Suspected cerebrovascular air embolism during endoscopic esophageal varices ligation under sedation with fatal outcome: A case report

BACKGROUND Air embolism is a very rare,yet serious and potentially fatal complication of digestive endoscopic treatment.Air embolism is the result of air directly entering the arteries or veins.However,to recognize neurological dysfunction under sedation can be difficult.Therefore,it is extremely important to identify high-risk groups and take preventive measures.CASE SUMMARY Herein,we report a 74-year-old female patient with esophageal varices who suffered from consciousness disturbance after the third endoscopic ligation of esophageal varices under sedation.Combined with the patient’s imaging examination results and medical history,we highly suspected that the patient had developed paradoxical cerebral air embolism during endoscopic ligation.We learned that the patient died at a later follow-up.In order to be able to identify and prevent the occurrence of air embolism early,we summarize and analyze the risk factors,pathogenesis,clinical manifestations,prevention and treatment options of gastrointestinal endoscopy complicated by cerebral air embolism.CONCLUSION Electroencephalographic monitoring helps to recognize the occurrence of air embolism in time and increase the patient's chance of survival.

Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices:Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

AIM: To detect the hemodynamic alterations in collateral circulation before and after combined endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization by ultrasonography, and to evaluate their effect using hemodynamic parameters. METHODS: Forty-three patients with esophageal varices received combined EVL and splenectomy with pericardial devascularization for variceal eradication. The esophageal vein structures and azygos blood flow (AZBF) were detected by endoscopic ultrasonography and color Doppler ultrasound. The recurrence and rebleeding of esophageal varices were followed up. RESULTS: Patients with moderate or severe varices in the esophageal wall and those with severe peri- esophageal collateral vein varices had improvements after treatment, while the percentage of patients with severe para-esophageal collateral vein varices decreased from 54.49% to 2.33%, and the percentage of patients with detectable perforating veins decreased from 79.07% to 4.65% (P < 0.01). Color Doppler flowmetry showed a significant decrease both in AZBF (43.00%, P < 0.05) and in diameter of the azygos vein (28.85%, P < 0.05), while the blood flow rate was unchanged. The recurrence rate of esophageal varices was 2.5% (1/40, mild), while no re-bleeding cases were recorded. CONCLUSION: EVL in combination with splenectomy with pericardial devascularization can block the collateral veins both inside and outside of the esophageal wall, and is more advantagious over splenectomy in combination with pericardial devascularization or EVL in preventing recurrence and re-bleeding of varices.

Efficacy of β-adrenergic blocker plus 5-isosorbide mononitrate and endoscopic band ligation for prophylaxis of esophageal variceal rebleeding:A meta-analysis

AIM: To systematically assess the efficacy and safety of β-adrenergic blocker plus 5-isosorbide mononitrate (BB + ISMN) and endoscopic band ligation (EBL) on prophylaxis of esophageal variceal rebleeding. METHODS: Randomized controlled trials (RCTs) comparing the efficacy and safety of BB + ISMN and EBL on prophylaxis of esophageal variceal rebleeding were gathered from Medline, Embase, Cochrane Controlled Trial Registry and China Biological Medicine database between January 1980 and August 2007. Data from five trials were extracted and pooled. The analyses of the available data using the Revman 4.2 software were based on the intention-to-treat principle. RESULTS: Four RCTs met the inclusion criteria. In comparison with BB + ISMN with EBL in prophylaxis of esophageal variceal rebleeding, there was no significant difference in the rate of rebleeding [relative risk (RR), 0.79; 95% CI: 0.62-1.00; P = 0.05], bleeding-related mortality (RR, 0.76; 95% CI: 0.31-1.42; P = 0.40), overall mortality (RR, 0.81; 95% CI: 0.61-1.08; P = 0.15) and complications (RR, 1.26; 95% CI: 0.93-1.70; P = 0.13). CONCLUSION:In the prevention of esophageal variceal rebleeding, BB + ISMN are as effective as EBL. There are few complications with the two treatment modalities. Both BB + ISMN and EBL would be considered as the first-line therapy in the prevention of esophageal variceal rebleeding.

