本文關(guān)鍵詞： 內(nèi)鏡 下硬 化劑 注射 套扎 治療 食管 靜脈曲張 出血　出處：《山東大學(xué)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：簡介本研究的主要目的是比較食管靜脈曲張出血內(nèi)鏡下硬化劑注射治療與套扎治療的療效及安全性。食管靜脈曲張出血是肝硬化危及生命且易復(fù)發(fā)的一個(gè)并發(fā)癥,具有較高的發(fā)病率和死亡率。靜脈曲張出血是門脈高壓的主要并發(fā)癥,也是肝硬化患者死亡的主要原因之一。靜脈曲張出血最常見的部位是食管,其他部位曲張靜脈出血約占全部靜脈曲張出血的30%。因患者的一般情況及肝功能差,急癥手術(shù)的死亡率非常高。近年來急性靜脈曲張出血的管理有了很大的提高。數(shù)據(jù)顯示,經(jīng)驗(yàn)豐富的多學(xué)科團(tuán)隊(duì)的綜合管理對于肝硬化靜脈曲張出血的最終預(yù)后起非常重要的作用。食管靜脈曲張出學(xué)的治療有諸多方法,但如球囊壓迫止血、血管收縮藥物、外科手術(shù)并不能減少再出血率及并發(fā)癥,不能提高食管靜脈曲張出血的生存率。經(jīng)頸靜脈肝內(nèi)門腔靜脈內(nèi)支架分流術(shù)術(shù)后最常見的短期并發(fā)癥是肝性腦病,這種風(fēng)險(xiǎn)抵消了其獲益。近年來應(yīng)用的內(nèi)鏡下硬化劑注射與內(nèi)鏡下套扎治療能夠有效的止血、降低再出血率及延長患者生存時(shí)間。硬化劑注射通過直接栓塞血管及局部炎癥纖維化使血管表面粘膜增厚達(dá)到止血及預(yù)防再次出血的目的。硬化治療時(shí),硬化劑可注射至血管內(nèi)或血管旁。許多技術(shù)因素可影響患者硬化治療的療程及臨床效果,其中對并發(fā)癥發(fā)生率有影響的重要因素有:內(nèi)鏡醫(yī)生的臨床經(jīng)驗(yàn),注射方法的選擇,輔助設(shè)施的應(yīng)用包括先端帽、球囊壓迫止血、急癥止血或擇期治療。其他相關(guān)的解剖學(xué)因素有食管與縱隔毗鄰,硬化劑注射反復(fù)破壞食管黏膜,且硬化劑進(jìn)入門靜脈后有可能播散至肺及體循環(huán)引起異位栓塞。套扎治療與硬化劑注射同樣有效,但并發(fā)癥更少,被認(rèn)為可以取代硬化劑注射治療食管靜脈曲張出血。但是,內(nèi)鏡前端的套扎器是套扎治療非常大的一個(gè)缺陷,它會(huì)使視野降低30%,尤其在急癥止血時(shí)血液吸入套扎器使視野更差。新型套扎器可以明顯提高視野。對于食管靜脈曲張?zhí)自委煹男Ч?每2月行一次好于每2周一次,因有資料顯示長間隔療程套扎治療食管靜脈曲張清除率更高,復(fù)發(fā)率更低,且較少需要追加治療。研究顯示套扎聯(lián)合藥物可有效預(yù)防食管靜脈曲張出血的復(fù)發(fā)。有學(xué)者認(rèn)為套扎治療可以完全取代硬化治療,因?yàn)橛不瘎┳⑸洳l(fā)癥發(fā)生率明顯高于套扎,但同樣有學(xué)者認(rèn)為硬化劑注射目前仍然是食管胃底靜脈出血急癥止血最有效的手段,是不能被完全取代的。硬化劑注射止血成功率高,扔是目前推薦的治療食管靜脈曲張出血的治療方法之一。與套扎相比,硬化劑注射的療效因操作者的技術(shù)往往有很大差異。套扎治療聯(lián)合小劑量硬化劑注射可能會(huì)結(jié)合二者優(yōu)勢,快速的實(shí)現(xiàn)靜脈曲張的清除,降低靜脈曲張的復(fù)發(fā)率,進(jìn)而降低遠(yuǎn)期再出血率。病人及方法:本研究比較了套扎治療與硬化劑注射治療食管靜脈曲張出血的安全性及療效。這是一項(xiàng)前瞻性研究,124例內(nèi)鏡證實(shí)為食管靜脈曲張出血患者,根據(jù)治療方法隨機(jī)分為EIS組及EVL組,其中EIS組64例行硬化劑注射治療,EVL組60例行套扎治療。所有病人隨訪2年,比較兩組的并發(fā)癥發(fā)生率、再出血率、靜脈曲張清除所需的治療次數(shù)、死亡率及生存率。結(jié)果:EIS組19例、EVL組16例患者行急癥止血,均止血成功,EIS組與EVL組相比在早期再出血率(7.8%vs 11.7%,P=0.47)、遠(yuǎn)期再出血率(28.1%vs 23.3%,P=0.54)、靜脈曲張清除率(79.7%vs 86.7%,P=0.30)、死亡率(1.6%vs 3.3%,P=0.61)及生存率(71.9%vs 78.3%,P=0.41)(all P0.05)方面均無統(tǒng)計(jì)學(xué)差異。但EIS組與EVL組相比術(shù)后發(fā)熱的幾率較高(n=17,26.6%vs n=6,10.0%,p=0.02).結(jié)論:硬化劑注射與套扎治療食管靜脈曲張安全、有效、簡單、易接受,均能獲得滿意的療效且并發(fā)癥少,我們應(yīng)該根據(jù)醫(yī)院條件、操作者的經(jīng)驗(yàn)以及靜脈曲張的特點(diǎn)選擇合適的治療方式。
[Abstract]:The main purpose of this study was to compare the efficacy and safety of esophageal ligation in the treatment of endoscopic injection sclerotherapy with variceal bleeding. Esophageal variceal bleeding is a life-threatening complication of cirrhosis and recurrence, with high morbidity and mortality. Variceal bleeding is a major complication of portal hypertension. The main reason is the death of patients with cirrhosis. Variceal hemorrhage is the most common site of esophageal variceal bleeding in other parts, accounting for all variceal bleeding due to general 30%. and the liver function in patients with emergency operation, a very high mortality rate of acute variceal hemorrhage. In recent years, management has been greatly improved. The data shows comprehensive management, multidisciplinary team of experienced for final diagnosis of variceal bleeding in liver cirrhosis plays very important role in esophageal varices. Study of treatment of a number of methods, but such as balloon compression hemostasis, vasoconstrictor drugs, not surgery and reduce the rebleeding rate and complications of esophageal variceal bleeding can improve the survival rate. After a short period of the most common complications of transjugular intrahepatic portosystemic stent shunt postoperative hepatic encephalopathy is, the risk of cancellation the benefit. In recent years the application of endoscopic sclerotherapy and endoscopic ligation treatment can effectively stop bleeding, reduce the rebleeding rate and prolong the survival time of the patients. The injection of sclerosing agent through direct vascular embolism and local inflammation fibrosis causes blood vessels to stop bleeding and thickening of mucosal surfaces to prevent re bleeding. Hardening treatment, hardeners injected into