Willson P D, Kunkler R, Blair S D, Reynolds K W
Gastrointestinal Unit, Charing Cross Hospital, London, UK.
Br J Surg. 1994 Jul;81(7):992-5. doi: 10.1002/bjs.1800810721.
Continued haemorrhage from oesophageal varices despite adequate injection sclerotherapy and tamponade has a high mortality rate. Such patients are usually referred for surgery. Over a 10-year period, 30 patients (21 men and nine women of median age 52 (range 21-70) years) with acute variceal haemorrhage uncontrolled by initial treatment underwent early emergency oesophageal transection. Portal hypertension was caused by alcoholic cirrhosis in 22 patients; other forms of cirrhosis were present in seven and portal vein thrombosis in one. Hepatic function immediately before operation was Pugh grade A in two patients, B in six and C in 22. Deterioration between admission and transection from grade A to B occurred in one patient and from B to C in five. Oesophageal transection stopped variceal haemorrhage in 29 of the 30 patients. Rebleeding from gastric varices within 35 days of surgery occurred in five patients. Postoperative haemorrhage also occurred from perioesophageal vessels (two patients), a gastrotomy (one) and oesophageal ulceration (two). Hepatic failure developed in seven patients, renal failure in five and both hepatic and renal failure in four. Mortality at 30 days occurred in neither of the two patients with liver function of grade A, in one of six of grade B and in 18 of 22 of grade C. The overall 30-day mortality rate was thus 63 per cent. Mortality was related to the preoperative Pugh grade (hazard ratio 3.95 per grade; P = 0.013) and preoperative blood transfusion (hazard ratio 1.37 per unit; P = 0.035). Four of six patients with grade B liver function died within 3 months and 21 of 22 with grade C disease within 1 year. Oesophageal transection is effective at stopping variceal bleeding but does not modify the underlying disease. Caution is urged for patients with grade C hepatocellular impairment proceeding to acute oesophageal transection after initial sclerotherapy. Such patients may benefit more from treatment with somatostatin or an intrahepatic porta-systemic stent shunt while awaiting definitive therapy.
尽管进行了充分的注射硬化疗法和压迫止血，食管静脉曲张仍持续出血，其死亡率很高。这类患者通常会被转诊进行手术。在10年期间，30例（21例男性和9例女性，中位年龄52岁（范围21 - 70岁））急性静脉曲张出血经初始治疗未能控制的患者接受了早期急诊食管横断术。22例患者的门静脉高压由酒精性肝硬化引起；7例存在其他形式的肝硬化，1例为门静脉血栓形成。手术前肝功能为Pugh A级的有2例，B级的有6例，C级的有22例。入院至横断术期间，1例患者肝功能从A级恶化为B级，5例从B级恶化为C级。30例患者中有29例食管横断术止住了静脉曲张出血。5例患者在术后35天内胃静脉曲张再出血。术后食管周围血管出血（2例）、胃切开术部位出血（1例）和食管溃疡出血（2例）也有发生。7例患者发生肝衰竭，5例发生肾衰竭，4例肝和肾衰竭均发生。肝功能A级的2例患者30天内均未死亡，B级的6例中有1例死亡，C级的22例中有18例死亡。因此，总体30天死亡率为63%。死亡率与术前Pugh分级（每级风险比3.95；P = 0.013）和术前输血（每单位风险比1.37；P = 0.035）有关。肝功能B级的6例患者中有4例在3个月内死亡，C级的22例中有21例在1年内死亡。食管横断术在止住静脉曲张出血方面有效，但不能改变潜在疾病。对于初始硬化治疗后进行急性食管横断术的C级肝细胞损伤患者，应谨慎行事。这类患者在等待确定性治疗期间，使用生长抑素或肝内门体分流支架分流术治疗可能获益更多。