Effect of aluminum phosphate gel on prevention of early rebleeding after ligation of esophageal variceal hemorrhage

BACKGROUND Liver cirrhosis is the main cause of portal hypertension.The leading cause of death in patients with liver cirrhosis is its most common complication,esophageal variceal bleeding(EVB).Endoscopic variceal ligation(EVL)is recommended by many guidelines to treat EVB and prevent rebleeding;however,esophageal ulcers occur after treatment.Delayed healing of ulcers and unhealed ulcers lead to high rebleeding and mortality rates.Thus,the prevention of early postoperative rebleeding is of great significance in improving the quality of life and prognosis of patients.AIM To evaluate the efficacy of aluminum phosphate gel(APG)plus a proton pump inhibitor(PPI)in the prevention of early rebleeding after EVL in patients with EVB.METHODS The medical records of 792 patients who were diagnosed with EVB and in whom bleeding was successfully stopped by EVL at Shenzhen People’s Hospital,Guangdong Province,China from January 2015 to December 2020 were collected.According to the study inclusion and exclusion criteria,401 cases were included in a PPI-monotherapy group(PPI group),and 377 cases were included in a PPI and APG combination therapy(PPI+APG)group.We compared the incidence rates of early rebleeding and other complications within 6 wk after treatment between the two groups.The two-sample t-test,Wilcoxon rank-sum test,and chisquared test were adopted for statistical analyses.RESULTS No significant differences in age,sex,model for end-stage liver disease score,coagulation function,serum albumin level,or hemoglobin level were found between the two groups.The incidence of early rebleeding in the PPI+APG group(9/337;2.39%)was significantly lower than that in the PPI group(30/401;7.48%)(P=0.001).Causes of early rebleeding in the PPI group were esophageal ulcer(3.99%,16/401)and esophageal varices(3.49%,14/401),while those in the PPI+APG group were also esophageal ulcers(5/377;1.33%)and esophageal varices(4/377;1.06%);such causes were significantly less frequent in the PPI+APG group than in the PPI group(P=0.022 and 0.024,respectively).The early mortality rate within 6 wk in both groups was 0%,which was correlated with the timely rehospitalization of all patients with rebleeding and the conduct of emergency endoscopic therapy.The incidence of adverse events other than early bleeding in the PPI+APG group(28/377;7.43%)was significantly lower than that in the PPI group(63/401;15.71%)(P<0.001).The incidence of chest pain in the PPI+APG group(9/377;2.39%)was significantly lower than that in the PPI group(56/401;13.97%)(P<0.001).The incidence of constipation in the PPI+APG group(16/377;4.24%)was significantly higher than that in the PPI group(3/401;0.75%)(P=0.002)but constipation was relieved after patients drank more water or took lactulose.In the PPI and PPI+APG groups,the incidence rates of spontaneous peritonitis within 6 wk after discharge were 0.50%(2/401)and 0.53%(2/377),respectively,and those of hepatic encephalopathy were 0.50%(2/401)and 0.27%(1/377),respectively,presenting no significant difference(P>0.999).CONCLUSION PPI+APG combination therapy significantly reduces the incidence of early rebleeding and chest pain in patients with EVB after EVL.

