Orloff M J, Isenberg J I, Wheeler H O, Haynes K S, Jinich-Brook H, Rapier R, Vaida F, Hye R J, Orloff S L
Department of Surgery, University of California, San Diego Medical Center, San Diego, California 92103-8999, USA.
Transplant Proc. 2010 Dec;42(10):4101-8. doi: 10.1016/j.transproceed.2010.09.035.
Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105).
Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up.
In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients.
If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.
肝硬化患者的食管静脉曲张破裂出血（BEV）一直被视为肝移植（LT）的指征。在一项针对未选择的、连续的晚期肝硬化合并BEV患者的随机对照试验（RCT）中，对内镜硬化治疗（EST；n = 106）与急诊直接门腔分流术（EPCS；n = 105）进行了比较，探讨了这一问题。
在8小时内开始诊断检查和治疗。患者入院时及之后反复接受LT评估；96%的患者接受了超过10年的定期随访。分析还纳入了1300例未随机分组的此前接受过门腔分流术（PCS）的肝硬化患者，随访率为100%。
在RCT中，EPCS后长期出血控制率为100%，EST后仅为20%。此外，EPCS后的3年、5年、10年和15年生存率分别为75%、73%、46%和46%，而EST后分别为44%、21%、9%和9%（P <.001）。RCT中只有13例患者（6%）最终因进行性肝衰竭而被转诊进行LT；只有7例（3%）获得LT批准，只有4例（2%）接受了LT。LT的1年和5年生存率分别为0.68%和0，而EPCS后的生存率分别为81%和73%。在1300例未随机分组的PCS患者中，50例（3.8%）被转诊，19例（1.5%）接受了LT。5年生存率为53%，而1300例患者的总体生存率为72%。
如果出血得到永久控制，如EPCS后总是出现的情况，BEV肝硬化患者很少需要LT。PCS是有效的一线长期治疗方法。对于接受PCS的患者，如果需要进行LT，尽管技术要求更高，但大量研究表明，PCS不会增加死亡率或并发症。EST不是有效的急诊或长期治疗方法。
