内镜下氰基丙烯酸酯注射与β受体阻滞剂用于胃静脉曲张出血二级预防的随机对照试验。
Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial.
机构信息
Department of Gastroenterology, G B Pant Hospital, 201 Academic Block, New Delhi 110002, India.
出版信息
Gut. 2010 Jun;59(6):729-35. doi: 10.1136/gut.2009.192039.
BACKGROUND AND AIMS
Bleeding from gastric varices is often severe and difficult to manage. Endoscopic injection of gastric varices with cyanoacrylate is effective in prevention of rebleeding. The efficacy of beta-blockers in secondary prophylaxis of gastric variceal bleed has not been well studied. A comparison of the efficacy of beta-blocker treatment and cyanoacrylate injection for the prevention of gastric variceal rebleeding was carried out.
METHODS
Patients with gastro-oesophageal varices type 2 (GOV2) with eradicated oesophageal varices or isolated gastric varices type 1 (IGV1) who had bled from gastric varices were randomised to cyanoacrylate injection (n=33) or beta-blocker treatment (n=34). Baseline and follow-up upper gastrointestinal endoscopy and hepatic venous pressure gradient (HVPG) measurements were performed. Primary end points were gastric variceal rebleeding or death.
RESULTS
The probability of gastric variceal rebleeding rate in the cyanoacrylate group was significantly lower than in the beta-blocker group (15% vs 55%, p=0.004) and the mortality rate was lower (3% vs 25%, p=0.026) during a median follow-up of 26 months. The median baseline and follow-up HVPG in the cyanoacrylate group were 15 (10-23) and 17 (11-24) mm Hg (p=0.001) and for the beta-blocker group 14 (11-24) and 13 (8-25) mm Hg (p=0.003). While no patient showed reduction of HVPG in the cyanoacrylate group, in the beta-blocker group 12 of 28 (42%) patients were responders, of which 5 (41% of responders) bled. On multivariate analysis, treatment method, portal hypertensive gastropathy and size of the gastric varix >20 mm independently correlated with gastric variceal rebleeding. Gastric variceal rebleeding independently correlated with mortality.
CONCLUSIONS
Cyanoacrylate injection is more effective than beta-blocker treatment for the prevention of gastric variceal rebleeding and improving survival.
背景和目的
胃静脉曲张出血通常很严重，难以控制。氰基丙烯酸酯内镜注射胃静脉曲张是预防再出血的有效方法。β受体阻滞剂在胃静脉曲张出血二级预防中的疗效尚未得到很好的研究。本研究比较了β受体阻滞剂治疗和氰基丙烯酸酯注射预防胃静脉曲张再出血的疗效。
方法
本研究纳入了胃食管静脉曲张 2 型（GOV2）患者，这些患者的食管静脉曲张已消除或孤立性胃静脉曲张 1 型（IGV1）患者的胃静脉曲张已出血。这些患者被随机分为氰基丙烯酸酯注射组（n=33）或β受体阻滞剂治疗组（n=34）。进行基线和随访上消化道内镜和肝静脉压力梯度（HVPG）测量。主要终点是胃静脉曲张再出血或死亡。
结果
氰基丙烯酸酯组的胃静脉曲张再出血率明显低于β受体阻滞剂组（15%比 55%，p=0.004），死亡率也较低（3%比 25%，p=0.026），中位随访时间为 26 个月。氰基丙烯酸酯组的基线和随访 HVPG 中位数分别为 15（10-23）和 17（11-24）mmHg（p=0.001），β受体阻滞剂组分别为 14（11-24）和 13（8-25）mmHg（p=0.003）。在氰基丙烯酸酯组中，没有患者的 HVPG 降低，但在β受体阻滞剂组中，28 例患者中有 12 例（42%）为应答者，其中 5 例（应答者的 41%）出血。多变量分析显示，治疗方法、门静脉高压性胃病和胃静脉曲张大小>20mm 与胃静脉曲张再出血独立相关。胃静脉曲张再出血与死亡率独立相关。
结论
与β受体阻滞剂治疗相比，氰基丙烯酸酯注射更能有效预防胃静脉曲张再出血并提高生存率。
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