Cost saving by reloading the multiband ligator in endoscopic esophageal variceal ligation: A proposal for developing countries

AIM:To assess the cost savings of reloading the multiband ligator in endoscopic esophageal variceal ligation (EVL) used on the same patient for subsequent sessions. METHODS:This single centre retrospective descriptive study analysed patients undergoing variceal ligation at a tertiary care centre between 1st January, 2003 and 30th June, 2006. The multiband ligator was reloaded with six hemorrhoidal bands using hemorrhoidal ligator for the second and subsequent sessions. Analysis of cost saving was done for the number of follow-up sessions for the variceal eradication. RESULTS:A total of 261 patients underwent at least one session of endoscopic esophageal variceal ligation between January 2003 and June 2006. Out of 261, 108 patients (males 67) agreed to follow the eradication program and underwent repeated sessions. A total of 304 sessions was performed with 2.81 sessions per patient on average. Thirty-two patients could not complete the programm. In 76 patients (70%), variceal obliteration was achieved. The ratio of the costs for the session with reloaded ligator versus a session with a new ligator was 1:2.37. Among the patients who completed esophageal varices eradication, cost saving with reloaded ligator was 58%. CONCLUSION:EVL using reloaded multiband ligators for the follow-up sessions on patients undergoing variceal eradication is a cost saving procedure. Reloading the ligator thus is recommended especially for developing countries where most of the patients are not health insured.

Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study

Endoscopic band ligation is regarded as the main therapeutic option for acute esophageal variceal bleeding, while sclerotherapy may be used in the acute setting if ligation is technically difficult. The incidence of difficult-to-perform band ligation in acute esophageal variceal bleeding, as well as the outcome of patients subjected to injection sclerotherapy as an alternative treatment, has not been clearly investigated. Our aim is to study the outcome of patients subjected to injection sclerotherapy in the acute setting of esophageal variceal bleeding when endoscopic band ligation is technically difficult to perform. We included 151 patients with acute esophageal variceal bleeding originnating from medium or large sized varices. All patients were planned for EBL as the 1st treatment option (EBL group 61.6%), meanwhile, EIS using 5% ethanolamine oleate was reserved as the 2nd treatment option when EBL was technically difficult (EIS group 38.4%). The mean time to restore hemodynamic stability was significantly prolonged in the EIS group (11.5 ± 6.5 hrs versus 9.5 ± 5.0 hrs, p 0.05). Initial control of bleeding was significantly higher in the EBL group versus the EIS group (96.7% vs 84.5%, p 0.021). Re-bleeding was more among the EIS group (42.9% vs 24.2%, p 0.04). There were no significant differences as regarding mortality and duration of hospital stay. So, a considerable proportion of cases presenting with acute variceal bleeding will have difficulty in performing EBL. In these patients, sclerotherapy is not a waning procedure with an accepted success rate, without much additional complications and without deranging mortality.

Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis

Variceal bleeding is a life threatening situation with mortality rates of at least 20%. Prophylactic treatment with non-selective beta blockers(NSBBs) is recommended for patients with small varices that have not bled but with increased risk for bleeding. The recommended treatment strategies on primary prevention of variceal bleeding in patients with medium and largesized varices are NSBBs or endoscopic band ligation. Nitrates, shunt surgery and sclerotherapy are not recommended in this setting. In this review, the most recent data on prevention of esophageal variceal bleeding are presented. Available data derived from randomized-controlled trials suggest both treatment strategies, and according to Baveno V consensus in portal hypertension "the choice of treatment should be based on local resources and expertise, patient preference and characteristics, side-effects and contra-indications".