blood vessels or blood vessels. Many factors can influence and clinical effects in patients with hardening treatment, which affect the rate of complications due to the important Known as the clinical experience of endoscopic doctors, the choice of injection method, application of auxiliary facilities including apex cap, balloon compression hemostasis, emergency hemostasis or elective treatment. Other related factors and the adjacent esophageal mediastinal anatomy, sclerotherapy repeated destruction of esophageal mucosa, and sclerosing agent into the portal vein is likely to spread to the lungs and body circulation caused by ectopic embolism. Ligation and sclerotherapy are equally effective, but fewer complications, is thought to replace injection sclerotherapy for esophageal variceal bleeding. However, the front end of the endoscope ligation ligation in the treatment of a defect is very large, it will make the vision is reduced by 30%, especially in the emergency hemostasis of blood inhalation ligation to make the vision worse. New ligation can significantly improve vision for esophageal variceal ligation treatment effect, every February a better than once every 2 weeks, because the data shows long The interval period of ligation in the treatment of esophageal varices clearance rate is higher, the recurrence rate is lower, and less need for additional treatment. Research shows that ligation combined with drugs can effectively prevent the recurrence of esophageal varices bleeding. Some scholars believe that the ligation can completely replace the hardening treatment, because the hardening agent injection rate of complications was significantly higher than that of ligation. But there are also scholars believe that sclerotherapy is still the most effective means of acute bleeding of esophageal gastric fundus vein bleeding, can not be completely replaced. Sclerotherapy hemostasis success rate is high, throw is one of the currently recommended treatment for the treatment of esophageal variceal bleeding. Compared with ligation, efficacy of injection sclerotherapy for the operator of technology are very different. Ligation injection combined with small dose of sclerosing agent may combine the advantages of two, remove varices quickly, reduce varicose veins The recurrence rate, thereby reducing the long-term rebleeding rate. Patients and methods: This study compared the ligation and sclerotherapy for esophageal varices bleeding in safety and efficacy. This is a prospective study of 124 cases of confirmed endoscopic esophageal variceal bleeding patients, according to the methods of treatment were randomly divided into EIS group and the EVL group, the EIS group of 64 cases of sclerosing agent injection therapy, 60 cases in group EVL ligation. All patients were followed up for 2 years, the incidence of complications of the two groups, the rate of re bleeding varices required to clear the number of treatment, mortality and survival rate. Results: 19 cases of EIS group, EVL group of 16 patients with acute bleeding, was successful, EIS group in the early rebleeding rate compared with EVL group (7.8%vs 11.7%, P=0.47), long-term rebleeding rate (28.1%vs 23.3%, P=0.54), the clearance rate of varices (79.7%vs 86.7%, P=0.30), the death rate (1.6%vs 3.3%, P=0.61) and survival rate (71. 9%vs 78.3%, P=0.41) (all P0.05) were not statistically significant. But the EIS group compared with EVL group, higher risk of postoperative fever (n=17,26.6%vs n=6,10.0%, p=0.02). Conclusion: sclerotherapy and ligation in treatment of esophageal varices is safe, effective, simple, easy to accept, can obtain satisfactory curative effect and complications less, we should according to the condition of hospital, the experience of the operator and the characteristics of varicose veins of the selection of appropriate treatment.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R575.2

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本文編號(hào)：1465654