Connacher A A, Campbell F C, Bouchier I A, Cuschieri A
Ann R Coll Surg Engl. 1986 Sep;68(5):256-9.
A policy of joint management of patients with acute variceal bleeding was constructed and applied prospectively to 37 consecutive patients. According to the protocol, every patient underwent an initial joint assessment by a physician and a surgeon soon after admission and resuscitation, which included age, previous history, physical examination and biochemical profile. Pugh's modification of Child's scoring system was used to assess the severity of the underlying hepatic disorder. Patients in groups A and B who were less than 70 years of age were treated by shunt surgery carried out during the same admission. Patients outwith this category were managed conservatively and a blood transfusion limit (10 units) imposed unless the clinical picture subsequently improved or the liver function was good but the patient was not eligible for surgery because of age. Twenty seven patients underwent shunt surgery, the most frequent procedure being a Warren shunt (n = 21). The average hospital stay in the surgically treated group was 18 days. The 30 day operative mortality was 15%. Two further deaths in the shunted group occurred during the follow-up period (mean = 30 months, range = 6-97 months). Seventeen patients in the shunted group remain well but three have required further therapy because of rebleeding episodes (two with sclerotherapy, one by surgery). Two patients who went abroad after recovery from their shunt surgery have been lost to follow up. The survival in the conservatively treated group was short and recurrent bleeding common. This experience indicates that an initial joint assessment using established criteria reliably identifies the poor prognosis group of patients with variceal haemorrhage and allows the rationalisation of the hospital resources.Early and expeditious selective shunt surgery in the good risk category carries an acceptable mortality and is cost effective in the long term.
制定了一项急性静脉曲张出血患者联合管理策略，并前瞻性地应用于37例连续患者。根据方案，每位患者在入院及复苏后不久，由内科医生和外科医生进行初始联合评估，评估内容包括年龄、既往史、体格检查及生化指标。采用Pugh改良的Child评分系统评估潜在肝脏疾病的严重程度。A组和B组年龄小于70岁的患者在同一住院期间接受分流手术治疗。不属于该类别的患者采用保守治疗，并设定输血上限（10单位），除非临床情况随后改善或肝功能良好但因年龄原因患者不适合手术。27例患者接受了分流手术，最常用的术式是Warren分流术（n = 21）。手术治疗组的平均住院时间为18天。30天手术死亡率为15%。分流组在随访期间又有2例死亡（平均 = 30个月，范围 = 6 - 97个月）。分流组17例患者情况良好，但3例因再出血事件需要进一步治疗（2例接受硬化疗法，1例接受手术）。2例分流手术后康复出国的患者失访。保守治疗组生存期短且再出血常见。这一经验表明，使用既定标准进行初始联合评估能够可靠地识别静脉曲张出血预后不良的患者群体，并实现医院资源的合理配置。对于风险较低的患者，早期快速进行选择性分流手术死亡率可接受，且从长期来看具有成本效益。
