Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding: a randomised trial.
Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding: a randomised trial.
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DOI：
10.1136/gutjnl-2017-314653
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发表时间：
2019-05
期刊：
影响因子：
24.5
通讯作者：
Devière J
中科院分区：
文献类型：
--
作者：
Ibrahim M;El-Mikkawy A;Abdel Hamid M;Abdalla H;Lemmers A;Mostafa I;Devière J
急性静脉曲张出血(AVB)需要有经验的内窥镜医生进行早期治疗，这往往给医院带来后勤挑战。在一项随机试验中，我们评估了一种不同的管理理念，即在常规治疗的基础上早期应用止血粉--这不需要很高的内窥镜专业知识。患有动静脉曲张的肝硬变患者接受标准的内科治疗，并被随机分成两组，一组在入院后2 小时内立即进行胃镜检查，并在入院后2 小时内应用止血粉，第二天进行早期选择性胃镜检查，即在入院后12-24小时内接受明确治疗(研究组)，或仅接受早期选择性胃镜检查(对照组)。在两组患者中，在早期选择性内窥镜检查前均未能达到临床止血效果，接受了抢救性内窥镜检查，并尝试了常规止血。主要结果是选择性内窥镜下的内窥镜止血。在86例AVB患者中，研究组中有5/43例患者在应用粉末后未能控制喷血(n=4)或因早期出血复发(1例在再次使用救援内窥镜前死亡)而需要抢救性内窥镜检查。在对照组中，13/43例患者因临床止血失败而需要抢救性内窥镜止血(12%vs30%，P=0.034)。在其余患者中，研究组38例患者均在早期选择性胃镜下止血，而对照组其余30例患者在早期选择性胃镜检查时均有新鲜胃血或(10%)喷血，全部止血成功。研究组6周存活率显著提高(7%vs30%，p=0.006)。即时粉末应用的新概念改善了早期临床和内窥镜止血。这种简化的内窥镜方法可能会对早期和6周的存活率产生影响。NCT03061604。
Acute variceal bleeding (AVB) requires early therapeutic management by experienced endoscopists that often poses logistical challenges for hospitals. We assessed a different management concept with early application of haemostatic powder—which does not require high endoscopic expertise—added to conventional management in a randomised trial. Cirrhotic patients with AVB received standard medical therapy and were randomised to either immediate endoscopy with haemostatic powder application within 2 hours of admission, followed by early elective endoscopy on the next day, that is, within 12–24 hours of admission for definitive treatment (study group) or to early elective endoscopy only (control group). In both groups, failures to achieve clinical haemostasis until the time of early elective endoscopy underwent rescue endoscopy with attempted conventional haemostasis. Primary outcome was endoscopic haemostasis at the elective endoscopy. Of 86 randomised patients with AVB, 5/43 in the study group required rescue endoscopy for failure of controlling spurting bleeding (n=4) after powder application or for early bleeding recurrence in one patient who died before repeating rescue endoscopy. In the control group, 13/43 patients required rescue endoscopic haemostasis for failure of clinical haemostasis (12%vs30%, p=0.034). In the remaining patients, early elective endoscopic haemostasis was achieved in all 38 patients in the study group, while all remaining 30 patients in the control group had fresh gastric blood or (10%) spurting bleeding at early elective endoscopy with successful haemostasis in all of them. Six-week survival was significantly improved in the study group (7%vs30%, p=0.006). The new concept of immediate powder application improves early clinical and endoscopic haemostasis. This simplified endoscopic approach may have an impact on early and 6-week survival. NCT03061604.
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