血清学指标联合Child-Pugh评分对肝硬化食管静脉曲张破裂出血患者EVL术后再出血的预测价值

目的分析血清学指标联合Child-Pugh评分对肝硬化食管静脉曲张破裂出血患者食管静脉曲张套扎术(EVL)术后再出血的预测价值。方法2020年9月—2022年9月右江民族医学院附属医院收治的肝硬化EVB行EVL治疗的患者97例,根据患者EVL术后6个月内是否发生再出血分为再出血组(n=31)和非再出血组(n=66),收集患者临床资料,采用多因素logistic回归分析影响肝硬化EVB患者EVL术后再出血的相关因素,采用受试者工作特征曲线(ROC)及曲线下面积(AUC)分析血清学指标联合Child-Pugh评分对肝硬化EVB患者EVL术后再出血的预测价值。结果多因素logistic回归分析,结果显示,Child-Pugh分级(OR=2.259,95%CI:1.040~4.909)、门静脉内径(OR=2.93395%CI:1.509~5.700)、APTT(OR=1.45195%CI:1.158~1.817)、PT(OR=1.98295%CI:1.120~3.506)、Child-Pugh评分(OR=3.83495%CI:1.849~7.950)是影响肝硬化EVB患者EVL术后再出血的危险因素,PLT(OR=0.58595%CI:0.369~0.927)、Alb(OR=0.82495%CI:0.723~0.940)是影响肝硬化EVB患者EVL术后再出血的保护因素(P<0.05);ROC曲线结果显示,PLT、APTT、PT、Alb、Child-Pugh评分以及各指标联合预测肝硬化EVB患者EVL术后再出血的AUC分别为0.800、0.671、0.729、0.721、0.789和0.916,其敏感度分别为83.9%、64.5%、71.0%、77.4%、80.6%和87.1%,特异度分别为63.6%、68.2%、75.8%、66.7%、65.2%和74.2%。结论Child-Pugh分级、门静脉内径、PLT、APTT、PT、Alb、Child-Pugh评分是肝硬化EVB患者EVL术后再出血的影响因素,血清学指标PLT、APTT、PT、Alb联合Child-Pugh评分有助于提升对肝硬化EVB患者EVL术后再出血的预测价值。

Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding

AIM:To compare band ligation(BL) with endoscopic sclerotherapy(SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS:A prospective,randomized,single-center study without crossover was conducted.After endoscopic diagnosis of esophageal variceal rupture,patients were randomized into groups for SCL or BL treatment.Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point,with a maximum volume of 20 mL.For BL patients,banding at the rupture point was attempted,followed by ligation of all variceal tissue of the distal esophagus.Primary outcomes for both groups were initial failure of bleeding control(5 d) ,early re-bleeding(5 d to 6 wk),and complications,including mortality.From May 2005 to May 2007,100 patients with variceal bleeding were enrolled in thestudy:50 SCL and 50 BL patients.No differences between groups were observed across gender,age,ChildPugh status,presence of shock at admission,mean hemoglobin levels,and variceal size. RESULTS:No differences were found between groups for bleeding control,early re-bleeding rates,complications,or mortality.After 6 wk,36(80%) SCL and 33(77 %) EBL patients were alive and free of bleeding.A statistically significant association between Child-Pugh status and mortality was found,with 16%mortality in Child A and B patients and 84%mortality in Child C patients(P<0.001) . CONCLUSION:Despite the limited number of patients included,our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.

Risk factors for predicting early variceal rebleeding after endoscopic variceal ligation

AIM: To analyze the clinical risk factors for early variceal rebleeding after endoscopic variceal ligation (EVL).METHODS: 342 cirrhotic patients with esophageal varices who received elective EVL to prevent bleeding or rebleeding at our endoscopy center between January 2005 and July 2010.were included in this study.The early rebleeding cases after EVL were confirmed by clinical signs or endoscopy.A case-control study was performed comparing the patients presenting with early rebleeding with those without this complication.RESULTS: The incidence of early rebleeding after EVL was 7.60%,and the morbidity of rebleeding was 26.9%.Stepwise multivariate logistic regression analysis showed that four variables were independent risk factors for early rebleeding: moderate to excessive ascites [odds ratio (OR) 62.83,95% CI: 9.39-420.56,P < 0.001],the number of bands placed (OR 17.36,95% CI: 4.00-75.34,P < 0.001),the extent of varices (OR 15.41,95% CI: 2.84-83.52,P = 0.002) and prothrombin time (PT) > 18 s (OR 11.35,95% CI: 1.93-66.70,P = 0.007).CONCLUSION: The early rebleeding rate after EVL is mainly affected by the volume of ascites,number of rubber bands used to ligate,severity of varices and prolonged PT.Effective measures for prevention and treatment should be adopted before and after EVL.

