The changing spectrum of treatment for variceal bleeding
The changing spectrum of treatment for variceal bleeding
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DOI：
10.1097/00000658-199810000-00010
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发表时间：
1998-10-01
影响因子：
9
通讯作者：
Rikkers, LF
中科院分区：
文献类型：
--
作者：
Rikkers, LF
本研究的目的是评估内镜治疗、肝移植和经颈静脉肝内门体分流术（TIPS）对门静脉高压症并发症患者选择和手术治疗结果的影响，就像一个外科医生的18-总结背景资料对门静脉高压出血患者的预防性治疗已经成为一种有效的方法，逐步改变在过去的20年期间，内窥镜治疗，肝移植，TIPS已相继成为替代治疗方案，以手术门体分流和断流procedures.MethodsTwo六百六十三连续患者谁是手术治疗的门静脉高压性出血1978年和1996年之间进行了回顾性分析。我们分析了内镜治疗（1981年1月）、肝移植（1985年7月）和TIPS（1993年1月）在我们机构可用的四个时期。在所有四个时代，采用选择性手术方法，使用远端脾肾分流术（DSRS），非选择性分流术和食管胃血管离断术。非选择性分流术和食管胃血管离断术最常见的适应症分别是药物难治性腹水和内脏静脉血栓形成。大多数其他患者接受了DSRS.ResultsThe风险状态（儿童类）进行手术的患者逐步改善（p = 0.001）在整个4年代，而急诊手术的需要下降（p = 0.002）。非选择性分流的比例下降，因为有更好的选择来管理急性出血事件（硬化疗法，TIPS）和晚期肝病并发腹水（肝移植，TIPS）（p = 0.009）。在所有年代，手术死亡率与Child分级直接相关（A，2.7%; B，7.5%; C，26.1%）（p = 0.001）。随着更多高风险患者接受静脉曲张出血手术，术后脑病的发生率降低（p = 0.015），长期生存率提高（p = 0.012），特别是因为肝移植可用于挽救既往手术后发生肝功能衰竭的患者。在再出血或分流闭塞方面，Eras之间没有差异。远端脾肾分流术（p = 0.004）和非选择性分流术（p = 0.001）更能防止再出血，而不是食管胃血管离断术。ConclusionsThe序贯介绍内镜治疗，肝移植，TIPS导致更好的选择和改善结果方面的质量和生存时间的手术治疗静脉曲张出血的患者。尽管有这些创新，门体分流术和食管胃血管离断术仍然是门静脉高压继发出血患者的重要和有效的选择。
ObjectiveThe objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage.Summary Background DataDefinitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures.MethodsTwo hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout ail four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS.ResultsThe risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). in all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1%) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012) especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization.ConclusionsThe sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.