Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.
Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.
Liver Int. 2018 Mar;38(3):477-483. doi: 10.1111/liv.13559. Epub 2017 Sep 13.
BACKGROUND & AIMS: Balloon tamponade (BT) can bridge patients to salvage therapy for uncontrollable acute variceal haemorrhage (AVH). However, data are limited regarding the reasons for, rate of and outcomes associated with Balloon tamponade use.
First, we performed an single-centre cohort study of all patients (N = 139) with oesophageal acute variceal haemorrhage from 01/2009 to 10/2015. Associations between Balloon tamponade use and adherence to four quality metrics (endoscopy within 12 hours, band-ligation, pre-endoscopy antibiotics and octreotide) were evaluated. Second, we analysed the National Inpatient Sample (2005-2011) to determine the association between in-hospital mortality for patients and their hospital's Balloon tamponade-utilization to acute variceal haemorrhage volume ratio.
In the national cohort, 5.5% of 140 521 acute variceal haemorrhage admissions required Balloon tamponade utilization. Adjusting for patient- and hospital-level confounders, the rate of Balloon tamponade use per acute variceal haemorrhage managed at any given hospital was associated with increased mortality for all-comers with acute variceal haemorrhage. Compared to the lowest tertile, acute variceal haemorrhage admissions in the highest Balloon tamponade utilizers were associated with increased mortality of (OR1.17 95%CI (1.01-1.37). In the single-centre cohort, 14 (10.1%) patients required Balloon tamponade. Balloon tamponade utilization was significantly associated with alcohol abuse (50.4% vs 21.4%, P = .04), hepatocellular carcinoma (35.7% vs 8.8%, P = .01), higher median model for end-stage liver disease (MELD) score (26.3vs15.5, P = .002) and active bleeding during endoscopy (64.3% vs 27.5%, P = .01). Failure to provide all quality metrics was associated with a higher model for end-stage liver disease-adjusted risk of Balloon tamponade use: OR 16.7 95% CI(4.17-100.0, P < .0001).
Balloon tamponade use is associated with severity of bleeding but may also implicate deficits in processes of care. Even for patients who did not need Balloon tamponade, presentation to hospitals with high Balloon tamponade utilization increases their odds of dying from acute variceal haemorrhage.
球囊填塞（BT）可用于治疗无法控制的急性静脉曲张出血（AVH），为患者争取挽救治疗的机会。然而，关于球囊填塞的使用原因、使用率以及与该操作相关的结果的数据十分有限。
首先，我们对 2009 年 1 月至 2015 年 10 月期间，所有因食管急性静脉曲张出血入院的 139 例患者（N=139）进行了单中心队列研究。我们评估了球囊填塞的使用与四项质量指标（12 小时内进行内镜检查、套扎术、内镜前使用抗生素和奥曲肽）的遵循情况之间的关系。其次，我们分析了国家住院患者样本（2005-2011 年），以确定患者院内死亡率与医院急性静脉曲张出血量与球囊填塞利用量的比值之间的关系。
在全国队列中，140521 例急性静脉曲张出血入院患者中有 5.5%需要使用球囊填塞。在校正了患者和医院水平的混杂因素后，在任何特定医院管理的急性静脉曲张出血中，球囊填塞的使用率与所有接受急性静脉曲张出血治疗患者的死亡率增加有关。与最低三分位相比，球囊填塞使用率最高的急性静脉曲张出血患者的死亡率更高（OR1.17，95%CI（1.01-1.37）。在单中心队列中，有 14 例（10.1%）患者需要使用球囊填塞。球囊填塞的使用与酒精滥用（50.4%比 21.4%，P=.04）、肝细胞癌（35.7%比 8.8%，P=.01）、更高的终末期肝病模型（MELD）评分中位数（26.3 比 15.5，P=.002）和内镜检查时的活动性出血（64.3%比 27.5%，P=.01）显著相关。未能提供所有质量指标与更高的终末期肝病调整后的球囊填塞使用率相关：OR 16.7，95%CI（4.17-100.0，P<.0001）。
球囊填塞的使用与出血的严重程度相关，但也可能暗示治疗过程中的不足。即使对于不需要球囊填塞的患者，就诊于球囊填塞使用率高的医院也会增加他们死于急性静脉曲张出血的几率。
