A novel therapeutic strategy for esophageal varices using endoscopic treatment combined with splenic artery embolization according to the Child-Pugh classification
A novel therapeutic strategy for esophageal varices using endoscopic treatment combined with splenic artery embolization according to the Child-Pugh classification
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DOI：
10.1371/journal.pone.0223153
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发表时间：
2019-09-26
期刊：
影响因子：
3.7
通讯作者：
Sakaida, Isao
中科院分区：
文献类型：
--
作者：
Ishikawa, Tsuyoshi;Sasaki, Ryo;Sakaida, Isao
静脉曲张出血可导致高再出血率和死亡率。预防首次发生静脉曲张出血是高危食管静脉曲张（EV）患者的强制性措施。本研究旨在确定内镜治疗（ET）后EV复发的预测因素，并制定肝硬化EV的合理治疗策略。2012年1月至2014年12月，45例肝硬化和高危EV患者接受了ET，包括硬化治疗和/或结扎。统计分析确定了与ET后EV复发相关的因素，Kaplan-Meier方法确定了累积静脉曲张复发率。EV治疗后1年、2年和3年累积复发率分别为13.3%、29.5%和32.2%。在治疗后1年，有和无静脉曲张复发的患者之间无显著差异。多变量回归分析确定部分脾栓塞（PSE）史和治疗前Child-Pugh分级是治疗后2年（p < 0.05）和3年（p < 0.05）静脉曲张复发的独立预测因素。Child-Pugh A级患者在ET和脾动脉栓塞后EV未复发，而Child-Pugh B或C级患者在ET前后进行PSE时，治疗后总的静脉曲张复发率分别为0%和66.7%。15例脾动脉栓塞术后肝静脉压力梯度明显降低，Child-Pugh评分明显降低。辅助性PSE和治疗前Child-Pugh A级可能与ET后EV累积复发率降低独立相关。从门静脉血流动力学和肝功能的角度来看，Child-Pugh A级患者在ET前或ET后行脾动脉栓塞可预防治疗后静脉曲张复发，Child-Pugh B或C级患者在ET前行PSE可实现ET后EV的长期根除。
Variceal hemorrhage may cause high rebleeding and mortality rates. Preventing the first episode of variceal bleeding is mandatory in patients with high-risk esophageal varices (EV). This study aimed to identify factors that predict the recurrence of EV after endoscopic treatment (ET), and to develop a reasonable therapeutic strategy for EV in cirrhosis. From January 2012 to December 2014, 45 patients with cirrhosis and high-risk EV underwent ET, including sclerotherapy and/or ligation. Statistical analyses identified factors associated with the recurrence of EV after ET, and the Kaplan-Meier method determined the cumulative variceal recurrence rates. The 1-, 2-, and 3-year cumulative posttreatment recurrence rates for EV were 13.3%, 29.5%, and 32.2%, respectively. No significant differences were evident between the patients with and without variceal recurrences at 1-year posttreatment. The multivariate regression analyses identified a history of partial splenic embolization (PSE) and the pretreatment Child-Pugh classification as independent predictors of variceal recurrences at 2 years (p < 0.05) and 3 years (p < 0.05) posttreatment. While EV did not recur after ET and splenic artery embolization in cases with Child-Pugh class A, the overall posttreatment variceal recurrence rates were 0% and 66.7% when PSE was performed before and after ET, respectively, in those with Child-Pugh class B or C. Splenic artery embolization significantly reduced the hepatic venous pressure gradient and markedly lowered the Child-Pugh score in 15 patients. Adjunctive PSE and pretreatment Child-Pugh class A could be independently associated with reduced cumulative recurrence rates of EV post-ET. From the perspectives of portal hemodynamics and hepatic function, splenic artery embolization before or after ET could prevent posttreatment variceal recurrence in patients with Child-Pugh class A, and PSE before ET could achieve the long-term eradication of EV following ET in those with Child-Pugh class B or C.