张患者的临床资料,根据治疗方法的不同分为对照组(80例)和研究组(86例)。对照组实施单独EVL治疗,研究组采用普萘洛尔联合EVL治疗。比较两组的临床资料、并发症发生情况、5年生存率及死亡原因。结果两组患者的年龄、性别、肝硬化病因、静脉曲张度、血红蛋白、血小板计数、总胆红素、直接胆红素以及肝功能Child-Pugh分级比较,差异均无统计学意义(P>0.05)。随访终止,对照组患者发生静脉曲张出血17例(21.3%),肝肾综合征6例(7.5%),肝性脑病3例(3.8%),自发性腹膜炎4例(5.0%),肝腹水11例(13.8%);研究组患者发生静脉曲张出血22例(25.6%),肝肾综合征11例(12.8%),肝性脑病4例(4.7%),自发性腹膜炎6例(7.0%),肝腹水12例(14.0%)。两组患者静脉曲张出血、肝肾综合征、肝性脑病、自发性腹膜炎、肝腹水发生率比较,差异均无统计学意义(P>0.05)。Kaplan-Meier生存分析显示,研究组的5年生存率53.5%(46/86)低于对照组的70.0%(56/80),差异具有统计学意义(P<0.05)。研究组患者因肝功能衰竭死亡占比18.6%、死亡率46.5%高于对照组的6.3%、30.0%,差异有统计学意义(P<0.05)。两组因静脉曲张出血、肝癌、肺栓塞、心肌梗死、败血症、其他恶性肿瘤、脑出血死亡占比比较,差异无统计学意义(P>0.05)。结论普萘洛尔联合EVL治疗可能增加出血发生率和患者死亡率,单独EVL治疗比联合疗法更为安全,可继续作为肝硬化伴食管静脉曲张静脉出血的一级预防策略。

Objective To compare the effect of endoscopic variceal ligation(EVL)versus propranolol combined with endoscopic variceal ligation on the long-term outcome of patients with liver cirrhosis and esophageal varices.Methods The clinical data of 166 patients with liver cirrhosis and esophageal varices were retrospectively analyzed and divided into a control group(80 cases)and a study group(86 cases)according to different treatment methods.The control group was treated with EVL alone,and the study group was treated with propranolol and EVL.The clinical data,complications,5-year survival rate and causes of death were compared between the two groups.Results There were no statistically significant differences between the two groups in terms of age,gender,cause of cirrhosis,severity of esophageal varices,hemoglobin,platelet count,total bilirubin,direct bilirubin and Child-Pugh classification of liver function(P>0.05).At the end of follow-up,17 patients(21.3%)in the control group developed varicose hemorrhage,6 patients(7.5%)had hepatorenal syndrome,3 patients(3.8%)had hepatic encephalopathy,4 patients(5.0%)had spontaneous peritonitis,11 patients(13.8%)had hepatic ascites.In the study group,22 patients(25.6%)developed varicose hemorrhage,11 patients(12.8%)had hepatorenal syndrome,4 patients(4.7%)had hepatic encephalopathy,6 patients(7.0%)had spontaneous peritonitis,and 12 patients(14.0%)had hepatic ascites.There were no statistically significant differences between the two groups in terms of incidence rates of varicose hemorrhage,hepatorenal syndrome,hepatic encephalopathy,spontaneous peritonitis and hepatic ascites(P>0.05).Kaplan-Meier survival analysis showed that the 5-year survival rate in the study group was 53.5%(46/86),which was lower than that of 70.0%(56/80)in the control group,and the difference was statistically significant(P<0.05).The proportion of liver failure related death and mortality were 18.6%and 46.5%in the study group,which were higher than those of 6.3%and 30.0%in the control group,the differences were statistically significant(P<0.05).There was no statistically significant difference in proportion of death due to varicose hemorrhage,liver cancer,pulmonary embolism,myocardial infarction,sepsis,other malignant tumors and cerebral hemorrhage between the two groups(P>0.05).Conclusion Propranolol combined with EVL therapy may increase the incidence of bleeding occurrence and mortality.EVL treatment alone is safer than combination therapy and can be continuously used as a primary prevention strategy for liver cirrhosis with esophageal variceal hemorrhage.