Henderson J M, Kutner M H, Millikan W J, Galambos J T, Riepe S P, Brooks W S, Bryan F C, Warren W D
Emory University Hospital, Atlanta, Georgia.
Ann Intern Med. 1990 Feb 15;112(4):262-9. doi: 10.7326/0003-4819-112-4-262.
To define the roles of endoscopic variceal sclerosis and distal splenorenal shunt in the prevention of recurrent variceal bleeding in patients with cirrhosis.
A prospective, randomized clinical trial with crossover for those failing therapy. The median follow-up was 61 months.
A private, tertiary-referral university hospital.
Seventy-two patients fulfilling inclusion criteria were drawn from a total of 420 patients treated during a 4.5-year interval.
Endoscopic variceal sclerosis or distal splenorenal shunt.
Survival was significantly (P = 0.02) improved in patients randomly assigned to receive sclerotherapy: 13 of these 37 (35%) patients failed sclerotherapy and required surgical rescue. A survival advantage (P = 0.01) was seen in patients with alcoholic cirrhosis who had this combined therapy; however, in patients with nonalcoholic cirrhosis, survival for those receiving sclerotherapy and surgical rescue was not significantly (P = 0.36) different from that of patients receiving distal splenorenal shunt. Control of variceal bleeding was significantly (P less than 0.001) better in the distal splenorenal shunt group (34 of 35 [97%] compared with 15 of 37 [41%] in the sclerotherapy group). Using death, uncontrolled rebleeding, or shunt thrombosis as the endpoints resulted in no significant difference between treatment groups. Hepatocyte function and portal perfusion were significantly better maintained in patients with alcoholic cirrhosis who were managed by sclerotherapy rather than shunt (P = 0.01 and P = 0.001, respectively).
Endoscopic sclerotherapy with surgical rescue for uncontrolled bleeding is the optimum therapy for patients with alcoholic cirrhosis and variceal bleeding. Survival is similar in nonalcoholic patients treated with either distal splenorenal shunt or endoscopic sclerotherapy, but shunting provides better control of variceal bleeding.
明确内镜下静脉曲张硬化术和远端脾肾分流术在预防肝硬化患者静脉曲张再出血中的作用。
一项前瞻性随机临床试验，对治疗失败的患者采用交叉设计。中位随访时间为61个月。
一家私立的三级转诊大学医院。
从4.5年期间治疗的420例患者中选取了72例符合纳入标准的患者。
内镜下静脉曲张硬化术或远端脾肾分流术。
随机分配接受硬化治疗的患者生存率显著提高（P = 0.02）：这37例患者中有13例（35%）硬化治疗失败，需要手术挽救。接受联合治疗的酒精性肝硬化患者有生存优势（P = 0.01）；然而，在非酒精性肝硬化患者中，接受硬化治疗和手术挽救的患者生存率与接受远端脾肾分流术的患者相比无显著差异（P = 0.36）。远端脾肾分流术组静脉曲张出血的控制明显更好（P < 0.001）（35例中的34例[97%]，而硬化治疗组为37例中的15例[41%]）。以死亡、未控制的再出血或分流血栓形成作为终点，治疗组之间无显著差异。硬化治疗而非分流术治疗的酒精性肝硬化患者的肝细胞功能和门静脉灌注得到显著更好的维持（分别为P = 0.01和P = 0.001）。
内镜下硬化治疗联合手术挽救控制出血是酒精性肝硬化合并静脉曲张出血患者的最佳治疗方法。非酒精性患者接受远端脾肾分流术或内镜下硬化治疗的生存率相似，但分流术能更好地控制静脉曲张出血。
