McCarty Thomas R, Njei Basile
Department of Internal Medicine, Yale University School of Medicine, New Haven, USA.
Section of Digestive Diseases, Yale University School of Medicine, New Haven, USA.
Dig Endosc. 2016 Jul;28(5):539-47. doi: 10.1111/den.12626. Epub 2016 Apr 22.
Esophageal variceal bleeding is a severe complication of portal hypertension with significant morbidity and mortality. A substantial portion of cirrhotics fail to respond to conventional medical therapy and band ligation, necessitating alternative treatments including self-expanding metal stent (SEMS) placement for acute refractory esophageal variceal bleeding. In the present study, we carried out a systematic review and structured meta-analysis of all eligible studies to evaluate the technical feasibility, safety, clinical efficacy, and survival advantage of SEMS placement for the treatment of of acute esophageal variceal bleeding.
Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were carried out through December 2015. Individual study proportions were transformed into a quantity using the Freeman-Tukey variant of the arcsine square root transformed proportion. Combined weighted proportions, and meta-regression were then determined.
The search yielded 12 studies involving n = 155 patients included in our meta-analysis. Pooled clinical success rate in achieving hemostasis within 24 h was 96% (95% CI, 0.90-1.00). Technical success for SEMS deployment endoscopically was achieved in 97% of patients (95% CI, 0.91-1.00). Total adverse events (including rebleeding after 48 h, ulceration, and stent migration) were shown in 36% of patients after SEMS placement (95% CI, 0.23-0.50). Pooled 30-day and 60-day survival rates were 68% (95% CI, 0.56-0.80) and 64% (95% CI, 0.48-0.78), respectively.
This study demonstrated that esophageal SEMS placement is a technically feasible modality and highly efficacious in achieving hemostasis in acute esophageal variceal hemorrhage.
食管静脉曲张破裂出血是门静脉高压的一种严重并发症，具有较高的发病率和死亡率。相当一部分肝硬化患者对传统药物治疗和套扎术无反应，因此需要包括放置自膨式金属支架（SEMS）在内的替代治疗方法来治疗急性难治性食管静脉曲张破裂出血。在本研究中，我们对所有符合条件的研究进行了系统评价和结构化荟萃分析，以评估放置SEMS治疗急性食管静脉曲张破裂出血的技术可行性、安全性、临床疗效和生存优势。
检索了截至2015年12月的PubMed、EMBASE、Web of Science和Cochrane图书馆数据库。使用反正弦平方根变换比例的Freeman-Tukey变体将个体研究比例转换为数量。然后确定合并加权比例和荟萃回归。
检索得到12项研究，共155例患者纳入我们的荟萃分析。24小时内实现止血的合并临床成功率为96%（95%CI，0.90-1.00）。97%的患者在内镜下成功部署了SEMS（95%CI，0.91-1.00）。放置SEMS后，36%的患者出现了总不良事件（包括48小时后再出血、溃疡和支架移位）（95%CI，0.23-0.50）。30天和60天的合并生存率分别为68%（95%CI，0.56-0.80）和64%（95%CI，0.48-0.78）。
本研究表明，放置食管SEMS在技术上是可行的，并且在急性食管静脉曲张出血的止血方面非常有效。