Role of band ligation for secondary prophylaxis of variceal bleeding

AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis. METHODS A literature review was performed using the MEDLINE and PubM ed databases. The search terms consisted of the words "endoscopic band ligation" OR "variceal band ligation" OR "ligation" AND "secondary prophylaxis" OR "secondary prevention" AND "variceal bleeding" OR "variceal hemorrhage" AND "liver cirrhosis". The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices. RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.

Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication

BACKGROUND Bleeding esophageal varices(BEV)is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25%within six weeks of the index variceal bleed.After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selectiveβ-blockers to prevent further bleeding and eradicate EV.AIM To assess the efficacy of endoscopic variceal ligation(EVL)in controlling acute variceal bleeding,preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices(EV)in patients who present with BEV.METHODS A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018.Control of acute bleeding,variceal recurrence,rebleeding,eradication and survival were analyzed using Baveno assessment criteria.RESULTS One hundred and forty patients(100 men,40 women;mean age 50 years;range,21-84 years;Child-Pugh grade A=32;B=48;C=60)underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions.One hundred and fourteen(81%)of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV,while 26(19%)patients had complicated and refractory variceal bleeding.EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients(95.7%).Six patients required balloon tamponade for control and 4 other patients rebled in hospital.Overall 5-d endoscopic failure to control variceal bleeding was 7.1%(n=10)and four patients required a salvage transjugular intrahepatic portosystemic shunt.Index admission mortality was 14.2%(n=20).EV were completely eradicated in 50 of 111 patients(45%)who survived>3 mo of whom 31 recurred and 3 rebled.Sixteen(13.3%)of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital.Overall rebleeding from all sources after 2 years was 21.7%(n=26).Sixty-nine(49.3%)of the 140 patients died,mainly due to liver failure(n=46)during follow-up.Cumulative survival for the 140 patients was 71.4%at 1 year,65%at 3 years,60%at 5 years and 52.1%at 10 years.CONCLUSION EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%.Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV,of whom 62%recurred,there was a significant reduction in subsequent rebleeding.

A new technique of combined endoscopic sclerotherapy and ligation for variceal bleeding

AIM: To develop a technique of combined endoscopic sclerotherapy and ligation (ESL) in which both techniques of endoscopic sclerotherapy (ES) and endoscopic variceal ligation (EVL) can be optimally used.METHODS: ESL was performed in 10 patients (age 46.4±7.9;9 males, 1 female) with cirrhosis of liver using sclerotherapy needle and Speedband, Superview multiple band ligater (Boston Scientific, Microvasive, Watertown, MA). A single band was placed 5-10 cm proximal to the gastro-esophageal junction over each varix from proximal to distal margin,followed by intravariceal injection of 1.5 % ethoxysclerol (4 ml each) 2 to 3 cm proximal to the gastroesophageal junction on the ligated varices distal to deployed band. EVL was then performed at the injection site. Similarly other varices were also injected and ligated from distal to proximally. In the subsequent sessions, ES alone was performed to sclerose small varices at the gastroesophageal junction.RESULTS: ESL was successfully performed in all patients.A median of 3 (ESL 1, ES 2) sessions (ranged 1-4) were required to eradicate the varices in 9 (90 %) of 10 patients.Recurrence of varices without bleed was seen in 1 patient during a mean follow-up of 10.3 months (ranged 6-15).Two patients died of liver failure. None died of variceal bleeding. None of the patients had procedure related complications.CONCLUSION: ESL may be useful in the fast eradication of esophageal varices. However, randomised controlled trials are required to find out its relative efficacy and impact on variceal recurrence in comparison to ES or EVL.

