The Study Of Efficacy And Mechanism Of The Mucosal Sclerosing Reinforcement Therapy For The Recurrence Of Esophageal Varices

ObjectiveIn order to deal with the recurrence of varicose veins after the endoscopic variceal ligation, many experts in recent years have made a lot of investigation. The results of endoscopic variceal ligation plus sclerotherapy(EVLS ) is different. However, whether the EVLS could effectively elinimate the recurrence of esophageal varices, cannot reach a consensus, and there also is no generally unified standards in the program of EVLS, especially about the best sequential interval time and the optimal dose of sclerosing agent. It still needs further large clinical trials. We chose postoperative patients of EVL to inject small dose of sclerosing agent to find a way that can improve the long-term efficacy of endoscopic treatment and decrease the complications. Through contrasting frequency of veins relevant recurrence of esophageal varices between the EVL-alone group and the EVL plus sclerotherapy-enforcing group under the EUS. we attempt to investigate the mechanism of the phenomenon that the low dose sclerotherapy-enforcing treatment can reduce the recurrence of esophageal varices. and provide reliable evidences for its better long-term efficacy.MethodsPart 1 257 cases of patients with esophageal varices bleeding were divided into sclerotherapy-enforcing group and EVL-alone group as a retrospective study from January 2004 to July 2009. EVL-alone group patients accepted EVL treatment . After varices disappeared or almost disappeared by ligation in sclerotherapy-enforcing group, the patients accepted 2 to 4 times of low dose of sclerotherapy-enforcing therapy. Regular follow-up period is 12 to 60 months. Variceal recurrence rate ,rebleeding rate and complication rate was observed.Part 2 the patients whoes esophageal varices disappeared or almost disappeared by ligation were randomly divided into the sclerotherapy-enforcing group and control group (EVL-alone group) for prospective study. The sclerotherapy-enforcing group underwent 2 to 4 times small doses of reinforce mucosal sclerosis treatment after ligation. The patients were followd up regulary for 12-22 months with endoscopic ultrasonography, and observed relevance ratio of veins associated with recurrent esophageal varices, including the mucosal small veins, esophageal varices, perforating veins, peri-esophageal collateral veins, and para-esophageal collateral veins. The two groups were statistically analyzed to investigate the possible mechanism of prevention of variceal recurrence.ResultsPart 1 In 139 cases with complete follow-up, 61 patients (43.88%) had variceal recurrence in sclerotherapy-enforcing group; While in 118 patients of EVL-alone group, 97 patients (82.2%) had recurrent varicose veins, the EV recurrence rate was statistically different in two groups. Rebleeding occured in 36 cases(25.9%) in sclerotherapy-enforcing group and 34 cases (28.8%) in EVL-alone group. It was not statistically significantly different. Of 348 cases accepting sclerotherapy in sclerotherapy-enforcing group, 28 cases (8.0%) had complications. While in 294 cases of EVL-alone, 47cases (15.9%) had complications.Part 2 With EUS monitoring veins associated with recurrent esophageal veins, we found that 19 case (45.2%) with mucosal small veins in 42 patients sclerotherapy-enforcing group, 15 cases (35.7%) with esophageal varices, 22 cases (52.4%) with perforating veins ,30 cases (71.4%) with peri-esophageal collateral veins , 27 cases (64.3%)with para-esophageal collateral veins. Amony 39 patients of EVL-alone group, 32 cases (82.0%) with mucosal small veins , 27 cases (69.2%) with esophageal varices, 26 cases (66.7%) with perforating veins, 29 cases (74.4%) with peri-esophageal collateral veins, 24 patients (61.5%) with para-esophageal collateral veins. EUS examination revealed that esophageal mucosa was thicker in sclerotherapy-enforcing group, and the detection rate of small veins and submucosal varices was significantly different between the two groups.Conclusions1. Mucosal reinforcement therapy by low dose of sclerosing agent can effectively reduce the recurrence of esophageal varices after EVL. It may be a way to improve long-term efficacy of endoscopic therapy.2. The mechanism of mucosal reinforcement therapy for reducing the esophageal varices recurrence may be to thicken esophageal mucosa and strengthen the supporting force of mucosa, and to control regeneration of the mucosal small veins and recanalisation of esophageal varices...