Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong.
Department of Surgery, The Chinese University of Hong Kong, Hong Kong.
J Gastroenterol Hepatol. 2020 Dec;35(12):2192-2201. doi: 10.1111/jgh.15168. Epub 2020 Jul 9.
Secondary prophylaxis (SP) of variceal rebleeding was reported to improve outcomes of hepatocellular carcinoma (HCC) patients, but the optimal endoscopic approach is not well defined. We compared outcomes in HCC patients who underwent SP by endoscopic ultrasound-guided cyanoacrylate obturation (EUS-CYA) versus no SP.
Between 2014 and 2018, 30 consecutive patients with inoperable HCC and recent endoscopically controlled variceal bleeding were prospectively recruited. Twenty-seven patients with persistent varices ≥ 3 mm on endoscopic ultrasound underwent EUS-CYA for SP. Thirty-three HCC patients treated by esophagogastroduodenoscopy-guided CYA obturation (EGD-CYA) alone for acute variceal bleeding between 2009 and 2013 were identified from a prospective gastrointestinal bleed registry as standard of care controls for comparison. Outcome measures were death-adjusted cumulative incidence of rebleeding, bleeding-free survival, technical success, and procedure-related adverse events of EUS-CYA.
The majority of patients in both groups had advanced HCC, portal vein thrombosis, and Child-Pugh B cirrhosis. EUS-CYA was successful in all 27 patients with no radiographic evidence of cyanoacrylate-lipiodol embolization. Significantly lower 30- and 90-day death-adjusted cumulative incidence of rebleeding (14.8% vs 42.4%, P = 0.023 and 18.5% vs 60.6%, P = 0.002, respectively) and significantly higher variceal bleeding-free survival at 3 and 6 months (51.9% vs 21.2%, P = 0.009, 40.7% vs 15.2%, P = 0.010, respectively) were observed in the EUS-CYA group when compared with standard of care group.
Secondary prophylaxis by EUS-CYA reduced rebleeding rate and improved variceal bleeding-free survival in patients with inoperable HCC and variceal bleeding when compared with no SP. Randomized studies are needed to confirm the benefits of EUS-CYA for this difficult-to-treat population.
二级预防（SP）可降低静脉曲张再出血的风险，从而改善肝细胞癌（HCC）患者的预后，但内镜治疗的最佳方法尚不清楚。我们比较了接受内镜超声引导下氰基丙烯酸酯栓塞（EUS-CYA）SP 治疗与未行 SP 治疗的 HCC 患者的结局。
2014 年至 2018 年间，前瞻性招募了 30 例因不可切除 HCC 且近期内镜控制的静脉曲张出血的连续患者。27 例内镜超声检查显示静脉曲张≥3mm 的患者行 EUS-CYA 进行 SP。从前瞻性胃肠出血登记处确定了 33 例 HCC 患者，这些患者在 2009 年至 2013 年间因急性静脉曲张出血接受了内镜下胃食管静脉曲张套扎术（EGD-CYA）治疗，作为标准护理对照进行比较。观察指标包括死亡调整后的再出血累积发生率、无出血生存、技术成功率和 EUS-CYA 相关不良事件。
两组患者均以晚期 HCC、门静脉血栓形成和 Child-Pugh B 级肝硬化为主。27 例患者均成功进行了 EUS-CYA，无氰基丙烯酸酯-碘油栓塞的影像学证据。EUS-CYA 组 30 天和 90 天死亡调整后的再出血累积发生率显著降低（14.8% vs. 42.4%，P=0.023 和 18.5% vs. 60.6%，P=0.002），EUS-CYA 组 3 个月和 6 个月的静脉曲张出血无复发生存率显著提高（51.9% vs. 21.2%，P=0.009 和 40.7% vs. 15.2%，P=0.010）。
与不进行 SP 相比，EUS-CYA 可降低不可切除 HCC 合并静脉曲张出血患者的再出血率，并改善静脉曲张出血无复发生存率。需要进行随机研究以证实 EUS-CYA 对这一治疗困难人群的益处。