Rare cause of dysphagia after esophageal variceal banding: A case report

BACKGROUND Esophageal varices are a result of progressive liver disease and portal hypertension. Treatment can be performed with band ligation versus nonselective beta blockers depending on the size of varices, ability to tolerate medications and history of variceal bleeding. Band ligation is an effective intervention with rare but serious complications including bleeding, ulcers and rarely obstruction. Few cases of esophageal obstruction and necrosis caused by banding have been reported, each with varied management from conservative treatment to band removal.CASE SUMMARY An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital with an inability to swallow one day after screening esophagogastroduodenoscopy where band ligation of esophageal varices was performed for primary prophylaxis. The patient was not able to tolerate her oral secretions. Initial blood work revealed a Model of End Organ Liver Disease score of 7. She was treated with sublingual nitroglycerin for esophageal spasm, a known complication after esophageal banding. When she failed to improve, esophagogastroduodenoscopy was performed and revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus. The band was purposefully dislodged, revealing distal ulceration and stricturing. Within 72 h after band removal, she was tolerating an oral diet. Endoscopy performed 2 wk later revealed an intrinsic stenosis,measuring 8 mm in diameter by 1 cm in length, which was dilated.CONCLUSION Esophageal obstruction is a complication of variceal banding that should be considered in patients with inability to tolerate oral diet after banding.

EVL+EVS序贯疗法治疗肝硬化食管胃底静脉曲张破裂出血的临床研究

目的:探讨内镜下套扎术(endoscopic variceal ligation,EVL)+内镜下硬化剂注射术(endoscopic varices sclerotherapy,EVS)序贯疗法治疗肝硬化食管胃底静脉曲张破裂出血后临床变化及并发症发生情况。方法:以2020年4月-2021年12月江阴市人民医院消化内科收治的138例肝硬化食管胃底静脉曲张破裂出血患者为研究对象,以随机数字表法分为治疗组与对照组,各69例。其中对照组予以EVL治疗,治疗组予以EVL+EVS序贯疗法。对比两组的临床效果及并发症发生情况。结果:治疗组的再次治疗次数少于对照组,差异有统计学意义(P<0.05)。两组的曲张静脉情况比较,差异无统计学意义(P>0.05)。治疗组治疗后的白细胞、血小板计数高于对照组(P<0.05)。治疗组的并发症发生率为4.35%,低于对照组的15.94%(P<0.05)。结论:EVL+EVS序贯疗法治疗有助于减少肝硬化食管胃底静脉曲张破裂出血患者再次治疗次数,降低并发症的发生率,在临床上值得推广。

EVL与早期行TIPS治疗肝硬化并发急性食管静脉曲张破裂出血的临床疗效及预后分析

目的比较食管曲张静脉套扎术(EVL)和经颈静脉肝内门体分流术(TIPS)治疗肝硬化并发食管静脉曲张破裂出血(EVB)患者的临床疗效、预后及术后并发症情况。方法选择2019年3月至2021年3月遂宁市中心医院收治的102例因肝硬化并发EVB首次接受EVL或TIPS治疗的患者,分为EVL组(50例)和TIPS组(52例)。比较2组的止血成功率、食管胃静脉曲张(GOV)好转率、并发症发生情况、肝功能指标[TBil、ALT、白蛋白(ALB)]及外周血象指标[凝血酶原活动度(PTA)、国际标准化比率(INR)、血红蛋白(Hb)、血小板计数(PLT)]及预后情况(再出血率、死亡率)。结果TIPS组和EVL组的72 h止血成功率分别为98.08%和96.00%,2组的差异无统计学意义(P>0.05)。2组的术后第7天GOV均较术前显著好转(P均<0.05),并且TIPS组的GOV好转率显著高于EVL组(73.08%比46.00%,P<0.05)。TIPS组的术后并发症总发生率显著低于EVL组(7.69%比22.00%,P<0.05)。2组的术后第7天TBil、ALT水平均显著低于术前,ALB水平均显著高于术前(P均<0.05);2组间上述指标水平的差异均无统计学意义(P>0.05)。2组的术后第7天PTA均显著低于术前,Hb、INR、PLT均显著高于术前(P均<0.05);组间比较结果显示,术后第7天TIPS组的Hb显著高于EVL组(P<0.05),而2组的PTA、INR及PLT差异则均无统计学意义(P均>0.05)。术后随访结果显示,TIPS组的再出血率显著低于EVL组(21.15%比40.00%,P<0.05),2组的死亡率差异无统计学意义(P>0.05)。结论EVL和早期行TIPS治疗肝硬化并发EVB患者的72 h止血效果均较好,而早期行TIPS在改善GOV及预防再出血方面的效果更好,且并发症发生较少。

