中国门静脉高压食管胃静脉曲张内镜治疗现状调研分析

A national questionnaire survey on endoscopic treatment for gastroesophageal varices in portal hypertension in China

目的全面了解我国门静脉高压食管胃静脉曲张内镜治疗的现状,为我国内镜治疗的发展提供数据支持和参考。方法本研究由中国肝脏健康联盟(Liver Health Consortium in China,CHESS)发起,通过网络分发调查问卷了解2022年国内开展门静脉高压食管胃静脉曲张内镜治疗的基本情况。问卷问题主要包括各类内镜治疗例数和适应证,依照指南预防食管胃静脉曲张出血(esophagogastric variceal bleeding,EGVB)的依从性,急性EGVB的处理、治疗时机,胃底及特殊类型静脉曲张的处理、内镜治疗的改善等方面。统计各项治疗数据的医院数量占参与调查问卷医院数量的比例,各级医院的指南依从性比较使用卡方检验进行分析。结果31个省(自治区、直辖市)共836家医院参与本调研,调查显示内镜治疗的主要适应证是控制急性出血(49.3%,412/836)和预防再出血(38.3%,320/836)。参与调研医院对于我国指南中EGVB一级预防的推荐意见(非选择性β受体阻滞剂或内镜治疗)的依从性为72.5%(606/836),对于EGVB二级预防推荐意见(非选择性β受体阻滞剂联合内镜治疗)的依从性为39.2%(328/836),三级医院和二级医院对于一级预防[71.0%(495/697)比79.9%(111/139),χ^(2)=4.11,P=0.033]和二级预防的依从性[41.6%(290/697)比27.3%(38/139),χ^(2)=9.31,P=0.002]差异有统计学意义。78.2%(654/836)的医院首选内镜治疗处理急性EGVB,三级医院首选内镜治疗的比例明显高于二级医院[82.6%(576/697)比56.1%(78/139),χ^(2)=46.33,P<0.001]。治疗时机通常为出血后12h内(48.5%,317/654)和12~24h(36.9%,241/654)。对于近贲门大弯侧的胃底静脉曲张和孤立性胃静脉曲张,分别有48.2%(403/836)和29.9%(250/836)的医院首选组织胶联合硬化剂注射进行处理,而12.4%(104/836)和26.4%(221/836)的医院首选以止血夹为基础的内镜治疗术式。参与调研医院认为提高内镜医师水平(84.2%,704/836)和对患者进行准确的术前评估并提高多学科诊疗水平(78.9%,660/836)是当前内镜治疗急需改进的方面。结论多种门静脉高压食管胃静脉曲张内镜治疗技术已在全国范围广泛开展,各级医院在开展急诊内镜进行EGVB止血方面较为积极,但对于预防EGVB首次出血和再出血方面的指南依从性欠佳。参与调研医院在胃静脉曲张的内镜治疗选择方面差异较大。

Objective To investigate the current status of endoscopic treatment for gastroesophageal varices in portal hypertension in China,and to provide supporting data and reference for the development of endoscopic treatment.Methods In this study,initiated by the Liver Health Consortium in China(CHESS),a questionnaire was designed and distributed online to investigate the basic condition of endoscopic treatment for gastroesophageal varices in portal hypertension in 2022 in China.Questions included annual number and indication of endoscopic procedures,adherence to guideline for preventing esophagogastric variceal bleeding(EGVB),management and timing of emergent EGVB,management of gastric and isolated varices,and improvement of endoscopic treatment.Proportions of hospitals concerning therapeutic choices to all participant hospitals were calculated.Guideline adherence between secondary and tertiary hospitals were compared by using Chi-square test.Results A total of 836 hospitals from 31 provinces(anotomous regions and municipalities)participated in the survey.According to the survey,the control of acute EGVB(49.3%,412/836)and the prevention of recurrent bleeding(38.3%,320/836)were major indications of endoscopic treatment.For primary[non-selective β-blocker(NSBB)or endoscopic therapies]and secondary prophylaxis(NSBB and endoscopic therapies)of ECGVB,adherence to domestic guideline was 72.5%(606/836)and 39.2%(328/836),respectively.There were significant differences in the adherence between secondary and tertiary hospitals in primary prophylaxis of ECVB[71.0%(495/697)VS 79.9%(111/139),χ^(2)=4.11,P=0.033]and secondary prophylaxis of ECVB[41.6%(290/697)VS 27.3%(38/139),χ^(2)=9.31,P=0.002].A total of 78.2%(654/836)hospitals preferred endoscopic therapies treating acute EGVB,and endoscopic therapy was more likely to be the first choice for treating acute EGVB in tertiary hospitals(82.6%,576/697)than secondary hospitals[56.1%(78/139),χ^(2)=46.33,P<0.001].The optimal timing was usually within 12 hours(48.5%,317/654)and 12-24 hours(36.9%,241/654)after the bleeding.Regarding the management of gastroesophageal varices type 2 and isolated gastric varices type 1,most hospitals used cyanoacrylate injection in combination with sclerotherapy[48.2%(403/836)and 29.9%(250/836)],respectivelyl,but substantial proportions of hospitals preferred clip-assisted therapies[12.4%(104/836)and 26.4%(221/836)],respectivelyl.Improving the skills of endoscopic doctors(84.2%,704/836),and enhancing the precision of pre-procedure evaluation and quality of multidisciplinary team(78.9%,660/836)were considered urgent needs in the development of endoscopic treatment.Conclusion A variety of endoscopic treatments for gastroesophageal varices in portal hypertension are implemented nationwide.Participant hospitals are active to perform emergent endoscopy for acute EGVB,but are inadequate in following recommendations regarding primary and secondary prophylaxis of ECVB.Moreover,the selection of endoscopic procedures for gastric varices differs greatly among hospitals.