Smith J L, Graham D Y
Gastroenterology. 1982 May;82(5 Pt 1):968-73.
Treatment of variceal hemorrhage is one of the most controversial subjects in medicine. The resurgence of old therapies (endoscopic sclerotherapy) and the introduction of new modalities (obliterative angiotherapy) has exacerbated the controversy. No widely accepted controlled therapeutic trial is available. The problem related to survival analysis has been studied in the light of the available information concerning the natural history of variceal bleeding. It is believed that controlled trials can be designed which will prove the efficacy, or lack of it, for any proposed treatment; however, valid conclusions based on previous studies are limited, largely because of the many confounding variables. Time, as a variable factor both for randomization and therapeutic intervention, has been largely ignored, yet, we believe it is the major variable in this setting. For the population of variceal bleeders, risk of rebleeding or death rapidly diminishes over the first few days after a bleed, and early survival may be the best marker for later survival. Neither presentation nor treatment seems to alter this fundamental behavior. Variceal hemorrhage may serve as a prototype for problems of survival analysis of diseases with early high mortality.
静脉曲张出血的治疗是医学中最具争议的话题之一。旧疗法（内镜下硬化疗法）的复兴以及新方法（闭塞性血管疗法）的引入加剧了这一争议。目前尚无广泛接受的对照治疗试验。已根据有关静脉曲张出血自然史的现有信息研究了与生存分析相关的问题。人们认为，可以设计对照试验来证明任何提议治疗方法的疗效或缺乏疗效；然而，基于先前研究得出的有效结论有限，这主要是因为存在许多混杂变量。时间作为随机化和治疗干预的可变因素，在很大程度上被忽视了，然而，我们认为它是这种情况下的主要变量。对于静脉曲张出血患者群体，出血后的头几天内再出血或死亡风险迅速降低，早期生存可能是后期生存的最佳指标。临床表现和治疗似乎都不会改变这种基本行为。静脉曲张出血可能是早期高死亡率疾病生存分析问题的一个典型例子。