Treatment of esophageal rupture or perforation

Esophageal rupture or perforation is a serious emergent disease.Without accurate diagnosis and effective treatment in time,it’s life-threatening.Esophageal rupture or perforation can be caused by:iatrogenic endoscopy examination and treatment,ligation and sclerotherapy of esophageal variceal,dilation of esophageal stricture,operative injury and so on; Spontaneous perforations; foreign body ingestion; trauma; tumor; calculus and ulcer of esophagus and so on.The key-point for the treatment of this disease lies in early diagnosis and accurate effective treatment.

食管静脉曲张一级预防对首诊原发性肝细胞癌患者预后的影响

目的探讨内镜下食管静脉套扎术(EVL)作为食管静脉曲张一级预防措施,对原发性肝细胞癌(HCC)患者预后的影响。方法选择2020年1月至2022年12月收治的首诊HCC患者149例,按随机数字表法分为观察组75例和对照组74例。观察组接受EVL治疗,对照组未接受EVL治疗。监测2组患者食管静脉出血和静脉曲张改善情况,并记录随访期间患者的生存情况,采用COX回归分析HCC患者预后不良的影响因素。结果观察组治疗后3、6、12个月食管静脉出血率均显著低于对照组(P<0.05)。观察组食管静脉曲张改善总有效率[76.00%(57/75)]显著高于对照组[59.46%(44/74)](P<0.05)。观察组总病死率[18.67%(14/75)]、因消化道出血病死率[4.00%(3/75)]均显著低于对照组[33.78%(25/74)、16.22%(12/74)](P<0.05)。Kaplan-Meier生存曲线显示,观察组总生存时间显著长于对照组(P<0.05)。多变量COX回归分析显示,EVL是HCC患者预后不良的独立保护因素(HR=0.529,95%CI:0.285,0.865,P<0.05)。结论EVL能显著降低HCC患者食管静脉出血的风险,并改善患者的预后,因此,在临床中EVL治疗可考虑作为HCC患者食管静脉曲张一级预防的首选治疗策略。

Comparison of emergency endoscopic variceal ligation plus octride or octride alone for acute esophageal variceal bleeding

Background Octride was the main method for the treatment of esophageal variceal bleeding （EVB）. The aim of this study was to compare the cost-effect and safety between esophageal variceal ligation （EVL） plus octride and octride alone in acute esophageal bleeding. Methods A total of 101 cirrhotic patients with EVB were involved in this study and received emergency EVL ± octride （EVL group） or only octride therapy randomly. The cost, efficacy and safety were analyzed and compared between the two groups. Results Among 51 patients in EVL group, 5 （10%） patients failed. Among 50 patients in the octride treatment group, 13 patients （26%） failed. The difference was significant （P 〈0.05）. The average blood transfusion volume was （2.4±2.2） units in the EVL group and （6.4±3.4） units in the octride treatment group （P〈0.05）. Hospital stay was （7.4±1.3） days in the EVL group and （11.4±3.3） days in the octride treatment group （P 〈0.05）. The average hospital cost was （10 983±1147） yuan in the EVL group and （13 921 ±2107） yuan in the octride treatment group （P 〈0.05）. Conclusion Emergency endoscopic ligation plus octride is superior to octride alone in the treatment of acute EVB with lower cost and higher efficacy with enough safety.