| Part ?:To establish noninvasive prediction models for decompensated esophagogastricvaricose bleeding in patients with cirrhosisObjective:the most important factor for decompensation of cirrhosis after hepatitis b is esophageal and gastric varicose bleeding.However,the onset of this disease is insidious and fierce.At present,gastroscope is the main follow-up and evaluation method,but it belongs to invasive examination and has the risk of inducing bleeding.Over the past 20 years,all over the world to explore a kind of noninvasive prediction model to predict cirrhosis after esophageal and gastric varices rupture bleeding risk,but the result is difficult to promote,the main reason lies in the sensitivity and specificity,insufficient clinical practice to detect when the missed diagnosis is high,especially one caused by hepatitis b virus cirrhosis esophageal and gastric varices noninvasive predictive model is less,the combined forecasting method is more rare,so this study is to establish the serum laboratory index combined imaging index build a noninvasive prediction model,predicting decompensated cirrhosis after hepatitis b-portal hypertension-the risk of esophageal and gastric varices rupture bleeding,Provide guidance for clinical treatment.Methods:to collect medical center from July 2010 to July 2017,a clear diagnosis of 3827 cases of patients with liver cirrhosis after hepatitis b,as far as possible to rule out confounding factors affecting conclusion,were collected with varicose vein rupture bleeding decompensated cirrhosis,524 cases of complete sets of data,compensatory phase cirrhosis group,340 cases of varicose vein rupture hemorrhage for statistical analysis.The group of data were analyzed with logistic stepwise regression and weighted TOPSIS nonlinear model,in which the logistic stepwise regression model innovatively verified the prediction equation repeatedly and extracted 200 times,and finally generated 3 varicose vein risk prediction models,and then further compared their advantages and disadvantages to establish a stable and efficient prediction model.The weighted TOPSIS nonlinear model also obtains the best prediction effect by giving the optimal weight.Results:multivariate logistic stepwise regression analysis showed that TBIL,PLT,RBC,ultrasonic /CT portal vein diameter and ultrasonic /CT spleen diameter were risk factors for esophagogastric variceal hemorrhage.Based on the preliminary results of the above factors,the prediction models P11 and P21 after 200 refinations were established.The ROC curve area of P11 was 0.952(95%CI :0.938~0.967),the sensitivity was 0.895,and the specificity was 0.932.The ROC curve area of P21 was 0.956(95%CI :0.942~0.970),the sensitivity was 0.905,the specificity was 0.938,and the prediction accuracy was 90.21% and 90.76%,respectively.The prediction effect of the two models was stable,and there was no significant difference in the area under the ROC curve(P>0.05).With the weighted TOPSIS nonlinear model,the prediction accuracy can reach more than 95%,the sensitivity distribution is between 60.3% and 96.2%,the specificity distribution is between 71.2% and 98.8%,and the prediction accuracy is between 69.0% and 95.5%.Conclusion:the non-invasive prediction model,which has been repeatedly verified and refined by serum laboratory indexes combined with imaging indexes,can well predict the risk of esophageal and gastric varices rupture hemorrhage after hepatitis b cirrhosis,and has a good application prospect.It can replace the invasive model after further improvement.Part ?:Study on the treatment strategy of severe nonneoplastic PVT and cirrhosis inliver combined with EECObjective:serious,portal vein thrombosis in patients with cirrhosis,can lead to portal hypertension,the stomach esophagus varicosity burst hemorrhage,intestinal necrosis,clinical manifestations,such as on the occurrence,development and treatment strategies exist a great deal of controversy,through this research given individualized treatment plan,understanding the characteristics and prognosis of the disease,in order to reference for clinical promotion.Liver cirrhosis with early esophageal cancer(EEC),endoscopic submucosal dissection(ESD)or radiofrequency ablation(RFA)are mature treatments for early esophageal cancer(EEC).However,the safety and efficacy of ESD or RFA in the treatment of EEC in patients with cirrhosis have not been fully elucidated.In this study,we aimed to establish a standard treatment strategy based on the relative position of esophageal varices and EEC in patients with liver cirrhosis.To provide more references for clinical work.Methods:First chapter,in January 2013,were retrospectively analyzed in October 2018 in my hospital treatment,serious non tumor,64 cases of portal vein thrombosis,which merge based 59 cases,cirrhosis of liver cirrhosis portal vein thrombosis in 5 cases,given intravenous door jugular vein bypass(TIPS),Percutaneous transhepatic portal vein catheterization direct thrombolysis,oral warfarin thrombolysis treatment,observation contrast the success rate of operation,safety,complications,clinical efficacy,to observe the short-term curative effect(June)and long-term efficacy(1-3 years)predictor,survival analysis,etc.,It was concluded that individualized treatment was given according to the portal thrombosis in different time periods,different pathogenesis and different degree of blockage,so as to achieve the best clinical effect and at the same time to minimize the complications.The second chapter,this study included 6 patients with liver cirrhosis patients with esophageal varices of EEC,through the esophageal varices ligation(EVL),or TIPS after treatment of varicose veins,ESD or any form of RFA,2 months after surgery,endoscopic follow-up contrast the curative effect and complications,it is concluded that the feasibility of this kind of disease treatment process.Results:In chapter 1,there were 64 patients with severe non-neoplastic portal vein thrombosis,including 59 patients combined with basic cirrhosis,of which 44 received TIPS treatment,37 were successful and 7 failed.In the TIPS failure group,the original symptoms did not improve.Of the other 15 patients with severe portal vein thrombosis,12 received oral warfarin treatment for 6 months without recanalization,2 received percutaneous transhepatic portal vein catheterization for direct thrombolysis,1 received mesenteric artery intubation for indirect thrombolysis,and only 1 was successful.All the 5 patients without cirrhosis received percutaneous transhepatic portal vein therapy,4 of them were successful and 1 of them failed.In chapter 2,liver cirrhosis with early esophageal cancer patients,four lesions were located on the esophageal varices,and two lesions were not close to the esophageal varices.The mean longitudinal length of the lesion was 4.3cm(range: 2-6cm).The mean operative time was 72.8 minutes(range: 34-135 minutes),and the mean longitudinal length of the resected specimen was 45.6 mm(range: 30-90 mm).One case had positive marginal tumor with lymphangitic infiltration.The total resection rate and cure rate were 80%(4/5 lesions).Patients receiving preoperative(EVL)showed significantly higher blood loss during ESD treatment than those receiving preoperative TIPS,but no serious complications or death related events occurred.Postoperative esophageal stenosis was found in 1 case,and no tumor recurrence or metastasis was found during follow-up.Conclusion:for patients with portal vein thrombosis in the basis of liver cirrhosis,TIPS has a good therapeutic effect in the chronic stage of thrombosis,and the percutaneous transhepatic portal vein catheter thrombolysis has a good effect in the acute stage of thrombosis.The efficacy of oral warfarin and mesenteric arterial intubation in indirect thrombolysis for subacute and chronic thrombosis is poor.In patients with cirrhosis complicated with early esophageal cancer,we proposed a new treatment strategy with ideal therapeutic effect,no tumor progression and acceptable incidence of adverse events. |
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